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Decriminalizing Drugs: The Social and Cultural Implications

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Published: Jan 25, 2024

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Introduction, history of drug criminalization, social implications of decriminalizing drugs, cultural implications of decriminalizing drugs, shifting the conversation around addiction and substance abuse.

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Decriminalisation or legalisation: injecting evidence in the drug law reform debate

Professor & Specialist in Drug Policy, UNSW Sydney

Disclosure statement

Alison Ritter receives funding from the NHMRC, the ARC and The Colonial Foundation Trust. She was a participant in the Australia 21 Roundtable held in January, 2012.

UNSW Sydney provides funding as a member of The Conversation AU.

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We should all be concerned about our laws on illegal drugs because they affect all of us – people who use drugs; who have family members using drugs; health professionals seeing people for drug-related problems; ambulance and police officers in the front line of drug harms; and all of us who pay high insurance premiums because drug-related crime is extensive.

Drug-related offences also take up the lion’s share of the work of police, courts and prisons. But what can we do? Some people feel that we should legalise drugs – treat them like alcohol and tobacco, as regulated products. And legalisation doesn’t necessarily need to apply for every illegal drug.

Why legalise?

One of the arguments for legalisation is that it would eliminate (or at least significantly reduce) the illegal black market and criminal networks associated with the drug trade. Other arguments include moving the problem away from police and the criminal justice system and concentrating responses within health.

Governments could accrue taxation revenue from illegal drugs as they currently do from gambling, alcohol and tobacco. A regulated government monopoly could secure direct income; our research suggests this may be as high as $600 million a year for a regulated cannabis market in New South Wales.

The strongest argument against legalisation is that it would result in significant increases in drug use. We know that currently legal drugs, such as alcohol and tobacco, are widely consumed and associated with an extensive economic burden to society – including hospital admissions, alcoholism treatment programs and public nuisance. So why create an environment where this may also come to pass for currently illegal drugs?

The moral argument against legalisation suggests the use of illegal drugs is amoral, anti-social and otherwise not acceptable in today’s society. The concern is that legalisation would “send the wrong message”.

Unfortunately, there’s no direct research evidence on legalisation because no country has legalised drugs yet. But suppositions can be made about the extent of cost-savings to society.

Indeed, some of our research on a regulated legal cannabis market suggests that there may not be the significant savings under a legalisation regime that some commentators have argued. But these are hypothetical exercises.

• Decriminalisation

An alternative to legalisation is decriminalisation. Experts don’t agree on the terminology and there’s much confusion. But, in essence, decriminalisation refers to a reduction of legal penalties. This can be done either by changing them to civil penalties, such as fines, or by diverting drug use offenders away from a criminal conviction and into education or treatment options (also known as “diversion”).

Decriminalisation largely applies to drug use and possession offences, not to the sale or supply of drugs. Arguments in favour of decriminalisation include its focus on drug users rather than drug suppliers. The idea is to provide users with a more humane and sensible response to their drug use.

Decriminalisation has the potential to reduce the burden on police and the criminal justice system. It also removes the negative consequences (including stigma) associated with criminal convictions for drug use.

One argument against decriminalisation is that it doesn’t address the black market and criminal networks of drug selling. There are also concerns that it may lead to increased drug use but this assumes that current criminal penalties operate as a deterrent for some people.

The moral arguments noted above also apply to decriminalisation – lesser penalties may suggest that society approves of drug use.

Many countries, including Australia, have decriminalised cannabis use: measures include providing diversion programs (all Australian states and territories), and moving from criminal penalties to civil penalties (such as fines in South Australia, Australian Capital Territory and the Northern Territory).

Our team’s research on Portugal suggests that drug use rates don’t rise under decriminalisation, and there are measurable savings to the criminal justice system.

In Australia also, there hasn’t been a rise in cannabis use rates despite states and territories introducing civil penalties for users. And research on diverting drug use offenders away from a criminal conviction and into treatment has shown that these individuals are just as likely to succeed in treatment as those who attend voluntarily.

At the same time, research has also noted a negative side effect to the way in which decriminalisation currently operates in Australia – “net widening” - whereby more people are swept up into the criminal justice system than would have occurred otherwise under full prohibition because discretion by police is less likely and/or they do not fulfil their obligations.

Despite the largely supportive evidence base, politicians appear reluctant to proceed along the decriminalisation path. Some commentators have speculated that this is because of public opinion – decriminalisation is regarded as an unpopular policy choice .

But public opinion is largely in support of decriminalisation, where it concerns cannabis (though not decriminalisation for other illegal drugs). In the last national survey , more than 80% of Australians supported decriminalisation options for cannabis. The other reason for equivocal policy support, I believe, is a lack of clarity about the issues.

There’s poor understanding about the different models of decriminalisation and some basic confusion exists. Many people equate decriminalisation with legalisation, but as detailed above, they are very different in policy, intent and action.

Decriminalisation is also sometimes incorrectly confused with harm reduction services, such as injecting centres or prescribed heroin programs.

The Australia21 Report released last week to stimulate informed public debate is an important step foward. In order for the debate to progress, we need clarity of terms, and dispassionate presentation of what evidence we have. Every policy has both risks and benefits and we need to talk about these.

• War on Drugs
• Drug reform
• Drug legalisation

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Drugs Decriminalization and Legalization Issues Essay

The current scale of the problem with the distribution of drugs makes the issue of legal regulation of this activity increasingly acute. In general, there are three approaches: decriminalization, legalization, and maintaining the status quo. Although the first two options are a certain kind of extremes, the need for their use is evident. The current generally accepted attitude towards drugs, in which their use and distribution in the vast majority of places is strictly prohibited, has led to the situation that we have now. A considerable number of teenagers are in prison for having even a tiny dose of cannabis. The existing legislation only increases the number of crimes associated with this activity and supports drug addiction. Consequently, the need to take at least some measures is obvious, and, in my opinion, decriminalization or legalization may be the answer to this question.

Since the tightening of laws has already been tried and given negative results, society is turning to two other alternatives. According to research, both decriminalization and legalization, despite the exact opposite in their essence, give approximately the same results (Maier et al., 2017). While this finding is somewhat unexpected, using any of these methods leads to a decrease in the level of drug-related crime. The overall statistical difference between the use of these methods is negligible, so additional benefits need to be evaluated. In this context, I believe that legalizing drugs is much more correct than decriminalizing them.

In the latter case, laws that punish people for using drugs are removed. However, this does not create any alternative, no official sales network. There is no way to manage this structure with this option, which could theoretically lead to much more chaos. On the other hand, legalization officially allows people to use drugs for medical or recreational purposes and creates a legal basis for drug trafficking. At the same time, since the state is the primary regulator of this issue, it will receive income from the sale of drugs. Practice shows that such an approach can bring in revenues of tens of millions of dollars (Maier et al., 2017). This money raised can be used for public projects, for example, building schools. Thus, I favor legalization rather than decriminalization since the first option provides many more advantages in both control and distribution, ultimately forming a more systematic structure.

Maier, S. L., Mannes, S., & Koppenhofer, E. L. (2017). The implications of marijuana decriminalization and legalization on crime in the United States. Contemporary Drug Problems, 44 (2), 125-146. Web.

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• Volume 10, Issue 9
• Impact evaluations of drug decriminalisation and legal regulation on drug use, health and social harms: a systematic review
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• http://orcid.org/0000-0001-8498-9829 Ayden I Scheim 1 , 2 ,
• Nazlee Maghsoudi 2 , 3 ,
• Zack Marshall 4 ,
• Siobhan Churchill 5 ,
• Carolyn Ziegler 6 ,
• Dan Werb 2 , 7
• 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
• 3 Institute of Health Policy, Management and Evaluation , University of Toronto , Toronto , Ontario , Canada
• 4 Social Work , McGill University , Montreal , Quebec , Canada
• 5 Epidemiology and Biostatistics , Western University , London , Ontario , Canada
• 6 Library Services , Unity Health Toronto , Toronto , Ontario , Canada
• 7 Medicine , University of California San Diego , La Jolla , California , USA
• Correspondence to Dr Dan Werb; dwerb{at}ucsd.edu

Objectives 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.

Design 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.

Results 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.

• substance misuse
• public health
• law (see medical law)

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjopen-2019-035148

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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.

Supplemental material

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.

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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.

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

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

Conclusions

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.

Acknowledgments

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

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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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Opinion: The real reason why Oregon recriminalizing drugs is a cautionary tale

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In a move widely hailed as a failure for the drug decriminalization movement, Oregon restored criminal penalties for low-level drug possession in April. Headlines chalked up this policy reversal to mounting overdoses , evoking a crisis in the state.

In reality, Oregon’s overdose rate remains in the middle of the pack nationally, with more than half of U.S. states having a greater number of deaths per capita. But increasing homelessness and visible drug use have spurred panic over drugs, which overruled statistics and scientific recommendations — and offers a cautionary tale about the fight for sensible drug laws.

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In 2020, a majority of Oregon voters approved decriminalization via Measure 110 — a landmark ballot measure that made simple possession of a small quantity of drugs for personal use subject to citation instead of jail. It diverted tax revenue from cannabis, which the state legalized for recreational use in 2014; in its first round of grants alone, the measure infused $300 million into the state’s threadbare drug treatment system and funded harm reduction services.

These were solid steps, backed by decades of science about addiction and consistent with United Nations recommendations in support of drug decriminalization. Other nations, including Portugal , Spain and Uruguay , have seen success with similar shifts away from arrest and toward healthcare-based approaches.

However, the same year Measure 110 passed, fentanyl use rose sharply on the West Coast. Despite nearly a decade of advance notice from the fentanyl crisis in the East, the region failed to prepare. As in other Western states, overdose rates in Oregon soared — from among the lowest in the country to nearly reaching the national average in 2022. Although data suggest that rates of drug use in Oregon have remained fairly stable in recent years, fentanyl makes for a much deadlier drug supply. At the same time, homelessness in Oregon has risen rapidly . As more people live outside, more drug use that used to occur behind closed doors now happens in plain sight.

The combination of these factors fed the perception that Oregon’s drug crisis was uniquely severe. Even though research shows that drug decriminalization did not increase the death rate and broadly supports leaving it in place to reduce the harms and wasteful spending of incarceration, Measure 110 became a scapegoat for Oregon’s social problems. Democrats, including Portland’s typically progressive district attorney , reversed their support and in effect repealed it.

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Since the law’s approval, the state has seen a surge in public drug use fueled by fentanyl and an increase in synthetic opioid overdose deaths.

Nov. 21, 2023

Criminal penalties do little to affect rates of drug use . Typically they just increase the degree to which people with addiction bounce between the street and jail, a cycle of imprisonment and release known to drive overdose deaths. Occasional anecdotes of people finding their way into recovery through contact with the criminal justice system are outliers. If police massively scale up arrests of people who use drugs, increased overdose deaths will be the predictable result .

Countries such as Portugal and Norway have followed a well-defined, alternative path to reduce drug-related deaths and public drug use. The steps include: Scale up opportunities for compassionate contact with the system, such as with free walk-in clinics for vulnerable people who use drugs. Make it easier and cheaper to access buprenorphine and methadone, medications that treat opioid addiction, than street fentanyl. Give people safe, controlled spaces to keep their drug use out of the public sphere while connecting with healthcare and shelter. Defend their human dignity and help them build positive relationships with health professionals and social workers. Drug decriminalization is worthwhile, but it does not replace these larger solutions.

Public drug use and streets full of tents are distressing for many Oregonians. They also provide images that are easily exploited by mainstream media and politicians to stoke public fears. But recriminalizing drugs is unlikely to decrease homelessness or eliminate public drug use.

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Although blaming drugs for homelessness is a common mistake, the scientific consensus shows that increased housing costs are the single most important cause. And Oregon simply does not have sufficient shelter beds or public housing options for those affected by extremely sharp increases in those costs. The state also struggles to hospitalize people in need of treatment for severe mental illness, both because there aren’t beds available and because its laws inhibit holding people involuntarily in many cases , including serious episodes of psychosis.

Oregon’s public safety system is struggling. Calling 911 frequently means being put on hold for several minutes. There are often no ambulances to dispatch. It took police 21 minutes on average to respond to a high-priority crime as of last year, five minutes longer than the year before.

These real public safety issues demand urgency. They also have nothing to do with the fact that drug users were not being arrested for possession. Under Measure 110, theft, public indecency, assault — and selling drugs — remained illegal. Focusing on punishing people who use drugs will further stretch the police force while not solving the larger problems.

Measure 110 took steps in the right direction by investing in social services. However, a single round of funding cannot undo decades of inadequate spending on addiction treatment and prevention. Robust mental health, substance treatment and public housing systems take years to build.

With the nation’s housing and overdose crises worse than ever, what’s happening in Oregon is not unique. Similar tensions between scientific approaches to addiction and concerns about homelessness and public drug use are playing out in San Francisco, Philadelphia, Boston and other cities. Our task is to resist the temptation to cave to panic and instead commit to evidence-backed solutions.

Morgan Godvin (@MorganGodvin) is a lifelong Oregonian, writer and drug policy researcher who served on the Measure 110 Oversight and Accountability Council and the Multnomah County Local Public Safety Coordinating Council. Joseph Friedman (@JosephRFriedman) is a researcher at UCLA who has published widely on the U.S. overdose crisis.

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More from our inbox:, jeff zucker’s tenure at cnn: news as entertainment, front and center with the good news, please.

To the Editor:

Re “ A Novel Drug Decriminalization Plan,” by Maia Szalavitz (Opinion guest essay, Sunday Review, Jan. 30):

Ms. Szalavitz entered dangerous territory with her essay about the experience of Oregon and Portugal with the decriminalization of drugs.

Of course, those with a substance use disorder deserve treatment — not prison — to address their addiction. But to suggest that America should follow Oregon’s approach, especially before the data are in, is a mistake.

Oregon’s policy change was opposed by recovery groups, law enforcement and addiction practitioners alike — because it doesn’t actually require any treatment (and early results show fewer than 1 percent of users have received treatment). How can anyone believe that offering those facing addiction a choice to pay $100 or call a hotline — with no accountability whatsoever — is going to help them, or society at large?

Ms. Szalavitz glosses over key details about the approach used by Portugal, a country that prioritizes and invests heavily in treatment and accountability. To be sure, our country needs a better approach to drug policy, one that integrates public health with public safety and demands high-quality treatment, wraparound services and supervision to ensure compliance. Drug courts are a good example. But decriminalization without accountability, which ultimately leads to the full legalization of drugs like heroin, fentanyl and methamphetamine, will only worsen our nation’s addiction problem.

Kevin A. Sabet Mitchell S. Rosenthal New York Dr. Sabet is president of Smart Approaches to Marijuana and a former White House drug policy adviser. Dr. Rosenthal is president of the Rosenthal Center for Addiction Studies and founder of Phoenix House, a nonprofit drug and alcohol rehabilitation organization.

The United States should swiftly adopt the Oregon model for decriminalization of personal-use drug possession to address the opioid use crisis, and the associated viral hepatitis epidemic.

Hepatitis C, which affects an estimated 2.4 million Americans, is largely tied to the opioid use epidemic. Injection drug use is now the main risk factor for new hepatitis C virus (H.C.V.) infections, and an estimated 80 percent of new H.C.V. infections occur among people who inject drugs. Rather than stigmatizing this population with criminal penalties and limited treatment access, the United States must provide easy access to lifesaving medications.

Data from Portugal have shown that its decriminalization model, which Oregon’s is based on, has not only shown declines in overdose deaths and addiction rates, but also significant drops in hepatitis B and C infections.

With policies that destigmatize drug use disorder and provide treatment to vulnerable populations, we can also root out related public health issues, including hepatitis C.

Daniel Raymond New York The writer is the director of policy for the National Viral Hepatitis Roundtable.

Oregon’s new plan for drug offenders is working for thieves but definitely not for law-abiding citizens or for neighborhoods. Addicts seem to be emboldened. Petty thefts have risen drastically, and the police won’t even bother to investigate: underfunded, understaffed and no jail space. Thieves know that if they are caught, they will receive only a ticket and orders to appear later for a hearing. Most never show up or pay the fines.

The police tell victims of theft that such incidents are considered “crimes of opportunity.” Thieves are looking for easily grabbed items that can quickly be converted to drugs or to cash for drugs. Everything that is not locked down is a target.

Jean Rubel Eugene, Ore.

Maia Szalavitz gets it right when she touts Oregon’s decriminalization of drugs as a hopeful step toward reducing the stigma associated with drug use and advancing access to addiction treatment. While state funds are starting to flow to chronically underfunded treatment providers who are now charged with solving an age-old problem almost by themselves, it’s critical that every law enforcement dollar saved — and then some — is invested expediently in evidence-based treatment and recovery services.

As law enforcement focuses on other issues and drug policy reformers celebrate, let’s make sure frontline providers and those who are imprisoned not by cops but by addiction have access to the help they need.

Jeffrey L. Reynolds New York The writer is the president and chief executive of Family and Children’s Association in Garden City, N.Y.

Re “ CNN Chief Out for Concealing a Relationship ” (front page, Feb. 3):

The humiliating forced exit of Jeff Zucker as president of CNN is about more than the fall from grace of yet another powerful media figure, or another embarrassing black eye for a once respected news organization. It’s about damaging the credibility of the news business as a whole.

During his nine-year stint at CNN, Mr. Zucker never fully grasped the huge responsibility a news executive has in today’s world, when unbiased, fact-based news reporting is under siege.

Instead, Mr. Zucker, who as president of NBC Entertainment signed Donald Trump for “The Apprentice” and presided over the likes of the gross-out reality show “Fear Factor” and sitcoms like “Friends” and “Scrubs,” approached CNN as entertainment as well. He shamelessly pursued younger demographics through the razzle dazzle of reality-style documentaries, on-air bickering by partisan pundits and political debate framed as sport, especially when it involved Mr. Trump.

That may be entertainment. But it sure isn’t news.

Greg Joseph Sun City, Ariz. The writer is a retired journalist and television critic.

Jeff Zucker said of his relationship with another CNN executive: “I was required to disclose it when it began but I didn’t. I was wrong.” Wow! How refreshing and seemingly increasingly unlikely it is for a prominent individual such as Mr. Zucker to simply tell the truth and admit wrongdoing. Thanks, Mr. Zucker, for being forthright.

Marc Chafetz Washington

For years, my husband and I have had a daily ritual: We make our way through your digital front page, usually on our phones, often while trying to wake up or fall asleep. Sometimes we are in different rooms, shouting our reactions to each other.

This year, though, his resolution is to read the news much less. Why? Because your home page has become a wholly depressing experience. Last Sunday’s edition was a perfect example, with an impressive range of bummer topics: dark money in Democratic politics, mental health challenges plaguing American teenagers, a retrospective on Bloody Sunday , the resurgence of book bans and pernicious social controls in China .

Last year, an economist at Dartmouth led a team of researchers who found that the tone of articles about the pandemic published by major U.S. media outlets was quite negative compared with those in other countries. ( The New York Times wrote about the findings .)

We are living through dark times, for sure, but why not feature, up front, more of the brighter pieces about our humanity? Perhaps a teacher who’s excelling in hybrid instruction, a neighborhood whose residents have found a way to support each other or a successful policy idea worth replicating. Positive stories are too often buried in another section (like Styles), or behind a second paywall (like a new recipe).

The Times is a filter through which many of us experience the world — all the more so when we are stuck inside. Please remember that your team has the power — and the great responsibility — to set the tone by which millions of Americans start and end their days.

Emily T. Broas San Francisco

Political fireworks about drug decriminalization leave Toronto request in limbo

B.c. partially rolled back its decriminalization effort, reigniting debate across canada.

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A request by Canada's biggest city to move forward on drug decriminalization is in limbo, facing significant provincial opposition and renewed political debate prompted by a partial rollback of B.C.'s existing policy.

Toronto put forward a request to the federal government in 2022, and provided additional information in 2023, Dr. Eileen de Villa, the city's medical officer of health, said in an interview on Rosemary Barton Live   that aired Sunday.

"Fundamentally, what that's about is recognizing that addiction is, at its core, a health issue not a criminal issue," she told CBC chief political correspondent Rosemary Barton.

The issue of drug decriminalization, already a tense political debate across the country, was reignited this week when B.C. announced it was looking to roll back part of an exemption that decriminalized possessing small amounts of some drugs.

• Analysis Despite all the shouting, the opioid crisis continues to defy simple answers
• British Columbia to recriminalize use of drugs in public spaces

B.C. now hopes to recriminalize the use of drugs in public places.

"We're taking action to make sure police have the tools they need to ensure safe and comfortable communities for everyone as we expand treatment options so people can stay alive and get better," B.C. Premier David Eby said this week.

Federal Conservatives have pointed to the B.C. request as a sign that drug decriminalization has failed, with leader Pierre Poilievre calling the policy "wacko."

B.C.'s drug decriminalization request was in support of a Vancouver municipal application, which had previously been sent by the city to the federal government.

Vancouver is not the only municipality to have weighed the benefits of decriminalization: Montreal's public health director  expressed support  for it in 2022, the same year Toronto made its first request.

Toronto medical officer sees drug decriminalization as 'health issue,' despite Ford's opposition

Municipal requests haven't gone far.

Toronto's request goes further than what B.C. has allowed. It does not include a threshold for the amount of drugs that would be permitted, and it also includes protections for minors. The B.C. exemption applies only to adults.

It's unclear where the Toronto request goes from here.

Asked about the issue at an event in Hamilton on Friday, Prime Minister Justin Trudeau said "the City of Toronto has no active application right now, so there's nothing to consider."

At Issue | Poilievre calls Trudeau’s drug policies ‘wacko’

Trudeau also suggested that provincial approval or support was needed for this kind of exemption.

"We knew that for any sort of pilot project to go forward ... the wraparound supports, the public safety implications required, that we couldn't just deal with the Vancouver application, we needed to work with the province on that," he said.

The Ontario government has not been supportive of Toronto's request. Ontario Premier Doug Ford this week called on Toronto to drop its application and promised to fight against it.

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"I will fight this tooth and nail. This is the wrong way to go. It's proven," Ford said.

In an interview with CP24 on Friday , Toronto Mayor Olivia Chow said decriminalization was only part of the solution to the problem of addictions, and that other services were needed.

"I'd rather focus on something practical. House these folks, get them into a treatment program," Chow said.

De Villa said the ongoing housing crisis in Canada has led to a worsening of the addictions crisis. She said the focus of decriminalization should be part of a fulsome approach to addiction that includes prevention and treatment.

"It's actually not about saying that public use is OK. Nor is it about saying selling or trafficking drugs is OK. It's actually about treating addiction as a health issue," she said.

But de Villa acknowledged that, ultimately, the fate of the Toronto request and the wider decriminalization policy was out of her hands.

"We are trying to provide the best possible advice with the best possible evidence — but at the end of the day the policy decisions rest with the decision-makers, who are the elected officials."

ABOUT THE AUTHOR

Christian Paas-Lang covers federal politics for CBC News in Ottawa as an associate producer with The House and a digital writer with CBC Politics. You can reach him at [email protected].

With files from Rosemary Barton and Lisa Mayor