"What I should be doing is harm reduction, if I'm doing my job right": Engagement with harm reduction principles among prosecutors enacting drug policy reform in the United States.

BACKGROUND: Prosecutorial discretion to pursue or decline criminal charges is a powerful mechanism determining criminal justice outcomes among people who use drugs (PWUD). In the US, prosecutors are increasingly employing this tool to prevent arrest, incarceration, and subsequent health and social harms among PWUD. Many cite harm reduction as a basis for these reforms; however, the extent of prosecutors' knowledge and understanding of harm reduction principles, and how they are operationalized in the policy process, remains unclear. METHODS: We assess references to and application of harm reduction in the policy design and implementation process of prosecutorial drug policy reform in 14 US jurisdictions. In-depth-interviews (N = 16) were conducted with elected prosecutors and their policy staff from November 2021-April 2022. Through initial structured analysis, policymakers' understanding and utilization of the term 'harm reduction' emerged as a salient theme which we conducted secondary thematic analysis to further explore. RESULTS: While all participants identified as progressive, there was wide variation in their ideologies, policy provisions, and engagement with harm reduction principles. Eleven participants explicitly referred to 'reducing harms of drug use' or 'harm reduction' as guiding their policy approach; the remainder did not invoke 'harm reduction' by name but highlighted relevant concepts like racial equity and 'public health approaches' as core policy tenets. While some prosecutors demonstrated familiarity with traditional harm reduction principles (meeting PWUD where they are, reducing harms to them), others focused on harm to the wider community (the 'public,' businesses, etc). Invocation of harm reduction was not always consistent with specific policy provisions: prosecutors implemented policies ranging from unconditional non-prosecution of drug possession to diversion, some of which were odds with core harm reduction principles of dignity and justice (i.e., involving coercive treatment incentives/requirements). CONCLUSIONS: As prosecutors shift their approach to redress the harms caused by drug criminalization, clarity is needed on what a harm reduction approach to using discretionary powers entails. Targeting reform-minded prosecutors with messaging on the principles, evidence base, and best practices of harm reduction is merited.

Decriminalization or police mission creep? Critical appraisal of law enforcement involvement in British Columbia, Canada's decriminalization framework.

The unregulated drug toxicity crisis in British Columbia (BC), Canada, has claimed over 14,000 lives since 2016. The crisis is shaped by prohibitionist policies that has led to the contamination of the unregulated drug supply, resulting in a surge of fatal and non-fatal overdose events. The criminalization of drug users exacerbates this situation, pushing individuals into carceral systems for the possession of and/or social practices related to drug use. This commentary examines the involvement of policing in the development, and throughout the first 15 months of its implementation, of BC's decriminalization framework. We highlight concerns regarding police discretion, the expansion of scope, and the interweaving of carceral logics into policies that purport to be public health-oriented.

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.

Emerging models of de facto drug policy reforms in the United States.

BACKGROUND: Health and human rights organizations have endorsed drug decriminalization to promote public health-oriented approaches to substance use. In the US, policymakers have begun to pursue this via prosecutorial discretion-or the decision by a prosecutor to decline criminal charges for drug possession in their jurisdiction. This study characterizes drivers of adoption, policy design and implementation processes, and barriers to impact and sustainability of this approach to inform evolving policy efforts promoting the health of people who use drugs (PWUD). METHODS: We conducted n=22 key informant interviews with policymakers and national policy experts representing 13 jurisdictions implementing de facto drug policy reforms. Analyses were informed by the Exploration, Preparation, Implementation and Sustainment (EPIS) framework and analyzed using a hybrid inductive-deductive approach. RESULTS: Drivers of policy adoption included racial inequities, perceived failures of criminalization, and desires to prioritize violent crime given resource constraints. Three distinct policy typologies are described with varying conditions for eligibility, linkage to services, and policy transparency and dissemination. Public misinformation, police resistance and political opposition were seen as threats to sustainability. CONCLUSIONS: Given evidence that criminalization amplifies drug-related harms, many policymakers are adopting de facto drug policy reforms in the absence of formal legislation. This is the first study to systematically describe relevant implementation processes and emerging policy models. Findings have implications for designing rigorous evaluations on health outcomes and informing sustainable evidence-based policies to promote health and racial equity of PWUD in the US.

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.

'It has gotten a lot better, but it is still bad': Experiences with the police among marginalized PWUDs in a context of depenalization.

Based on a survey (n = 249) and qualitative interviews (n = 38) with marginalized people who use drugs (PWUDs) in Copenhagen, Denmark, we investigate the experiences of this group with the police in a context where drug possession had been depenalized in and around drug consumption rooms (DCRs). Our findings point to positive experiences with the police, especially with the local community police in the depenalization zone, who refrained from drug law enforcement and practiced 'harm reduction policing.' However, marginalized PWUDs also reported that they were still targeted for drug possession by other sections of the police despite the depenalization policy. Specifically, the drug squad of the police would continue to confiscate illicit drugs for investigatory purposes to counter organized drug crime, as well as continue to target user-dealers who were not formally included in the depenalization policy. The findings illustrate how marginalized PWUDs still found themselves in a precarious legal situation without any legal rights to possess the drugs that they were dependent on, even though possession of drugs had been depenalized in and around DCRs.

People who use drugs' prioritization of regulation amid decriminalization reforms in British Columbia, Canada: A qualitative study.

BACKGROUND: North America and the province of British Columbia (BC), Canada, is experiencing an unprecedented number of overdose deaths. In BC, overdose has become the leading cause of death for people between the ages of 10-59 years old. In January 2023, BC decriminalized personal possession of a number of illegal substances with one aim being to address overdose deaths through stigma reduction and promoting access to substance use services. METHODS: We conducted a qualitative study to understand people who use drugs' (PWUD) perceptions of the new decriminalization policy, immediately prior to its' implementation (October-December 2022). To contextualize decriminalization within broader drug policy, we also asked PWUD what they perceived as the priority issues drug policy ought to address and the necessary solutions. Our final sample included 38 participants who used illegal drugs in the past month. RESULTS: We identified four themes: 1) The illicit drug supply as the main driver of drug toxicity deaths 2) Concerns about the impact of decriminalization on drug toxicity deaths 3) Views towards decriminalization as a policy response in the context of the drug toxicity crisis 4) Regulation as a symbol of hope for reducing drug toxicity deaths. CONCLUSION: From our data it became clear that many anticipated that decriminalization would have minimal or no impact on the overdose crisis. Regulation was perceived as the necessary policy approach for effectively and candidly addressing the drivers of the ongoing overdose crisis. These findings are important as jurisdictions consider different approaches to moving away from prohibition-based drug policy.

Public opinion on the expenditure of adult-use cannabis tax revenue: Evidence from New Jersey.

OBJECTIVES: To describe New Jersey residents' relative priorities for the allocation of tax revenue generated by recreational cannabis sales. We aim to assess preferences for public health initiatives, including drug treatment, compared to a range of alternatives, including traditional policing, especially within the social and demographic groupings of people generally most impacted by punitive drug enforcement policies. METHODS: We collected population-representative survey data four months post-implementation of recreational cannabis sales in New Jersey (N = 1,006). We gauge respondents' top preferences for the allocation of new revenue generated by the legal cannabis market. Using multinomial logistic regression, we assess how various demographic and political factors shape public support for devoting revenue toward public health initiatives. RESULTS: While priorities are mixed within the sample, we find more general support for funding community-based initiatives in public health, housing, and education than for funding police, courts, and prisons. Among Black residents, the largest proportion chose investments in affordable housing. Regression analysis reveals political orientation as having the most consistent association with expressed preferences, with Republicans favoring investments in traditional law enforcement priorities over other potential funding domains. CONCLUSIONS: Recreational cannabis legalization is occurring at a rapid pace, yet important context, including how the tax revenue could be invested in communities, remains unclear. Insight into current public opinion on funding priorities suggests a desire for investment in fundamental societal institutions, including education and public health, rather than the punitive enforcement mechanisms that have defined cannabis policy for many decades.

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.

Decriminalization of abortion by the Mexican Supreme Court.

In September 2021, the Mexican Supreme Court issued a decision disallowing any federal or local judicial authority to indict someone for the offense of voluntary or consensual abortion. This decision also declared unconstitutional penalties imposed on medical personnel who facilitate or assist such procedures. Furthermore, the Court decided that limiting access to abortion in cases of rape to a specific time frame was disproportionate. Later on, in September 2023, the Supreme Court confirmed that absolute criminalization of abortion was unconstitutional and declared that the rule supporting criminalization in the Federal Penal Code was without effects. Consequently, healthcare providers who work in public federal health institutions cannot be criminalized for guaranteeing the right to abortion. This article reviews the reasons advanced by the Supreme Court to guarantee the right of reproductive self-determination, as well as the effects of both decisions beyond the decriminalization of abortion by Mexican federal and state legislatures. The paper also examines the scope and limitations of these rulings and identifies the remaining challenges regarding voluntary abortion procedures in Mexico.

Domestication of the Maputo Protocol in the Democratic Republic of Congo: Leveraging regional human rights commitments for abortion decriminalization and access.

The Maputo Protocol, adopted over 20 years ago, is a promising regional treaty for advancing gender equity and sexual and reproductive health and rights. This instrument has driven progress in women's health and rights across Africa, with much remaining to achieve to realize its full potential for women and girls, including access to safe abortion. The present paper shares the strategies and lessons from the Democratic Republic of Congo's (DRC) reform centered on the domestication of the Protocol, specifically applying its commitments on abortion decriminalization and access. With a vision of addressing maternal mortality and rectifying the impacts of widespread sexual violence against women during war, abortion as a human right and health imperative was at the heart of the DRC's reform. Governmental commitment, broad coalition building, evidence generation, and an intersectional advocacy agenda were critical to overcoming opposition, stigma, and other challenges. This paper shares key learnings from the DRC's complex yet collaborative reform strategies and its processes. The strategy prioritized domestication of the Protocol for numerous reforms, including paving the path to legal abortion on the broad grounds of rape or incest, and saving women's health and/or life. With a commitment to maximizing quality, access, task sharing, and equity, progressive national comprehensive abortion guidelines were created alongside an implementation roadmap for accountability. The DRC's experience leveraging the Maputo Protocol's obligations to advance abortion rights and access offers valuable insights for consideration globally.

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.

Modeling as Visioning: Exploring the Impact of Criminal Justice Reform on Health of Populations with Substance Use Disorders.

In the context of historic reckoning with the role of the criminal-legal system as a structural driver of health harms, there is mounting evidence that punitive drug policies have failed to prevent problematic drug use while fueling societal harms. In this explainer article, we discuss how simulation modeling provides a methodological framework to explore the potential outcomes (beneficial and harmful) of various drug policy alternatives, from incremental to radical. We discuss potential simulation modeling opportunities while calling for a more active role of simulation modeling in visioning and operationalizing transformative change. Highlights: This article discusses opportunities for simulation modeling in projecting health and economic impacts (beneficial and harmful) of drug-related criminal justice reforms.We call on modelers to explore radical interventions to reduce drug-related harm and model grand alternative futures in addition to more probable scenarios, with a goal of opening up policy discourse to these options.

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.

Changes in arrests following decriminalization of low-level drug possession in Oregon and Washington.

BACKGROUND: Despite evidence that the U.S. "War on Drugs" is associated with increases in drug-related harm and other negative outcomes, all U.S. states have long criminalized most drug possession. In early 2021, both Oregon and Washington became exceptions to this rule when they fully (Oregon) or partially (Washington) decriminalized possession of small amounts of all drugs. METHODS: We obtained arrest data for 2019 to 2021 for intervention states (Oregon and Washington) and control states (Colorado, Idaho, Montana, and Nevada). We calculated monthly rates for arrests overall and for violent crimes, drug possession, equipment possession, non-drug crimes, and a set of low-level crimes termed displaced arrests. Using an interrupted time series analysis, we examined changes in monthly arrest rates after the implementation of policy change in Oregon and Washington compared to control states. RESULTS: In Oregon, there were 3 fewer drug possession arrests per 100,000 in the month after the policy change; the rate decreased throughout the post-implementation period. In Washington, there were almost 5 fewer drug possession arrests per 100,000 in the month following policy change, and the rate remained stable thereafter. Both declines were significantly greater than in comparison states. There were also statistically significant reductions in arrests for possession of drug equipment in Washington and a significant increase in displaced arrests in Oregon. There were no significant changes in overall arrests, non-drug arrests or arrests for violent crime in either state, relative to controls. CONCLUSION: This analysis demonstrates that it is possible for state drug decriminalization policies to dramatically reduce arrests for drug possession without increasing arrests for violent crimes, potentially reducing harm to people who use drugs and their communities. Additional research is needed to determine whether these legal reforms were associated with changes in overdose rates and other drug-related harms.

Does drug decriminalization increase unintentional drug overdose deaths?: Early evidence from Oregon Measure 110.

This paper evaluates the causal effect of drug decriminalization on unintentional drug overdose deaths in a context with relatively poor access to drug treatment services. Using the synthetic control method, I find that when Oregon decriminalized small amounts of drugs in February 2021, it caused 182 additional unintentional drug overdose deaths to occur in Oregon in 2021. This represents a 23% increase over the number of unintentional drug overdose deaths predicted if Oregon had not decriminalized drugs.

Decriminalization thresholds for drug possession: A multi-criteria policy analysis framework.

BACKGROUND: Decriminalization of personal possession of drugs has been proposed as an approach to mitigate the harms of drug prohibition. Despite growing interest, particularly in Canadian settings, analyses of approaches to defining the parameters of what constitutes personal possession within decriminalization models are lacking. Using the Province of British Columbia, Canada, as a case study, we undertook an evidence-based multi-criteria policy analysis of three models for defining personal possession: 1) a model that defines personal possession as the absence of evidence of drug trafficking; 2) a cumulative threshold of 15 grams; and 3) a cumulative threshold of 2.5 grams. METHODS: We utilized data from four sources: qualitative interviews with 16 experts, including representatives from government and law enforcement; Vancouver Police drug seizure data; self-reported drug consumption data from longitudinal cohorts of people who use drugs in Vancouver; and publicly available government documents (e.g., the Government of BC's submission for decriminalization). Data was used to identify and define evaluation criteria which reflect the stated policy objectives of decriminalization alongside other policy considerations. This framework was used to conduct a multi-criteria policy analysis of the three different models. RESULTS: The seven evaluation criteria included: 1) reduction in interactions with police; 2) reduction of police drug seizures; 3) coverage for those with high consumption; 4) impact on equity-deserving groups; and acceptance on the part key stakeholders, including: 5) people who use drugs; 6) law enforcement; and 7) the public. The model that performed the best was the cumulative threshold model of 15 grams. CONCLUSION: Findings highlight that different threshold models advance and constrain the stated policy objectives of drug decriminalization to varying degrees. This analysis provides a framework that other jurisdictions considering decriminalization could use to help inform determinations of threshold levels based on stated policy objectives.

'Drug decriminalization' in Canada: a plea for a nuanced, evidence-informed, and realistic approach towards improved health outcomes.

Canada has been home to an exceptional public health crisis of illicit (mainly synthetic opioid but increasingly other) drug deaths for numerous years. Despite extensive health-oriented interventions, this crisis remains acute and devastating. Earlier this year, the federal and British Columbia governments implemented the 'drug decriminalization initiative' (DDI) which exempts drug users from criminal enforcement of small amounts of personal drug possession; this has been promoted as a 'solution' for the drug-death crisis. This commentary examines and discusses that while decriminalization of drug use is fundamentally required to align drug policy with principles of health, evidence-based consideration of the drug death crisis' essential dynamics as well as enforcement realities substantially curtail the DDI's plausible prospects to significantly reduce the drug-fatality toll. Decriminalization efforts elsewhere ('Portugal model') are set in distinct ecologies and parameters, and not readily transferable to Canadian contexts. While the DDI has symbolic value for policy reform, for decriminalization to provide tangible benefits for drug users and public health, its scope and design require fundamental reconsideration and improvement. Meanwhile, given the principally causal role of toxic drug supply for the current drug-death epidemic, more effective health and life-saving measures-specifically involving 'safer supply'-need to be urgently implemented to alleviate this crisis.

RéSUMé: Le Canada connaît depuis de nombreuses années une crise de santé publique hors du commun avec des décès liés aux drogues illégales (principalement des opioïdes synthétiques, mais de plus en plus d'autres également). Malgré de vastes interventions axées sur la santé, cette crise reste d'actualité et demeure dévastatrice. Plus tôt cette année, les gouvernements fédéral et de la Colombie-Britannique ont mis en œuvre 'l'initiative de dépénalisation des drogues' (IDD) qui exempte les consommateurs de drogues de peine pour la possession de petites quantités de drogue à des fins personnelles; cela a été mis de l'avant comme une « solution ¼ à la crise des décès liés aux drogues. Ce commentaire examine et discute du fait que, bien que la dépénalisation de l'usage de drogues soit fondamentalement nécessaire pour aligner la politique en matière de drogue sur les principes de promotion de la santé, la prise en compte basée sur les preuves des principales dynamiques de la crise ainsi que des réalités de leur application limite la capacité plausible de l'IDD de réduire considérablement le bilan des décès liés aux drogues. Les efforts de décriminalisation ailleurs ('modèle portugais') sont définis dans des situations et des paramètres distincts, et ne sont pas facilement transférables aux contextes canadiens. Bien que l'IDD ait une valeur symbolique pour la réforme des politiques, pour que la dépénalisation apporte des avantages tangibles aux consommateurs de drogues et à la santé publique, sa portée et sa conception nécessitent une ré-évaluation et des améliorations importantes. En attendant, étant donné le rôle essentiellement causal de l'approvisionnement en substances toxiques dans l'épidémie actuelle de décès liés aux drogues, des mesures de santé plus efficaces et permettant de sauver des vies­impliquant spécifiquement un « approvisionnement plus sûr ¼­doivent être mises en œuvre de toute urgence pour atténuer cette crise.

Attitudes and beliefs about Vermont's 2021 buprenorphine decriminalization law among residents who use illicit opioids.

BACKGROUND: In July 2021, Vermont removed all criminal penalties for possessing 224mg or less of buprenorphine. METHODS: Vermont residents (N=474) who used illicit opioid drugs or received treatment for opioid use disorder in the past 90 days were recruited for a mixed-methods survey on the health and criminal legal effects of decriminalization. Topics assessed included: motivations for using non-prescribed buprenorphine, awareness of and support for decriminalization, and criminal legal system experiences involving buprenorphine. We examined the frequencies of quantitative measures and qualitatively summarized themes from free-response questions. RESULTS: Three-quarters of respondents (76%) reported lifetime use of non-prescribed buprenorphine. 80% supported decriminalization, but only 28% were aware buprenorphine was decriminalized in Vermont. Respondents described using non-prescribed buprenorphine to alleviate withdrawal symptoms and avoid use of other illicit drugs. 18% had been arrested while in buprenorphine, with non-White respondents significantly more likely to report such arrests (15% v 33%, p<0.001). CONCLUSION: Decriminalization of buprenorphine may reduce unnecessary criminal legal system involvement, but its health impact was limited by low awareness at the time of our study.

The impact of cannabis legalization and decriminalization on acute poisoning: A systematic review.

BACKGROUND AND AIMS: Many countries have recently legalized medicinal and recreational cannabis. With increasing use and access come the potential for harms. We aimed to examine the effect of cannabis legalization/decriminalization on acute poisoning. METHODS: A systematic review and meta-analysis registered with PROSPERO (CRD42022323437). We searched Embase, Medline, Scopus and Cochrane Central Register of Controlled Trials from inception to March 2022. No restrictions on language, age or geography were applied. Abstracts from three main clinical toxicology conferences were hand-searched. Included studies had to report on poisonings before and after changes in cannabis legislation, including legalization and decriminalization of medicinal and recreational cannabis. Where possible, relative risk (RR) of poisoning after legalization (versus before) was calculated and pooled. Risk of bias was assessed with ROBINS-I. RESULTS: Of the 1065 articles retrieved, 30 met inclusion criteria (including 10 conference abstracts). Studies used data from the United States, Canada and Thailand. Studies examined legalization of medicinal cannabis (n = 14) and decriminalization or legalization of recreational cannabis (n = 21). Common data sources included poisons centre records (n = 18) and hospital presentations/admissions (n = 15, individual studies could report multiple intervention types and multiple data sources). Most studies (n = 19) investigated paediatric poisoning. Most (n = 24) reported an increase in poisonings; however, the magnitude varied greatly. Twenty studies were included in quantitative analysis, with RRs ranging from 0.81 to 29.00. Our pooled estimate indicated an increase in poisoning after legalization [RR = 3.56, 95% confidence interval (CI) = 2.43-5.20], which was greater in studies that focused on paediatric patients (RR = 4.31, 95% CI = 2.30-8.07). CONCLUSIONS: Most studies on the effect of medicinal or recreational cannabis legalization/decriminalization on acute poisoning reported a rise in cannabis poisoning after legalization/decriminalization. Most evidence is from US legalization, despite legalization and decriminalization in many countries.