Discussion Paper: A Public Health Approach to Drugs
Around the world, governments are considering different approaches to drugs. Some countries are decriminalizing drug use and possession while others are legalizing and regulating drugs. Change is happening in Canada too. Soon it will be legal for adults to purchase cannabis for personal use. And some are calling for changes in our approach to other drugs, especially in the midst of Canada’s overdose crisis, which is affecting Canadians across the country.
How could we change our approach to drugs? What would a public health approach to drugs look like for Canada? This paper is intended to start that discussion.
Under a public health approach, drug use would be treated as a health issue not a criminal issue.
Canadian Public Health Association
There are three main legal approaches to drugs:
- Criminalization – personal use, possession, production and sale of drugs is illegal (e.g. heroin, cocaine).
- Decriminalization – personal use and possession of drugs is allowed, but production and sale is illegal (no examples in Canada).
- Regulation – use of drugs is legal, and production and sale are regulated by government (e.g. alcohol, tobacco, prescription drugs).
In Canada, all legal drugs are regulated in some way by government, but they are sold in different ways, including:
- Government control – full or partial monopolies on sale of drugs (e.g. alcohol), and rules about places of use, advertising, etc.
- Prescription – drugs are medically prescribed (e.g. codeine, morphine).
People from all walks of life have used alcohol and other drugs throughout human history, for many reasons. Some cultures use drugs as part of their spiritual or religious practice. People use drugs out of curiosity, for pleasure, and to enhance social interactions. People are prescribed drugs for illness and injury, and some “self-medicate” to cope with stress or trauma.1
Most substance use does not harm the individual or anyone else. In a small percentage of cases, people can develop problematic use (experience negative consequences from their substance use) or become physically or psychologically dependent on drugs. The reasons people develop substance use issues are complex, and include genetic, biological and social factors, including experiences of trauma.
Dealing with a substance use issue can be challenging. It can be hard to find the right services, such as treatment, and there are often long waiting lists. People also face significant stigma, from family and friends, service providers they look to for help, and society at large. Our laws have made it illegal to use and possess certain drugs, and this criminalization has increased the stigma people face. People internalize this stigma, which affects their self-confidence and hope for the future. It also increases isolation and stops people from asking for help, including from much needed programs and services.
The criminalization of drug use in Canada is fairly recent. Laws prohibiting the use and possession of cannabis, heroin, cocaine and other drugs were passed in the early 1900s. These laws were often based on moral judgements and racist ideas about specific groups of people and the drugs they were using (e.g. Asian immigrants who consumed opium). Decisions about the legal status of drugs, including alcohol, were not based on scientific assessments of their potential for harm.
Consider alternatives to criminalization and incarceration for people who use drugs and focus criminal justice efforts to those involved in supply. We should increase the focus on public health, prevention, treatment and care as well as on economic, social and cultural strategies.
Ban Ki Moon, former UN Secretary-General
The “War on Drugs,” which began in the 1970s, has not reduced the supply or the demand for drugs. Despite the trillions of government dollars spent enforcing drug prohibition, the illegal drug market continues to grow and is estimated at between $426 and $652 billion (US) per year. And people continue to want to use drugs, whether they are legal or not. Alcohol was once illegal in Canada, but people still wanted to consume it. Some turned to the illegal alcohol market, sometimes with tragic results. The federal government soon realized that the health, social and criminal harms of alcohol prohibition far outweighed any benefits. It is for the same reasons that cannabis laws are changing in Canada, and why some want to see similar action for all drugs.
Parts of the illegal drug supply in Canada have become toxic. For example, high-dose opioids such as fentanyl are being added to heroin and other opioids and causing overdoses. In an unregulated market, anything can and does happen. Prevention, harm reduction and treatment services can help, but they can only do so much as long as the drug supply is toxic.
Research shows that laws that criminalize people simply for using and possessing drugs have created serious health and social harms.
Criminalizing people who use drugs has fueled a “global pandemic” of HIV and hepatitis C.
Global Commission on Drug Policy
Criminalizing people who use drugs has:
- Resulted in negative beliefs and stereotypes about people who use drugs from service providers, family members and society at large.[4,9] People who use illegal drugs are judged more harshly than people who use other drugs such as alcohol.
- Resulted in criminal records that make it hard for people to find a job and a place to live. [6,7]
- Made it difficult for people to access harm reduction services, increasing the risk of injury, disease, and other harms.
- Forced people into unsafe spaces and high-risk behaviours, which has led to increases in overdose and blood-borne infections like HIV, hepatitis and tuberculosis.[1,8,9]
- Increased rates of HIV infection and high-risk behaviours such as needle sharing and initiation into injection drug use at a younger age among people jailed for drug offences.
- Created an illegal drug market that produces stronger drugs for higher profits resulting in poisonings, overdoses and other harms.
- Cost Canadians $2 billion a year for police, courts, and prisons to enforce our drug laws.
Criminalization of people who use drugs harms some of the world’s most vulnerable citizens. This has to stop.
Stephen Lewis, former UN Special Envoy for HIV/AIDS in Africa
Some people who use drugs are more impacted by our drug laws than others, including:
- people who are homeless or otherwise living in poverty
- people with mental health and substance use issues
- people from racialized groups
- Indigenous peoples
- women, and
It is possible to have drug laws and policies that prevent, reduce and respond to the potential harms of drugs while also respecting human rights and promoting health and well-being. A public health approach would be based on principles and strategies that have been shown to support healthy individuals, families and communities.
A public health approach means…”ending the criminalization of drugs and drug consumers, prioritizing proven treatment and harm reduction strategies, and expanding (and removing barriers to) treatment and harm reduction services.
American Public Health Association
Examples of public health principles:
- commitment to social justice (i.e. equal access to wealth, opportunity and privilege)
- attention to human rights and equity
- evidence-informed policy and practice
- addressing basic needs (e.g. income, housing, education)
Examples of public health strategies:
- health promotion – helping people make informed choices about their substance use
- health protection – creating healthy environments such as smoke-free public spaces
- prevention – helping youth avoid or delay drug use until they are older
- harm reduction – helping reduce the harms of drug use such as through needle distribution
- treatment – providing treatment when issues arise.
What is decriminalization?
Decriminalization refers to the removal of criminal penalties for the personal use and possession of drugs. The production and sale of drugs is still against the law.
Are there different types of decriminalization?
Yes, there are different models of decriminalization used around the world applied to some or all drugs. Portugal and the Czech Republic, for example, have laws that allow the personal use and possession of all drugs (within specified amounts). In the Netherlands cannabis is still illegal but officials allow it to be consumed and sold in licensed “coffee shops.”
Some countries impose administrative penalties such as fines or mandatory treatment. For example, in Portugal, people found with drugs above permitted amounts twice in a six-month period are referred to a “dissuasion commission” of health/social workers who may issue a fine, refer them to treatment, or take no further action. In Uruguay, there are no penalties for the possession of “a reasonable quantity” of drugs for personal use, but there are criminal penalties for people who produce drugs. Administrative penalties must be reasonable and not create further health or social harms. For example, people should not be jailed for not paying a fine.
The International Drug Policy Consortium and the Global Commission on Drug Policy recommend a “best practice” model of decriminalization based on public health and human rights principles.[14,15] Under this model, there would be no penalties for the use or possession of drugs for personal use, although there could be restrictions on activities such as use in public spaces. In addition, there would be evidence-based health, harm reduction, treatment, and support services available for people who need them.
Over the past decade, my country, Portugal, has implemented innovative policies that are people-centered, focused on health and aimed at keeping people alive while respecting human rights.
Jorge Sampaio, former President of Portugal
Is decriminalization effective?
Countries that have decriminalized personal drug use and possession and also invested in public health interventions have seen results:
- In Portugal, there has been a reduction in drug use among certain vulnerable populations, and increases in the number of people accessing treatment. There have been significant decreases in HIV transmission (85%), and drug-related deaths.
- In Portugal, there was also an estimated 18% reduction in social costs (i.e. indirect health costs due to fewer deaths, and costs associated with criminal proceedings).
- In the Czech Republic, HIV rates are less than 1% among people who inject drugs, one of the lowest rates in the region.
- In California, there was $1 billion in savings to the criminal justice system in the 10 years after the possession of cannabis was decriminalized in 1976.
- Police in jurisdictions that have decriminalized drug possession effectively have reported improved community relations because of the reforms.
What would the regulation of all drugs look like?
Decriminalization can reduce some harms for people who use drugs, but people would still rely on an illegal market where the contents and strength of drugs are unknown. Parts of this unregulated drug supply in Canada have become toxic and have led to overdoses and death. It may be hard to imagine how drugs such as heroin and cocaine could be legalized in a safe way. Figuring out how best to do this would be complicated and take time. Currently, no country in the world has regulated all drugs. Most countries have regulated alcohol, tobacco and pharmaceutical drugs. Medical cannabis is approved for use in Canada and elsewhere.
Uruguay and some US states have regulated non-medical cannabis as will Canada this year.
In a regulated market decisions would need to be made about how drugs are produced, distributed and sold. It would depend on the drug and its potential for harm. For example, high-risk drugs could be available by prescription-only and distributed through pharmacies. Lower-risk drugs could be sold through government-controlled stores similar to how cannabis will be sold in Ontario. A public health approach to legal regulation would include a strong role for government to control and regulate the production (e.g. purity, strength), sale, marketing and consumption of any drug. It would also apply lessons about what has and has not worked for the regulation of drugs that are legal now, such as alcohol.
We need to regulate drugs because they are risky. Drugs are infinitely more dangerous when produced and sold by criminals who do not worry about safety measures. Legal regulation protects health. Consumers need to be aware of what they are taking and have clear information on health risks and how to minimize them.
Kofi Annan, former UN Secretary-General
Health and drug policy organizations are calling for a new approach to drugs ranging from decriminalization to legal regulation, including:
- Canadian Public Health Association
- Canadian Drug Policy Coalition
- Canadian Mental Health Association
- Canadian Society of Addiction Medicine
- Centre for Addiction and Mental Health
- Health Officers Council of British Columbia
- American Public Health Association
- Global Commission on Drug Policy
- World Health Organization
 Canadian Public Health Association (2014). A New Approach to Managing Illegal Psychoactive Substances in Canada.
 Boyd, S. et al. (2016) More Harm Than Good: Drug Policy in Canada.
 Global Financial Integrity (2017). Transnational Crime and the Developing World. Washington, DC.
 Neale, J., Kennedy, C. (2002). Good practice towards homeless drug users: research evidence from Scotland. Health and Social Care in the Community 10(3): 196-205.
 Room, R. et al (2001). Cross-Cultural Views on Stigma, Valuation, Parity, and Societal Values Towards Disability, as cited in: Ustun, B. et al, (Eds.). Disability and Culture: Universalism and Diversity. Seattle, US, Hogrefe and Huber: 247-291.
 Canadian Bar Association (2017). Collateral Consequences of Criminal Convictions: Considerations for Lawyers.
 DeVillaer, M. (2017). Cannabis Law Reform in Canada: Pretense & Perils. The Peter Boris Centre for Addictions Research. Hamilton Canada: McMaster University.
 Count the Costs (YEAR) The War on Drugs: Threatening Public Health, Spreading Death and Disease.
 Csete, J. et al (2016). The Lancet Commissions: Public health and international drug policy. The Lancet, 387 (10026): 1427-1480.
 Correctional Service of Canada (2004). A Profile of Visible Minority Offenders in the Federal Canadian Correctional System.
 Department of Justice (2008). Cost of Crime in Canada.
 Hughes, C., & Stevens, A. (2010). What can we learn from the Portuguese decriminalization of illicit drugs? British Journal of Criminology, 50, pp. 999–1022.
 Transform Drug Policy Foundation. After the War on Drugs: Blueprint for Regulation.
 International Drug Policy Consortium (2015). A Public Health Approach to Drug Use in Asia: Principles and practices for decriminalization.
 Global Commission on Drug Policy (2016) Advancing Drug Policy Reform: A New Approach to Decriminalization.
 Hughes, C., & Stevens, A. (2012). A resounding success of a disastrous failure: re-examining the interpretation of evidence on the Portuguese decriminalization of illicit drugs. Drug and Alcohol Review 31:108, as cited in: Global Commission on Drug Policy (2016) Advancing Drug Policy Reform: A New Approach to Decriminalization.
 Gonsalves, R. et al (2015). A social cost perspective in the wake of the Portuguese strategy for the fight against drugs. International Journal of Drug Policy, 26, 199-209.
 The National Monitoring Centre for Drugs and Addiction, Annual Report: The Czech Republic Drug Situation 2013, 2, as cited in: Global Commission on Drug Policy (2016) Advancing Drug Policy Reform: A New Approach to Decriminalization.
 Aldrich, M.R. & Mikuriya, T. (1988) Savings in California Marijuana Law Enforcement Costs Attributable to the Moscone Act of 1976: A Summary. Journal of Psychoactive Drugs 20 (1):75-81., as cited in: Global Commission on Drug Policy (2016) Advancing Drug Policy Reform: A New Approach to Decriminalization.
 Magson, J. (2014) Drugs, Crime and Decriminalization: Assessing the Impact of Drug Decriminalization Policies on the Efficiency and Integrity of the Criminal Justice System, Winston Churchill Fellowship, 27, as cited in: Global Commission on Drug Policy (2016) Advancing Drug Policy Reform: A New Approach to Decriminalization.
Toronto Public Health would like to thank the members of the Public Health Approach to Drug Policy Steering Committee for their assistance in developing this discussion paper.