Awareness and knowledge of drug decriminalization among people who use drugs in British Columbia: a multi-method pre-implementation study.

BACKGROUND: In January 2023, British Columbia implemented a three-year exemption to Controlled Drugs and Substances Act, as granted by the federal government of Canada, to decriminalize the personal possession of small amounts of certain illegal drugs. This decriminalization policy, the first in Canada, was announced in response to the overdose emergency in British Columbia as a public health intervention that could help curb overdose deaths by reducing the impact of criminalization and increasing access to health and social services through stigma reduction. METHODS: The current multi-method study examines people who use drugs' awareness and knowledge of British Columbia's decriminalization model through cross-sectional quantitative surveys and qualitative interviews among people who use drugs from September-November 2022, immediately prior to the implementation of decriminalization. RESULTS: Quantitative findings show that two-thirds (63%) of people who use drugs were aware of the policy, but substantial knowledge gaps existed about the legal protections afforded (threshold amount, substances included, drug trafficking, confiscation). The qualitative findings suggest that people who use drugs misunderstood the details of the provincial decriminalization model and often conflated it with regulation. Results suggest that information sharing about decriminalization were minimal pre-implementation, highlighting areas for knowledge dissemination about people who use drugs' rights under this policy. CONCLUSIONS: Given that decriminalization in British Columbia is a new and landmark reform, and that the success of decriminalization and its benefits may be undermined by poor awareness and knowledge of it, efforts to share information, increase understanding, and empower the community, may be required to promote its implementation and benefits for the community.

Navigating the nexus between British Columbia's public consumption and decriminalization policies of illegal drugs.

In January 2023, the province of British Columbia (BC) decriminalized the possession of certain illegal drugs for personal use. The province's primary intent was to reduce the stigma associated with drug use, as well as barriers for people who use drugs (PWUD) to access treatment and supports. However, less than ten months into the decriminalization policy, due to growing concerns about public safety voiced by municipal governments and communities, the provincial government made amendments to the policy to ban the public consumption of illicit drugs in additional locations, and subsequently introduced additional legislation, Bill 34, aimed at regulating public consumption of drugs in public spaces. Some communities have also implemented local bylaws similarly regulating public drug use. Bill 34 and local bylaws may serve as tools to promote community health and safety and minimize direct and indirect harms associated with public drug use. However, such legislation may re-criminalize PWUD and reinforce negative perceptions surrounding drug use, especially if these policies are not paired with strategies to expand the availability and accessibility of critical harm reduction and housing services. Without ample access to these services, limitations on public drug use can potentially displace individuals to areas where they are more likely to use alone, further exposing them to substance use-related harms, and undermining the goals of decriminalization. The potential effects of these restrictions may also disproportionately impact marginalized populations. As of April 2024, Bill 34 remains on hold. Moving forward, it will be important to monitor this bill, as well as other public consumption bylaws and legislation, and their impact on BC's overall decriminalization initiative. Decision-makers are urged to increase engagement with PWUD and relevant stakeholders in the design and implementation of policies pertaining to public consumption to ensure that they effectively address the evolving needs and realities of PWUD, and align with decriminalization goals.

Beliefs and Attitudes about Vermont's Buprenorphine Decriminalization Law among Clinicians Who Prescribe Buprenorphine.

BACKGROUND: On June 1, 2021, Vermont repealed all criminal penalties for possessing 224 milligrams or less of buprenorphine. We examined the potential impact of decriminalization with a survey of Vermont clinicians who prescribed buprenorphine within the past year. METHODS: All 638 Vermont clinicians with a waiver to prescribe buprenorphine were emailed the survey by Vermont Department of Health; 117 responded. We estimated the prevalence of the following four outcomes, for all responding clinicians and stratified by clinician demographics and practice characteristics: awareness of decriminalization, beliefs about the effects of decriminalization, support for decriminalization, and changes in practice resulting from decriminalization. RESULTS: 72 (62%) prescribers correctly stated that Vermont does not have criminal penalties for buprenorphine possession. 107 (91%) support decriminalization. 56 (48%) believe that, because buprenorphine is decriminalized, their patients are more likely to give, sell, or trade the buprenorphine that is prescribed to them to someone else. However, only 5 providers (4%) said they now prescribe to fewer patients. CONCLUSION: The great majority of Vermont clinicians who prescribe buprenorphine support its decriminalization and have not changed their prescribing practices because of decriminalization.

In 2021, Vermont repealed criminal penalties for buprenorphine possession.We surveyed Vermont (n = 117) buprenorphine prescribers about decriminalization.91% of providers support decriminalization.48% of providers believe decriminalization will increase diversion of medications.Only 4% of providers prescribe to fewer patients because of decriminalization.

Drug decriminalization: The importance of policy change for the health and wellbeing of children and youth in Canada.

The criminalization of drug use and possession has demonstrable harms on the health of children and youth, with disproportionate effects on Black people, Indigenous people, people from other racially oppressed communities, and people living in poverty. Drug decriminalization, by separating personal possession and use of drugs from the criminal justice system, allows for a health-based approach to drug policy. Paediatricians are well-positioned to advocate for policies within a decriminalization framework to prioritize the physical and mental health of children and youth.

The impact of syringe decriminalization within the Pennsylvania harm reduction community.

INTRODUCTION: Syringe decriminalization is a harm reduction approach to decrease deaths and disease related to drug use. The purpose of this study was to develop an understanding of the impact of syringe decriminalization on the harm reduction community in Pennsylvania. METHODS: Semi-structured interviews were conducted with ten participants identified as harm reduction experts. ANALYSIS: Narrative content analysis to the point of thematic saturation was used to generate themes around harm reduction and syringe decriminalization in Pennsylvania, specifically the meaning of harm reduction, the importance of harm reduction, and the opinions on syringe decriminalization. RESULTS: The following themes reflect the meaning of harm reduction: human compassion; meeting people where they are at; minimizing the risk; and shifting power to the person. The themes of being personally impacted, human compassion, innate imperfection, and respecting human autonomy reflect why participants care about harm reduction. All ten participants support syringe decriminalization in Pennsylvania citing the following rationales: improved health outcomes; decreased costs to society; less involvement of the criminal justice system; and increased engagement into treatment. CONCLUSIONS: Harm reduction is a pioneering approach to drug use that empowers individuals to make positive impacts in their lives. Harm reduction experts in Pennsylvania support syringe decriminalization as a cost-effective way to increase the engagement and improve health outcomes of people who use drugs.

Decriminalisation and smart regulation of psychoactive substances: a modern alternative to prohibition.

Prohibition has been the globally dominant concept for the regulation and control of psychoactive substances for nearly 70 years. Its effectiveness and legitimacy as a sustainable solution to the problems associated with the existence of psychoactive substances in society has been repeatedly questioned. It is based on the normative assumption that the use of psychoactive substances for other than therapeutic purposes is not allowed, and non-medical supply should be severely punished. This precludes the use of the full range of regulatory, public health, prevention, and harm reduction strategies, reduces well-being, and increases harms for the human-rights, health, and social cohesion. It is time to replace the prohibitionist paradigm with modern regulation that considers the different harms and risks of psychoactive substances, but also the benefits of psychoactive substances for mental health and well-being, lifestyle, and socialisation. This new paradigm (the so-called 'smart regulation') should accept non-medical use of psychoactive substances, apply criminal law as an exceptional tool to regulate human behaviour, regulate the availability of substances according to their harmfulness, regulate the risk profile of the product, strictly regulate marketing and advertising, protect minors and 'others' from the use and supply of psychoactive substances, protect the legal market from the supply of substances from the illegal market, and use economic instruments to regulate demand and to subsidise prevention and treatment.

Racial resentment and support for decriminalization of drug possession in the United States.

Drug criminalization creates significant barriers to prevention and treatment of substance use disorders and racial equity objectives, and removal of criminal penalties for drug possession is increasingly being endorsed by health and justice advocates. We present empirical data estimating the share of U.S. adults who support eliminating criminal penalties for possession of all illicit drugs, and examine factors associated with public support. Data from the Johns Hopkins COVID-19 Civic Life and Public Health Survey, a probability-based nationally representative sample of 1222 U.S. adults, was collected from November 11-30, 2020. Support for decriminalizing drug possession was assessed overall and by sociodemographic factors and attitudes towards politics and race. Correlates of support were examined using multivariable logistic regression. Thirty-five percent of adults supported eliminating criminal penalties for drug possession in the U.S. In adjusted regression models, respondents who were younger or identified as politically liberal were more likely to support decriminalization relative to other groups, and respondents who were Hispanic or identified strongly with their religious beliefs were less likely to support decriminalization. Among white respondents, greater racial resentment was strongly associated with reduced support for drug decriminalization. Support for drug decriminalization varies considerably by beliefs about politics and race, with racial resentment among white Americans potentially comprising a barrier to drug policy reform. Findings can inform communication and advocacy efforts to promote drug policy reform in the United States.

Cloudy with a chance of munchies: Assessing the impact of recreational marijuana legalization on obesity.

Obesity in the US arguably constitutes the most significant health epidemic over the past century. Recent legislative changes allowing for recreational marijuana use further create a need to better understand the relationship between marijuana use and health choices, leading to obesity. We examine this relationship by using a synthetic control approach to examine the impact of legalized recreational marijuana access on obesity rates by comparing Washington State to a synthetically constructed counterfactual. We find that recreational marijuana's introduction did not lead to increased obesity rates and may have led to decreases in obesity.

Decriminalizing suicide attempt in the 21st century: an examination of suicide rates in countries that penalize suicide, a critical review.

BACKGROUND: Decriminalizing suicide may decrease overall suicide rates because then individuals who are at risk of suicide would be more willing to seek help from the community and from mental health professionals, therefore enabling early interventions for preventing suicidality. We aimed to examine the suicide trends over the last 20 years in 20 countries that still criminalize attempted suicide, and to compare the suicide rates of these 20 countries against the global average suicide rate and to a comparison sample of 20 countries that do not criminalize suicide, matched according to region and majority religion. METHODS: Age-standardized suicide rates were extracted from the WHO Global Health Estimates, available for the period 2000-2019. Population data were extracted from the World Bank. We analyzed only countries which criminalize attempted suicide under its criminal justice system. Countries were further categorized according to their membership in the Commonwealth of Nations and countries in Africa. Countries from the same region and with the same majority religion were chosen as a matching group. Joinpoint analysis was used to compare the trends of the two groups with the global average. RESULTS: Based on the 2019 WHO Global Health Estimates data, there is a large range in the suicide rates of the countries that criminalize attempted suicide, from 2.5 (Brunei) to 40.9 (Guyana) per 100,000 population. The mean suicide rate was 8.3 (Standard Deviation = 10.6). Out of the 20 countries, seven have suicide rates higher than the global average, covering a total population of about 387.3 million. Of these seven countries, five are in the African region. The other thirteen countries have suicide rates between 2.5 to 8.2. Mean scores of the countries which criminalized attempted suicide was lower than the global average and 20 comparison countries over the 20 years, but average annual percentage in the decrease of suicide was greater for countries in which attempted suicide was not criminalized. CONCLUSIONS: Based on our review, there was no substantial evidence here to indicate that countries which criminalized attempted suicide had consistently lower suicide rates compared to the global average. There is a need to acknowledge that the currently available evidence is inadequate to definitively claim that criminalizing suicide is beneficial or harmful for the reduction of suicide rate for the entire populations. Future studies should continue to evaluate the unique effects of decriminalizing attempted suicide while controlling for other key associated factors.

Should commercial sex workers have unrestricted healthcare access across the world?

We argue commercial sex workers have rights to healthcare and psychosocial support. While decriminalization is not legally enacted in most countries, we would suggest these workers rights include freedom from harassment and opportunities to lead healthy lives. The need for healthcare access for all is heightened in the COVID-19 pandemic where some people flout rules on lockdown by engaging with commercial sex workers and may unwittingly spread SARS-CoV-2 in so doing. Unrestricted healthcare access without stigma for commercial sex workers protects them, and has a beneficial societal effect on those who engage with them and on their contacts.

Cannabis Legalization and College Mental Health.

PURPOSE OF REVIEW: To assess how the changing landscape of marijuana use affects the developing brain and mental health of college students. RECENT FINDINGS: Legalization of cannabis may facilitate use in the college population, with 38% of college students, whose brains are still maturing, regularly using marijuana products. Earlier and increased use, higher potency, pre-existing issues, and genetic predispositions increase negative outcomes by precipitating or worsening mental illness and ultimately impacting academic success. In the USA, the sharpest increase in cannabis users following legalization has been in the college age population (18-25 years of age). This population is especially vulnerable to the negative impacts and risks associated with cannabis use, including risk for the onset of major psychiatric illness. College mental health practitioners should remain informed about health effects of cannabis use, assess patient use on a regular basis, provide education and be familiar with interventions to reduce harm.

The drug war must end: The right to life, liberty and security of the person during the COVID-19 pandemic for people who use drugs.

Since the start of the opioid epidemic in 2016, the Downtown Eastside community of Vancouver, Canada, has lost many pioneering leaders, activists and visionaries to the war on drugs. The Vancouver Area Network of Drug Users (VANDU), the Western Aboriginal Harm Reduction Society (WAHRS), and the British Columbia Association People on Opiate Maintenance (BCAPOM) are truly concerned about the increasing overdose deaths that have continued since 2016 and have been exacerbated by the novel coronavirus (SARS-COVID-19) despite many unique and timely harm reduction announcements by the British Columbia (B.C.) government. Some of these unique interventions in B.C., although in many cases only mere announcements with limited scope, are based on the philosophy of safe supply to illegal street drugs. Despite all the efforts during the pandemic, overdose deaths have spiked by over 100% compared to the previous year. Therefore, we urge the Canadian federal government, specifically the Honorable Patty Hajdu, the federal Minister of Health, to decriminalize simple possession immediately by granting exemption under the Controlled Drugs and Substances Act. The Canadian federal government has a moral obligation under Sect. 7 of the Canadian Charter of Rights and Freedoms to protect the basic human rights of marginalized Canadians.

Decriminalization in action: lessons from the Los Angeles model.

Los Angeles County's Office of Diversion and Reentry (ODR) has removed over 3800 people from the largest jail system in the country. Across various diversion programs, ODR's fundamental goal is to provide permanent, lifetime care for each diverted person. This article describes ODR's various diversion programs, and elucidates the types of elaborate clinical and court-related interventions that are necessary to remove persons with serious mental disorders from jail custody. As Los Angeles continues to build the necessary community-based continuum of mental health care, ODR's model proves that thoughtfully removing persons with serious mental disorders from jail is possible and necessary for the health of both patients and community.

Decriminalizing severe mental illness by reducing risk of contact with the criminal justice system, including for forensic patients.

Risk of contact with the criminal justice system (CJS) is greater among those with mental illness, including severe mental illness-an observation that many argue reflects a process of "criminalizing" mental illness. Forensic patients represent a subgroup at one end of a spectrum of such criminalization, typically with histories of serious violence and psychotic illness. Strategies for decriminalizing mental illness in this context should consider a range of approaches, including intervening to prevent CJS contact in those with severe mental illness, particularly in the early or emerging stages of psychosis. However, it may be that even gold standard mental healthcare applied universally is insufficient to address CJS contact risks. While there is now an extensive literature documenting the relatively low rates of repeat CJS contact for forensic patients released from secure care, appropriate comparison groups are lacking and the key ingredients of any benefits of treatment are unknown. The CJS may well have something to learn from forensic mental health systems and services given the abject failure to stem rates of prison-release reoffending internationally. Understanding how to best identify risk and effectively intervene to prevent CJS contact in those with mental illness, whether early in the course of psychosis or following release from secure care, remains a priority for those seeking to address the criminalization of mentally illness in our communities.

Dopamine antagonist antipsychotics in diverted forensic populations.

In community settings, negative symptoms and cognitive deficits are the primary barriers to independent living, stable relationships, and employment for individuals suffering from schizophrenia-spectrum disorders. In contrast, however, positive psychotic symptoms (e.g., command hallucinations and persecutory delusions) often drive behavior which serves as the gateway to arrest and criminalization. Historically, the keystone of treatment for positive psychotic symptoms has been antagonism of dopamine D2 receptors in the mesolimbic tract. In this article, we review and explore the principles underlying dopamine antagonism for the treatment of psychosis; optimization of dopamine antagonists in treating positive psychotic symptoms; the advantages of depot dopamine antagonist antipsychotics in forensic settings; the concepts of pharmacokinetic and pharmacodynamic treatment failures; and the role of medication plasma concentrations in optimizing and managing treatment.

Conscientious objection to abortion: why it should be a specified legal right for doctors in South Korea.

BACKGROUND: In 2019, the Constitutional Court of South Korea ruled that the anti-abortion provisions in the Criminal Act, which criminalize abortion, do not conform to the Constitution. This decision will lead to a total reversal of doctors' legal duty from the obligation to refuse abortion services to their requirement to provide them, given the Medical Service Act that states that a doctor may not refuse a request for treatment or assistance in childbirth. I argue, confined to abortion services in Korea that will take place in the near future, that doctors should be granted the legal right to exercise conscientious objection to abortion. MAIN TEXT: Considering that doctors in Korea have been ethically and legally obligated to refrain from abortions for many years, imposing a universal legal duty to provide abortions that does not allow exception may endanger the moral integrity of individual doctors who chose a career when abortion was illegal. The universal imposition of such a duty may result in repudiation of doctors as moral agents and damage trust in doctors that forms the basis of medical professionalism. Even if conscientious objection to abortion is granted as a legal right, most patients would experience no impediment to receiving abortion services because the healthcare environment of Korea provides options in which patients can choose their doctors based on prior information, there are many doctors who would be willing to provide an abortion, and Korea is a relatively small country. Finally, the responsibility to effectively balance and guarantee the respective rights of the two agents involved in abortion, the doctor and the patient, should be imposed on the government rather than individual doctors. This assertion is based on the government's past behaviours, the nature of its relationship with doctors, and the capacity it has to satisfy both doctors' right to conscientious objection and patients' right to legal medical services. CONCLUSION: With regard to abortion services that will be sought in the near future, doctors should be granted the legal right to exercise conscientious objection based on the importance of doctor's moral integrity, lack of impediment to patients, and government responsibility.

Cannabis Use as Determined by Biologic Testing in Maternal and Newborn Urines during a Period of Drug Liberalization.

Introduction: Cannabis use is common in pregnancy and prevalence of reported past month use have been increasing despite recommendations of abstinence. Our study aimed to evaluate the prevalence of cannabis use in pregnancy using urine drug screens obtained at the time of admission to Labor and Delivery. Methods: De-identified laboratory data from three birthing hospitals located in Maryland were used to determine the percentage of cannabis positive urine toxicology tests among women admitted to Labor and Delivery. Data were collected at each site starting the year that universal urine cannabis testing was instituted. One hospital also performed universal testing of newborns which was contrasted with maternal data there. Results: Overall, 5.7% of the 22,435 maternal and 3.4% of the 8,346 newborn urine toxicology tests and were positive for cannabis. Trends varied between institutions. When all three institutions were combined, the percent of positive urine toxicology tests was unchanged between 2016 and 2018. At Site 1 between 2014 and 2018, the percentage of cannabis positive urine toxicology tests increased from 5.7% to 9.9% and newborn tests increased from 1.7% to 3.4%. Only 27.7% of the neonates born to women with positive screens also had a positive screen at the time of birth. Conclusions: Prevalence of cannabis use until the time of delivery vary by location but were largely unchanged over a period of drug liberalization.

Experience obtaining legal abortion in Uruguay: knowledge, attitudes, and stigma among abortion clients.

BACKGROUND: The abortion law in Uruguay changed in 2012 to allow first trimester abortion on request. Implementation of the law in Uruguay has been lauded, but barriers to care, including abortion stigma, remain. This study aimed to assess women's experiences seeking abortion services and related attitudes and knowledge following implementation of the law in Uruguay. METHODS: We interviewed 207 eligible women seeking abortion services at a high-volume public hospital in Montevideo in 2014. We generated univariate frequencies to describe women's experiences in care. We conducted regression analysis to examine variations in experiences of stigma by women's age and number of abortions. RESULTS: Most of the women felt that abortion was a right, were satisfied with the services they received, and agreed with the abortion law. However, 70% found the five-day waiting period unnecessary. Women experienced greater self-judgement than worries about being judged by others. Younger women in the sample (ages 18-21) reported being more worried about judgment than women 22 years or older (1.02 vs. 0.71 on the ILAS sub-scale). One quarter of participants reported feeling judged while obtaining services. Women with more than one abortion had nearly three times the odds of reporting feeling judged. CONCLUSIONS: These findings highlight the need to address abortion stigma even after the law is changed. Some considerations from Uruguay that may be relevant to other jurisdictions reforming abortion laws include: the need for strategies to reduce judgmental behavior from staff and clinicians towards women seeking abortions, including training in counseling skills and empathic communication; addressing stigmatizing attitudes about abortion through community outreach or communications campaigns; mitigating the potential stigma that may be perpetuated through policies to prevent "repeat" abortions; ensuring that younger women and those with more than one abortion feel welcome and are not mistreated during care; and assessing the necessity of a waiting period. The rapid implementation of legal, voluntary abortion services in Uruguay can serve in many ways as an exemplar, and these findings may inform the process of abortion law reform in other countries.

"It's something that marks you": Abortion stigma after decriminalization in Uruguay.

BACKGROUND: Abortion stigma is experienced by women seeking abortion services and by abortion providers in a range of legal contexts, including Uruguay, where abortion was decriminalized up to 12 weeks gestation in 2012. This paper analyzes opinions and attitudes of both abortion clients and health professionals approximately two years following decriminalization and assesses how abortion stigma manifests among these individuals and in institutions that provide care. METHODS: In 2014, we conducted twenty in-depth, semi-structured interviews with abortion clients (n = 10) and health care professionals (n = 10) in public and private facilities across Uruguay's health system. Interviews were recorded, transcribed, and then coded for thematic analysis. RESULTS: We find that both clients and health professionals express widespread satisfaction with the implementation of the new law. However, there exist critical points in the service where stigmatizing ideas and attitudes continue to be reproduced, such as the required five-day waiting period and in interactions with hospital staff who do not support access to the service. We also document the prevalence of stigmatizing ideas around abortion that continue to circulate outside the clinical setting. CONCLUSION: Despite the benefits of decriminalization, abortion clients and health professionals still experience abortion stigma.

A Burning Problem: Cannabis Lessons Learned from Colorado.

With recent increases in cannabis' popularity, including being legalized in several states, new issues have emerged related to use. Increases in the number of users, new products, and home growing all present distinct concerns. In the present review, we explored various cannabis-related concerns (i.e. use, acquiring, growing, and public health/policy) that have arisen in Colorado in order to provide information on emerging issues and future directions to mitigate negative outcomes that could occur in states considering, or that already have implemented, a legalized cannabis market. Specific to Colorado, issues have arisen related to edibles, vaporizers/'e-cannabis', concentrates, growing, quantifying use, intoxicated driving, and arrests. Understanding cannabis dosing (including dose-dependent effects and related consequences), standardizing quantities, evaluating the safety of new products, and developing harm reduction interventions are important next steps for informing public policy and promoting health and well-being. Overall, increasing our knowledge of emerging issues related to cannabis is key to promoting the benefits and combating the potential harms of cannabis, especially for states legalizing medical or recreational cannabis.