Page last updated January 4, 2024 by Doug McVay, Editor.

1. States and Municipalities That Have Decriminalized or Legalized Any Currently Prohibited Controlled Substances

States and cities that have opted to legally regulate adult social use and/or medical use of marijuana:

Marijuana Legalization
(24): Alaska, Arizona, California, Colorado, Connecticut, Delaware, Illinois, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Montana, Nevada, New Jersey, New Mexico, New York, Ohio, Oregon, Rhode Island, Vermont, Virginia, Washington.
*Note: Marijuana is also legal in Washington, DC, Guam, and the Marshall Islands, however these are not states.

Marijuana Decriminalization
(14): Connecticut, Delaware, Maryland, Hawaii, Minnesota, Mississippi, Missouri, Nebraska, New Hampshire, North Carolina, North Dakota, Ohio, Rhode Island

Medical Marijuana Legalization
(38): Alabama, Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Hawaii, Illinois, Kentucky*, Louisiana*, Maine, Maryland, Massachusetts, Michigan, Minnesota*, Mississippi, Missouri, Montana, Nevada, New Hampshire, New Jersey, New Mexico, New York*, North Dakota, Ohio*, Oklahoma, Oregon, Pennsylvania*, Rhode Island, South Dakota, Utah, Vermont, Virginia, Washington, West Virginia* (also, Washington, DC)

*no smoking allowed

Medical Marijuana Legalization - CBD Oil Only
(14): Alabama, Georgia, Indiana, Iowa, Kansas, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee, Texas, Virginia, Wisconsin, Wyoming

Hemp Legalization*
Hemp is now federally legal. Only two states in the country - Idaho and Mississippi - do not allow cultivation of hemp for commercial, research or pilot programs.

Cities That Have Legalized Marijuana
(5): Breckenridge, CO; Denver, CO; Portland, ME; South Portland, ME; Washington, DC

Cities That Have Decriminalized or Depenalized Marijuana
(57): Albuquerque, NM; Allentown, PA; Ann Arbor, MI; Athens, OH; Atlanta, GA; Austin, TX; Bellaire, OH; Berkeley, CA; Berkley, MI; Chicago, IL; Cincinnati, OH; Cocoa Beach, FL; Columbia, MO; Dayton, OH; Daytona Beach, FL; Detroit, MI; East Lansing, MI; Eau Claire, WI; Ferndale, MI; Flint, MI; Fremont, OH; Grand Rapids, MI; Houston, TX; Huntington Woods, MI; Jackson, MI; Jersey City, NJ; Kansas City, MO; Keego Harbor, MI; Lancaster, PA; Logan, OH; Madison, WI; Miami, FL; Milwaukee, WI; Monona, WI; Mount Pleasant, MI; New Orleans, LA; Newark, OH; Norfolk, VA; Norwood, OH; New York, NY; Oregon, OH; Orlando, FL; Philadelphia, PA; Pittsburgh, PA; Pleasant Ridge, MI; Portage, MI; Port Huron, MI; Roseville, OH; Saginaw, MI; State College, PA; Santa Fe, NM; St. Louis, MO; Tampa, FL; Toledo, OH; Wichita, KS; Windham, OH; York, PA

Cities That Have Made Marijuana Arrests the Lowest Priority
(12): Eureka Springs, AR; Fayetteville, AR; Hailey; ID; Kalamazoo, MI; Oakland, CA; San Francisco, CA; Santa Barbara, CA; Santa Cruz, CA; Santa Monica, CA; Seattle, WA; Tacoma, WA; Tampa, FL; West Hollywood, CA

States That Have Decriminalized Entheogenic Plants (including psilocybin)
(3): Colorado, New Jersey*, Oregon

*for possessing an ounce or less of mushrooms from a third-degree crime to a disorderly-persons offense

Cities That Have Decriminalized Entheogenic Plants (including psilocybin)
(8): Ann Arbor, MI; Cambridge, MA; Denver, CO; Oakland, CA; Santa Cruz, CA; Somerville, MA; Vancouver, BC; Washington, DC

States That Have Decriminalized Possession of Controlled Substances
(1): Oregon

Nations That Have Legalized Marijuana
(3): Canada, Uruguay, Malta

Nations That Have Decriminalized Possession of Controlled Substances
(1): Portugal

National Organization for the Reform of Marijuana Laws. Legalization. Last accessed June 30, 2021.
ProCon.org. (2021, June 22). Legal Medical Marijuana States and DC, last accessed August 5, 2022.
Office of the Governor, State of Connecticut, Governor Lamont Statement on Final Passage of Legislation Legalizing Adult-Use Cannabis, June 17, 2021.
State of NY.
"Governor Cuomo Signs Legislation Legalizing Adult-Use Cannabis." Governor's Office. March 31, 2021.
"Madison Takes ‘Pot’shot at Wisconsin, Joins Growing List of Municipalities to Decriminalize Cannabis." National Law Review. Dec. 11, 2020.
State of Rhode Island. "Governor McKee Signs Legislation Legalizing and Safely Regulating Recreational Cannabis in Rhode Island." Office of the Governor, May 25, 2022. Last accessed June 3, 2022.
Malta. Bill No. 241 Authority on the Responsible Use of Cannabis Bill. Parliament of Malta. Last accessed June 3, 2022.
State of Maryland, State Board of Elections, Unofficial 2022 Gubernatorial General Election Results for Question 4, last accessed Nov. 11, 2022.
Ballotpedia, Colorado Proposition 122, Decriminalization and Regulated Access Program for Certain Psychedelic Plants and Fungi Initiative (2022), last accessed Nov. 11, 2022.
Ballotpedia, Missouri Amendment 3, Marijuana Legalization Initiative (2022), last accessed Nov. 13, 2022.
Office of the Governor of the State of Kentucky, Gov. Beshear Signs Historic Legislation Legalizing Medical Cannabis, March 31, 2023.
Delaware Legislature. 152nd General Assembly. House Bill 2, AN ACT TO AMEND TITLES 4, 11, 16, AND 30 OF THE DELAWARE CODE RELATING TO CREATION OF THE DELAWARE MARIJUANA CONTROL ACT. Last accessed April 27, 2023.
Christopher Ingraham, "What's in Minnesota's Marijuana Legalization Bill," Minnesota Reformer, May 31, 2023.
Ballotpedia. Ohio Issue 2, Marijuana Legalization Initiative (2023). Last accessed Nov. 15, 2023.

2. President Nixon Declares War On Drugs: Remarks About an Intensified Program for Drug Abuse Prevention and Control, June 17, 1971

"America's public enemy number one in the United States is drug abuse. In order to fight and defeat this enemy, it is necessary to wage a new, all-out offensive."

The American Presidency Project. Richard M. Nixon. 37th President of the United States: 1969 ‐ 1974. Remarks About an Intensified Program for Drug Abuse Prevention and Control, June 17, 1971.

3. Washington State Data On Marijuana Use Following Enactment of I-502

"In these initial investigations, we found no evidence that I-502 enactment, on the whole, affected cannabis abuse treatment admissions. Further, within Washington State, we found no evidence that the amount of legal cannabis sales affected cannabis abuse treatment admissions.

"The bulk of outcome analyses in this report used the within-state approach to focus on identifying effects of the amount of legal cannabis sales. We found no evidence that the amount of legal cannabis sales affected youth substance use or attitudes about cannabis or drug-related criminal convictions.

"We did find evidence that higher levels of retail cannabis sales affected adult cannabis use in certain subgroups of the population. BRFSS respondents 21 and older who lived in counties with higher levels of retail cannabis sales were more likely to report using cannabis in the past 30 days and heavy use of cannabis in the past 30 days.

"We also found two effects that are difficult to interpret. Among the portion of the population aged 18 to 21, BRFSS respondents living in counties with higher sales were less likely to report using cannabis in the past 30 days, in some analyses. It may be that legal cannabis sales have made cannabis more difficult to access by persons below the legal age, for instance, by reducing black market supply through competition.

"We also found that in the portion of the BRFSS sample who smoked cigarettes, respondents living in counties with higher levels of legal cannabis sales were less likely to report past-month cannabis use. It is particularly difficult to explain why increased sales would lead to lower cannabis use among cigarette smokers."

Darnell, A.J. & Bitney, K. I-502 evaluation and benefit-cost analysis: Second required report. Document Number 17-09-3201. Olympia, WA: Washington State Institute for Public Policy, 2017.

4. Prevalence in Marijuana Use in Colorado Before and After Legalization

Total US
According to the National Survey on Drug Use and Health (NSDUH), in 2008-2009, an estimated 13.37% of young people in the US aged 12 through 17 had used marijuana in the past year, falling to 12.29% in 2015-2016. The NSDUH also estimates that, in 2008-2009, an estimated 7.03% of young people in the US aged 12 through 17 had used marijuana in the past month, dropping to 6.75% in 2015-2016.

Colorado State
According to the NSDUH, in 2008-2009, an estimated 18.55% of young people in Colorado aged 12 through 17 had used marijuana in the past year, falling to 16.21% in 2015-2016. The NSDUH also estimates that, in 2008-2009, an estimated 10.17% of young people in Colorado aged 12 through 17 had used marijuana in the past month, dropping to 9.08% in 2015-2016.

Table: Prevalence of marijuana use in Colorado before and after passage and implementation of Amendment 64

Substance Abuse and Mental Health Services Administration. (2017). National Survey on Drug Use and Health: Comparison of 2008-2009 and 2015-2016 Population Percentages (50 States and the District of Columbia). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration.
Substance Abuse and Mental Health Services Administration. (2017). National Survey on Drug Use and Health: Comparison of 2014-2015 and 2015-2016 Population Percentages (50 States and the District of Columbia). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration.

5. Limitation on Federal Interference With Implementation of State Medical Marijuana Laws

In December 2014, the federal budget for FY2015 was enacted, containing this provision:
"SEC. 538. None of the funds made available in this Act to the Department of Justice may be used, with respect to the States of Alabama, Alaska, Arizona, California, Colorado, Connecticut, Delaware, District of Columbia, Florida, Hawaii, Illinois, Iowa, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nevada, New Hampshire, New Jersey, New Mexico, Oregon, Rhode Island, South Carolina, Tennessee, Utah, Vermont, Washington, and Wisconsin, to prevent such States from implementing their own State laws that authorize the use, distribution, possession, or cultivation of medical marijuana."

Consolidated and Further Continuing Appropriations Act, 2015, US Congress, Enrolled Bill Published December 17, 2014, p. 88.

6. Marijuana Legalization and Arrests in Colorado

"The total number of marijuana arrests decreased by 52% between 2012 and 2017, from 12,709 to 6,153. Marijuana possession arrests, which make up the majority of all marijuana arrests, were cut in half (‐54%). Marijuana sales arrests decreased by 17%. Arrests for marijuana production increased appreciably (+51%%). Marijuana arrests that were unspecified, meaning the specific reason for the arrest was not noted by law enforcement, went down by 45%.

"The number of marijuana arrests decreased by 56% for Whites, 39% for Hispanics, and 51% for Blacks. The marijuana arrest rate for Blacks (233 per 100,000) was nearly double that of Whites (118 per 100,000) in 2017.

"Nine large Colorado counties (Adams, Arapahoe, Boulder, Douglas, El Paso, Jefferson, Larimer, Mesa, and Weld) showed a decrease in marijuana arrests, ranging between ‐8% (Boulder) and ‐67% (Adams). The average decline across these nine counties was ‐46%.

"Separate data provided by the Denver Police Department’s Data Analysis Unit indicates an 81% decrease in total marijuana arrests, from 1,605 in 2012 to 302 in 2017.

"The most common marijuana industry‐related crime in Denver was burglary, accounting for 59% of marijuana crime related to the industry in 2017."

Impacts of Marijuana Legalization in Colorado: A Report Pursuant to Senate Bill 13-283. Colorado Department of Public Safety, Division of Criminal Justice, Office of Research and Statistics. October 2018.

7. Impact of Marijuana Legalization on Traffic and Driving Safety in Colorado

"The increase in law enforcement officers who are trained in recognizing drug use, from 129 in 2012 to 214 in 2018, can increase drug detection rates apart from any changes in driver behavior.

"Traffic safety data were obtained from a number of different sources. Please note that traffic safety data may be incomplete because law enforcement officers may determine that alcohol is impairing the driver, and therefore additional (time consuming and costly) drug testing may not be pursued.

"The total number of DUI citations issued by the Colorado State Patrol (CSP) decreased from 5,705 in 2014 to 4,849 in 2017. The prevalence of marijuana or marijuana‐in‐combination identified by Patrol officers as the impairing substance increased from 12% of all DUIs in 2014 to 15% in 2017.

"In 2016, the most recent data available, 27,244 cases were filed in court that included a charge of driving under the influence; 17,824 of these were matched with either a breath or blood test.1

"Of these, 3,946 had blood samples screened for the presence of marijuana: 2,885 cases (73.2%) had a positive cannabinoid screen and a follow‐up confirmation for other cannabis metabolites, and 47.5% detected Delta‐9 THC at 5.0 ng/mL or above.

"According to CDOT, the number of fatalities in which a driver tested positive for Delta‐9 THC at or above the 5.0 ng/mL level declined from 52 (13% of all fatalities) in 2016 to 35 in 2017 (8% of all fatalities).

"The number of fatalities with cannabinoid‐only or cannabinoid‐in‐combination positive drivers increased 153%, from 55 in 2013 to 139 in 2017.

"However, note that the detection of any cannabinoid in blood is not an indicator of impairment but only indicates presence in the system. Detection of Delta‐9 THC, one of the primary psychoactive metabolites of marijuana, may be an indicator of impairment.

"A 2017 survey conducted by the Colorado Department of Public Health and Environment found that 3.0% of adults reported driving within two‐to‐three hours of using marijuana in the past‐30 days, while 19.7% of recent marijuana users reported this behavior."

Impacts of Marijuana Legalization in Colorado: A Report Pursuant to Senate Bill 13-283. Colorado Department of Public Safety, Division of Criminal Justice, Office of Research and Statistics. October 2018, pp. 2-3.

8. Emergency Department Visits and Hospitalizations Related to Marijuana Use Post-Legalization in Colorado

"The Colorado Department of Public Health and Environment (CDPHE) analyzed data from the
Colorado Hospital Administration (CHA) with these findings:

"Hospitalization rates (per 100,000 hospitalizations) with possible marijuana exposures, diagnoses, or billing codes increased from 803 per 100,000 before commercialization (2001‐2009) to 2,696 per 100,000 after commercialization (January 2014‐September 2015). The period from October 2015‐December 2015 indicated another increase, but due to changes in coding systems, variable structures, and policies at CHA, the numbers for 2016 are considered preliminary by CDPHE.

"The period of retail commercialization showed an increase in emergency department visits, from 739 per 100,000 ED visits (2010–2013) to 913 per 100,000 ED visits (January 2014–September 2015). There was no definitive trend during the period October 2015‐December 2015 and, due to changes in coding systems, variable structures, and policies at CHA, these figures for 2016 are considered preliminary by CDPHE.

"The number of calls to poison control mentioning human marijuana exposure increased over the past 10 years. There were 45 calls in 2006 and 222 in 2017. Between 2014 and 2017, the frequency of calls reporting human marijuana exposure stabilized."

Impacts of Marijuana Legalization in Colorado: A Report Pursuant to Senate Bill 13-283. Colorado Department of Public Safety, Division of Criminal Justice, Office of Research and Statistics. October 2018.

9. Data on First Two Months of Operation of First Legally Authorized Supervised Consumption Sites in the US

"Between November 30, 2021, and January 31, 2022, 613 individuals used OPC services 5975 times across 2 sites. Most individuals identified as male (78.0%), and 55.3% identified as Hispanic, Latino, or Latina. The mean (range) age was 42.5 (18-71) years. A plurality of individuals (36.9%) reported being street homeless. Fewer than one-fifth of individuals (17.8%) were living in their own rooms or apartments (Table).

"In self-reported data, the drug most commonly used across 2 sites was heroin or fentanyl (73.7%) and the most frequent route of drug administration at the OPC was injection (65.0%). Among all participants, 75.9% reported that they would have used their drugs in a public or semipublic location if OPC services had not been available (Figure).

"During the first 2 months of OPC operation, trained staff responded 125 times to mitigate overdose risk. In response to opioid-involved symptoms of overdose, naloxone was administered 19 times and oxygen 35 times, while respiration or blood oxygen levels were monitored 26 times. In response to stimulant-involved symptoms of overdose (also known as overamping), staff intervened 45 times to provide hydration, cooling, and de-escalation as needed. Emergency medical services responded 5 times, and participants were transported to emergency departments 3 times. No fatal overdoses occurred in OPCs or among individuals transported to hospitals.

"More than half of individuals using OPC services (52.5%) received additional support during their visit. This included, but was not limited to naloxone distribution, counseling, hepatitis C testing, medical care, and holistic services (eg, auricular acupuncture)."

Harocopos A, Gibson BE, Saha N, et al. First 2 Months of Operation at First Publicly Recognized Overdose Prevention Centers in US. JAMA Network Open. 2022;5(7):e2222149. doi:10.1001/jamanetworkopen.2022.22149

10. Marijuana Arrests in Washington State Following Legalization

"Preliminary look at racial disparities in select counties of Washington

"The Crime, Cannabis & Police Research Group at Washington State University used preliminary data from a Department of Justice funded study to compare white vs. Black arrests.11 Latinos were not included in the analysis, because of difficulties measuring ethnicity in arrest data. Their main preliminary findings are that after legalization in Washington, African Americans/Blacks continue to be disproportionally arrested for the possession and selling of marijuana when compared to whites. Though the disparity in marijuana possession between African American/Blacks and whites was reduced slightly after legalization, the disparity for selling marijuana has more than doubled since legalization.

"Local trends

"While statewide studies have the ability to control for individual law enforcement agencies or police departments, monitoring trends in marijuana-related crimes within a local police department can provide details of violations that statewide data systems do not. For example, violations for public consumption of marijuana cannot be directly queried from state-derived data; however, local law enforcement agencies and municipal courts maintain details on the nature of the crime that would indicate whether someone was ticketed for public consumption vs. possession or a different drug-related charge. One example of the potential of local data to explore issues of criminal justice can be made using data from the Seattle Police Department (SPD). A 2015 report for the Seattle Community Police Commission showed a disproportionate number of citations for marijuana public consumption issued to African Americans/Blacks in Seattle.12 Using local police department data is key to understanding differences in the implementation and enforcement of polices pertaining to the legalization of marijuana."

Firth C. Marijuana Legalization in Washington State: Monitoring the Impact on Racial Disparities in Criminal Justice. Alcohol & Drug Abuse Institute, University of Washington, June 2018.

11. Racial Disparities in Marijuana Arrests in CO and OR

"Compelling evidence in other states suggest racial disparities persist or have become worse after legalization and the opening of a licensed marijuana market, even while total marijuana-related criminal justice incidents have decreased.

"In Colorado, marijuana court filings decreased by 85% from 2010 to 2014 after legalizing marijuana in 2012. During the same time frame the rate of arrests for marijuana possession among African Americans/Blacks remained 2.4 times higher compared to the arrest rate for whites. The disparities for African American/Blacks were even larger for arrests for marijuana cultivation (2.5 times the arrest rate for whites) and distribution of marijuana (5.4 times the arrest rate for whites).13

"Results from Oregon are consistent with findings in Colorado. The Oregon Public Health Division examined changes in the age-adjusted rates of marijuana arrests by racial groups.14 The age adjusted rate of marijuana arrests for African Americans/Blacks was 2 to 3 times the rate of whites during 2010–2014. Oregon legalized marijuana in 2014 and in the following year the disparity between African Americans/Blacks and whites persisted. Specifically, the rate of arrest was 77% higher among African Americans/Blacks in 2015 when compared to whites.

"Preliminary results suggest that legalization of marijuana for adults has greatly reduced the number of people arrested and convicted for marijuana-related crimes, yet racial disparities persist in Washington and in other states. Other factors may contribute to sustaining the racial disparities, such as over-policing in low-income neighborhoods, racial profiling, and other racially biased police practices.15 These inequitable practices may minimize the potential positive impacts of I-502 and marijuana legalization on all communities."

Firth C. Marijuana Legalization in Washington State: Monitoring the Impact on Racial Disparities in Criminal Justice. Alcohol & Drug Abuse Institute, University of Washington, June 2018.

12. Impact of Marijuana Legalization on the State of Washington

"In these initial investigations, we found no evidence that I-502 enactment, on the whole, affected cannabis abuse treatment admissions. Further, within Washington State, we found no evidence that the amount of legal cannabis sales affected cannabis abuse treatment admissions.

"The bulk of outcome analyses in this report used the within-state approach to focus on identifying effects of the amount of legal cannabis sales. We found no evidence that the amount of legal cannabis sales affected youth substance use or attitudes about cannabis or drug-related criminal convictions.

"We did find evidence that higher levels of retail cannabis sales affected adult cannabis use in certain subgroups of the population. BRFSS respondents 21 and older who lived in counties with higher levels of retail cannabis sales were more likely to report using cannabis in the past 30 days and heavy use of cannabis in the past 30 days.

"We also found two effects that are difficult to interpret. Among the portion of the population aged 18 to 21, BRFSS respondents living in counties with higher sales were less likely to report using cannabis in the past 30 days, in some analyses. It may be that legal cannabis sales have made cannabis more difficult to access by persons below the legal age, for instance, by reducing black market supply through competition.

"We also found that in the portion of the BRFSS sample who smoked cigarettes, respondents living in counties with higher levels of legal cannabis sales were less likely to report past-month cannabis use. It is particularly difficult to explain why increased sales would lead to lower cannabis use among cigarette smokers."

Darnell, A.J. & Bitney, K. (2017). I-502 evaluation and benefit-cost analysis: Second required report. Document Number 17-09-3201. Olympia: Washington State Institute for Public Policy.

13. Rhode Island Becomes First State in US to Approve Legal Establishment of Overdose Prevention Sites

"Gov. Dan McKee has signed legislation introduced by Majority Floor Manager John G. Edwards (D-Dist. 70, Tiverton, Portsmouth) and Sen. Joshua Miller (D-Dist. 28, Cranston, Providence) that authorizes a two-year pilot program to prevent drug overdoses through the establishment of harm reduction centers, which are a community-based resource for health screening, disease prevention and recovery assistance where persons may safely consume pre-obtained substances.

"The law (2021-H 5245A, 2021-S 0016B) authorizes facilities where people may safely consume those substances under the supervision of health care professionals. It requires the approval of the city or town council of any municipality where the center would operate."

State of Rhode Island General Assembly. Harm reduction center pilot program to combat overdose deaths becomes law. News Release, July 7, 2021.

14. New York City Opens First Legally Authorized Safe Consumption Sites In US

On November 30, 2021, the Office of the Mayor of the City of New York announced that "the first publicly recognized Overdose Prevention Center (OPC) services in the nation have commenced in New York City. OPCs are an extension of existing harm reduction services and will be co-located with previously established syringe service providers."

According to the release:
"OPCs, also referred to as supervised consumption sites or facilities, are safe places where people who use drugs can receive medical care and be connected to treatment and social services. OPC services are proven to prevent overdose deaths, and are in use in jurisdictions around the world. There has never been an overdose death in any OPC. A Health Department feasibility study found that OPCs in New York City would save up to 130 lives a year.

"Additionally, OPCs are a benefit to their surrounding communities, reducing public drug use and syringe litter. Other places with OPCs have not seen an increase in crime, even over many years.

"OPCs will be in communities based on health need and depth of program experience. A host of City agencies will run joint operations focused on addressing street conditions across the City, and we will include an increased focus on the areas surrounding the OPCs as they open."

Office of the Mayor of the City of New York, "Mayor de Blasio Announces Nation's First Overdose Prevention Center Services to Open in New York City," City of New York, NY, Nov. 30, 2021.

15. Decriminalization and Deaths from a Toxic Unregulated Drug Supply and Overdose

"Oregon and Washington have recently made changes to their drug laws to fully or partially legalize possession of small amounts of drugs and increase investment in treatment access. To our knowledge, this is the first study to evaluate the association between those changes and fatal drug overdose. Using the synthetic control method to compare post-drug policy changes in fatal drug overdose rates in Oregon and Washington and estimated rates in the absence of these drug policy changes, we found no evidence that either Measure 110 in Oregon or the Washington Blake decision and subsequent legislative amendments were associated with changes in fatal drug overdose rates in either state. These findings were also robust to variations in the donor pool and the modeling strategy."

Joshi S, Rivera BD, Cerdá M, et al. One-Year Association of Drug Possession Law Change With Fatal Drug Overdose in Oregon and Washington. JAMA Psychiatry. Published online September 27, 2023. doi:10.1001/jamapsychiatry.2023.3416

16. Safer Opioid Supply Outcomes

"Overall, the currently available evidence regarding health outcomes among safer opioid supply clients is generally favorable. Specifically, when reported, most studies found reductions (Brothers et al., 2022; Haines & O'Byrne, 2023a; Lew et al., 2022) or a lack of change (Gomes et al., 2022) in the occurrence of opioid toxicity events, along with a reduction in the frequency of unregulated opioid use among clients of safer opioid supply programs (Bardwell et al., 2023; Giang et al., 2023; Haines & O'Byrne, 2023a; Ivsins et al., 2020, 2022; McNeil et al., 2022). Other health outcomes were also shown to improve among safer opioid supply clients, including increased access to the healthcare system (Gomes et al., 2022; Kolla & Fajber, 2023; Kolla et al., 2021), infectious complications (Gomes et al., 2022), and improvements to clients’ mental health (Gomes et al., 2022; Haines et al., 2022; Kolla & Fajber, 2023; Kolla et al., 2021). Also, participants of qualitative studies expressed that safer opioid supply program participation improved their access to healthcare and other wraparound services (Foreman-Mackey et al., 2022; Giang et al., 2023; Haines & O'Byrne, 2023a; Ivsins et al., 2020; McMurchy & Palmer, 2022), allowing them to address health issues such as HIV and hepatitis C (Kolla et al., 2021). Additionally, safer opioid supply program clients and providers interviewed in qualitative studies expressed that safer opioid supply recipients were afforded a greater sense of stability as clients were less preoccupied with concerns related to drug procurement (Foreman-Mackey et al., 2022; Giang et al., 2023; Haines & O'Byrne, 2023a; Ivsins et al., 2020, 2022; McNeil et al., 2022), or engagement in criminal activity as a means of income generation for drug related purchases (Atkinson, 2023; Haines & O'Byrne, 2023a; Haines et al., 2022; Ivsins et al., 2020, 2021, 2022; Kolla et al., 2021; McNeil et al., 2022)."

Ledlie, S., Garg, R., Cheng, C., Kolla, G., Antoniou, T., Bouck, Z., & Gomes, T. (2024). Prescribed safer opioid supply: A scoping review of the evidence. The International journal on drug policy, 125, 104339. Advance online publication. doi.org/10.1016/j.drugpo.2024.104339

17. Safer Supply of Opioids and Diversion

"Diversion of safer opioid supply drugs was examined in six qualitative studies (Giang et al., 2023; Haines & O'Byrne, 2023a; Haines et al., 2022; Kalicum, 2023; Kolla et al., 2021; McMurchy & Palmer, 2022) and one quantitative study (Brothers et al., 2022). These studies found that diversion does occur (Brothers et al., 2022; Haines et al., 2022; Kolla et al., 2021; McMurchy & Palmer, 2022), although the extent of diversion remains unknown. Importantly, safer opioid supply programs include measures and protocols to prevent and address diversion, including urine drug screens, lock boxes and observed dosing (Atkinson, 2023; Kalicum, 2023; Kolla et al., 2021; McMurchy & Palmer, 2022; Selfridge et al., 2022; Waraksa et al., 2022). Despite concerns regarding the diversion of hydromorphone from safer opioid supply programs, unregulated fentanyl remains the largest contributor of death in both Ontario (Public Health Ontario, 2023) and British Columbia (British Columbia Centre for Disease Control, 2021; Owens, 2023), Canada with no substantial changes in occurrence of deaths related to prescription opioids use, including hydromorphone. These factors indicate that diversion in the context of safer opioid supply requires further study, and ongoing refinement and sharing of protocols to address diversion within safer opioid supply programs is likely the most effective response."

Ledlie, S., Garg, R., Cheng, C., Kolla, G., Antoniou, T., Bouck, Z., & Gomes, T. (2024). Prescribed safer opioid supply: A scoping review of the evidence. The International journal on drug policy, 125, 104339. Advance online publication. doi.org/10.1016/j.drugpo.2024.104339

18. Barriers to Implementation of Safer Supply Programs

"Several client- and provider-reported barriers to safer opioid supply program engagement were also identified. Provider identified barriers to prescribing opioids for the purposes of safer supply primarily reflected a perceived lack of guidance and training with the introduction of the Risk Mitigation Guidance in British Columbia (Giang et al., 2023; Kalicum, 2023; Mansoor et al., 2023), and the limited evidence base regarding the effectiveness and safety of safer opioid supply. For providers, some facilitators to safer opioid supply programs were also identified and included belonging to a team (Foreman-Mackey et al., 2022), as well as strong communication between providers (Mansoor et al., 2023). Barriers reported by clients included challenges accessing safer opioid supply prescribed drugs when program policies mandated multiple visits throughout the day to obtain the complete daily dose (Atkinson, 2023; Haines & O'Byrne, 2023a; Ivsins et al., 2020), and lack of familiarity with the program by non-safer opioid supply providers (Haines et al., 2022; Kolla et al., 2021). The mismatch between the potency of the unregulated drug supply and what was prescribed to safer opioid supply clients was also identified as a limitation of safer opioid supply programs (Atkinson, 2023; Bardwell et al., 2023; Giang et al., 2023; Haines & O'Byrne, 2023a; Haines et al., 2022; Ivsins et al., 2020; Karamouzian et al., 2023; Kolla et al., 2021; McNeil et al., 2022). In particular, the lack of availability of higher potency opioids and multiple formulations that allow for consumption by either injection or inhalation was described in some studies as leading to continued use of unregulated drugs, which may undermine the effectiveness of safer opioid supply programs for prevention of toxicity events. This aligns with a recent study conducted in Ontario, which found a shift in the mode of drug use toward inhalation, contributing significantly to opioid toxicity deaths (MacDonald et al., 2023). A survey conducted among people who use drugs in British Columbia also found that half of respondents would prefer smokeable options if they were provided by safer opioid supply program. Kamal et al., 2023). Furthermore, as the opioid toxicity crisis continues to evolve across North America, polysubstance use is increasingly associated with substance-related deaths (Konefal et al., 2022; Park et al., 2022). In addition to the availability of higher potency opioids, provision of non-opioid prescription medication should continue to be implemented. This is supported by findings generated from interviews conducted with people who use drugs highlighting the need for access to a regulated supply of stimulants and benzodiazepines for people currently accessing these substances from the unregulated supply and to help prevent non-opioid related withdrawal symptoms when transitioning to safer supply programs (Canadian Community Epidemiology Network on Drug Use., 2021; Xavier et al., 2023). Together, identified barriers, facilitators, and suggestions for the improvement of safer supply programs may help to inform the implementation, scale-up and operation of current and future safer supply programs."

Ledlie, S., Garg, R., Cheng, C., Kolla, G., Antoniou, T., Bouck, Z., & Gomes, T. (2024). Prescribed safer opioid supply: A scoping review of the evidence. The International journal on drug policy, 125, 104339. Advance online publication. doi.org/10.1016/j.drugpo.2024.104339

19. Considerations for Implementing Safe Supply

"In British Columbia, a new policy directive—termed “prescribed safer supply”—has recently been announced that will extend prescribing practices outlined in the risk mitigation guidelines beyond the pandemic,29 although the original guidelines remain in effect and have since been revised with a more explicit focus on mitigating COVID-19 risk. However, although the recent policy directive has been broadened to include fentanyl patches and sublingual fentanyl, it does not presently support stimulant prescriptions and thus raises concerns for people who have been accessing stimulants. As the overdose crisis continues, it is imperative that safe supply be extended to all PWUD while being continuously modified to maximize access, efficacy, and equity.

"Finally, our findings draw attention to the tensions surrounding safe supply approaches primarily oriented toward managing withdrawal and drug cravings versus the desire of PWUD to experience enjoyment from drug use.34 There is a need to account for pleasure in the design and implementation of safe supply approaches—something seldom examined in North American research and policy discussions on drug use. Better aligning safe supply approaches with the real-world experiences and desires of PWUD will likely necessitate expanding the options available to include regulated versions of criminalized drugs that they are accustomed to using, such as methamphetamine, cocaine, heroin, and even fentanyl. With growing support for drug decriminalization and strides being made in Oregon and elsewhere,35,36 it is time that these discussions be broadened to also consider what a regulated drug market might look like in North America."

Ryan McNeil, Taylor Fleming, Samara Mayer, Allison Barker, Manal Mansoor, Alex Betsos, Tamar Austin, Sylvia Parusel, Andrew Ivsins, and Jade Boyd. (2022).
Implementation of Safe Supply Alternatives During Intersecting COVID-19 and Overdose Health Emergencies in British Columbia, Canada, 2021. American Journal of Public Health 112, S151_S158, doi.org/10.2105/AJPH.2021.306692

20. Risk Mitigation Prescribing of Safer Supply

"The risk-mitigation prescribing guidelines were a harm reduction approach in response to the evolving risk environment during COVID-19—namely, continued drug market changes and increasing socioeconomic marginalization—that facilitated reliable access to opioids and stimulants of known contents and potency. Access to no-cost pharmaceutical alternatives enabled participants to exercise greater control over their drug use and reduced vulnerability to overdose. Participants emphasized that, although they had experienced more sporadic drug use patterns characterized by frequent periods of withdrawal and cravings at the outset of the pandemic because of supply shortages, rising prices, and reduced income, they remained uninterested in addiction treatment and yet wanted greater control over their drug use. This was often attributable to past negative experiences with medication-based treatment and recovery services. Prescription opioids and stimulants made available at no cost through the risk mitigation guidelines were positioned as a way to exercise greater agency over drug use and thereby avoid withdrawal and cravings amid deepening socioeconomic marginalization, drug market changes, and escalating overdose deaths."

Ryan McNeil, Taylor Fleming, Samara Mayer, Allison Barker, Manal Mansoor, Alex Betsos, Tamar Austin, Sylvia Parusel, Andrew Ivsins, and Jade Boyd. (2022).
Implementation of Safe Supply Alternatives During Intersecting COVID-19 and Overdose Health Emergencies in British Columbia, Canada, 2021. American Journal of Public Health 112, S151_S158, doi.org/10.2105/AJPH.2021.306692

21. MySafe: Safer Opioid Supply Via Biometric Dispenser

"Participants enrolled in the MySafe program described a variety of facilitators and barriers to program access and engagement. Facilitators included accessibility and choice, nonwitnessed dosing, a lack of consequences for missing doses, a judgment-free setting and an ability to accumulate doses as contingency plans (e.g., for travel). Barriers included technological issues with the machine, dosing challenges and prescriptions being tied to individual machines. Participants reported reduced use of illicit drugs, decreased overdose risk, financial improvements and improvements to health and well-being. Taken together, these findings illustrate promising aspects of, and areas for improvement to, the MySafe model of safer supply.

"Our findings add to a small but emerging body of research on safer supply programs in Canada that reports how these programs have the potential to reduce overdose risk by limiting illicit opioid exposure,3,15,2931 with 1 study reporting no opioid-related deaths among program participants3 and another reporting 0 overdoses among program participants.31 As most participants in this study reported using fewer illicit drugs and described reductions in overdose risk since enrolling in MySafe, our findings provide further support of the potential that safer supply programs may offer to address overdose risk. Our findings also illustrate how the MySafe program provides secondary benefits beyond the intended program outcomes (e.g., reduction in overdose risk), addressing physical, mental and social well-being. Given the known associations between sociostructural factors and overdose risk,3235 our findings underscore the importance of addressing issues attendant to drug use and overdose vulnerability, and are in line with previous research showing the feasibility of safer supply programs to address matters at the intersection of drug use, drug market volatility and social determinants of health.3,13,15,36

"Little research has examined barriers and facilitators to engagement in and adherence to safer supply programs.13,37 A recent study reported benefits of accessing pharmaceutical alternatives, including increased agency regarding how participants consumed their drugs and when they chose to attend the clinic.13 However, participants also described barriers, including limited hours of operation, the need to attend the clinic several times a day and nurse-witnessed ingestion.13 These findings are similar to studies on opioid agonist therapy that report how stigma and programmatic restrictions constrain initiation and retention.2,3841 Our study findings suggest that the MySafe program circumvents these barriers by providing 24-hour access (or 13-hour access, for the overdose prevention site) and not requiring witnessed ingestion. Integrating the MySafe program in supportive housing allowed greater ease of access to residents, which is particularly important, given the reported links between housing and overdose42,43 and calls for targeted interventions in housing environments where people are most at risk.26,34,44 In addition, this program appears to have potential to limit exposure to violence that is associated with procuring drugs from the illegal market, although further research is needed to confirm such impacts.45

"The MySafe program was not without its issues. Technological issues were described by most participants, resulting in some having withdrawal symptoms and others seeking illicit opioids when unable to access medications from the machine. However, many participants reported accumulating their prescriptions for circumstances when they were not able to use the machine, such as when away on vacation or when technological issues arose. A lack of takeaway doses has been described as a barrier in studies on access to opioid agonist therapy.40,4648 In the case of the MySafe program, however, patients should not have to stockpile their medications because of technological issues; this could lead to intentional or unintentional diversion of medications.

"A problem confronting all programs of safer supply and opioid agonist therapy in the current era of high-potency illicit drugs is addressing illicit fentanyl-induced withdrawal and the inability of previously sufficient dosages of pharmaceutical opioids to provide appropriate withdrawal management or anti-craving effects. Similar to our results, insufficient dosing of opioid agonist therapy has been found to shape continued use of illicit drugs.49,50 A recent study on adherence to safer supply opioids found that 60-day adherence was higher for those receiving higher daily doses.37 Dosing challenges therefore need to be addressed, which may include increasing the maximum daily dose or providing medications other than hydromorphone, such as prescription fentanyl or diacetylmorphine.4,51,52 However, this limitation speaks more to available medications and less of the MySafe model itself. Clinical guidelines that detail how to address dosing challenges in safer supply programs are urgently needed, including how and when to increase the maximum daily dosages of hydromorphone or provide access to alternative opioid medications.

"Our findings suggest that the MySafe model could be beneficial in other settings, particularly in jurisdictions with challenges in accessing safer supply, including rural and remote communities with geographical and transportation barriers and in pharmacies that are under-resourced and have limited hours of operation. 53,54 In addition, this model shows promise for medication delivery beyond safer supply and could include opioid agonist therapy, direct-acting antiviral tablets or other medications that are commonly accessed by marginalized groups. This would be especially beneficial for structurally vulnerable populations who have compounding barriers when accessing services related to substance use (e.g., Indigenous and racialized communities, sex workers, gender and sexual minorities). Future research is needed to assess the feasibility of the MySafe program in other communities, as well as to explore opportunities to emulate this model for the safe supply of other medications."

Geoff Bardwell, Andrew Ivsins, Manal Mansoor, Seonaid Nolan, Thomas Kerr. Safer opioid supply via a biometric dispensing machine: a qualitative study of barriers, facilitators and associated outcomes. CMAJ May 2023, 195 (19) E668-E676; DOI: 10.1503/cmaj.221550.

22. Syringe Service Programs in the US

"Syringe services programs are harm reduction programs that provide a wide range of services including, but not typically limited to, the provision of new, unused hypodermic needles and syringes and other injection drug use supplies, such as cookers, tourniquets, alcohol wipes, and sharps waste disposal containers, to PWID. Comprehensive SSPs also either directly provide, or offer linkage or referrals to entities that provide: substance use disorder treatment, including medication for addiction treatment; vaccination for viral hepatitis; screening for viral hepatitis, HIV, sexually transmitted infections, tuberculosis, and other infectious diseases; provision of pre- and post-exposure prophylaxis for HIV; naloxone and other overdose prevention tools; peer support services; educational materials and training in areas related to injection drug use; and referral and linkage to other services, including medical care, mental health services, and other support services.16 Contrary to popular perception, SSPs do not increase crime in areas where programs are based and do not increase illegal drug use.17 Further, “Nearly 30 years of research has shown that comprehensive SSPs are safe, effective, and cost-saving … and play an important role in reducing the transmission of viral hepatitis, HIV, and other infections.”18 Additionally, PWID who participate in an SSP are “five times more likely to enter drug treatment and about three times more likely to stop using drugs than those who don’t use the programs.”19 Individuals who regularly use an SSP are also “nearly three times as likely to report a reduction in injection frequency as those who have never used an SSP.” SSPs are also an important tool in the fight against unintentional drug overdose by teaching PWID how to recognize and respond to a drug overdose, as well as by providing participants with naloxone and training on administration.21

"Although only 38 states, the District of Columbia, and Puerto Rico either explicitly or implicitly authorize SSPs through statute, regulation, or executive order, as of September 2021, there are 392 operational SSPs in 44 states, the District of Columbia, and Puerto Rico.22,23

Legislative Analysis and Public Policy Association. Syringe Services Programs: Summary of State Laws. October 2021. LAPPA: Washington, DC.

23. The Drug User Liberation Front and the Compassion Club Model

"After losing a year-long battle to secure a federal exemption to operate, in August 2022, the Drug Users Liberation Front (DULF), a community-level non-profit in the Downtown Eastside, piloted an Evaluative Compassion Club for individuals who use cocaine, heroin or methamphetamine, live in Vancouver's Downtown Eastside, and were at high risk of overdose (Canadian Broadcasting Corporation, 2022). Over fourteen months, eligible individuals enrolled as members, granting them the ability to purchase, at cost, up to fourteen grams of cocaine, heroin, and methamphetamine per week at a fixed storefront space in Vancouver's Downtown Eastside (Drug Users Front Liberation, 2023). All substances were tested via paper spray mass spectrometry, nuclear magnetic resonance spectroscopy, fourier transform infrared spectroscopy and high-performance liquid chromatography prior to sale to ensure quality and a lack of potentially fatal contaminants, and labeled so that participants were aware of the contents (see Fig. 1, Fig. 2 for example) (Drug Users Front Liberation, 2023). The club's operations spanned four days per week, totaling twenty-four hours, and the Club's physical space included an on-site overdose prevention site (Drug Users Front Liberation, 2023). Compassion clubs of this kind are novel, and there appears to be no evidence specific to this form of intervention focused on ensuring access to a safe supply of heroin, cocaine and methamphetamine. This type of collective initiative does bear some similarities to other types of compassion or “buyers” clubs, including those focused on providing access to medicinal cannabis or antiretroviral therapy for HIV disease (Kent, 1999; Rhodes and van de Pas, 2022), but it represents a highly novel form of safe supply programming."

Jeremy Kalicum, Eris Nyx, Mary Clare Kennedy, Thomas Kerr, The impact of an unsanctioned compassion club on non-fatal overdose, International Journal of Drug Policy, 2024, 104330, ISSN 0955-3959, doi.org/10.1016/j.drugpo.2024.104330.

24. Closure of Syringe Service Programs Increases Risk of Rebound HIV Outbreaks

"This analysis presents the first study, to our knowledge, to quantitively examine the impact of SSP closure on HIV incidence using a modeling approach. In a rural American setting that had previously experienced an HIV outbreak among PWID, our modeling results suggest that closing an existing SSP would likely lead to a rebound HIV outbreak, with a 1.6-fold increase in incident infections among PWID in 5 years relative to SSP sustainment. The potential impact of SSP closure was found to be substantially greater for other settings with lower baseline HIV prevalence (in which a larger share of the population is susceptible to HIV infection). Although delaying SSP closure with another renewal was found to reduce the size of the rebound, sustaining SSP operation and associated health services will be imperative to maintain long-term epidemic control."

Zang, Xiaoa; Goedel, Williams C.a; Bessey, Sam E.a; Lurie, Mark N.a; Galea, Sandrob; Galvani, Alison P.c,d,e; Friedman, Samuel R.f; Nosyk, Bohdang; Marshall, Brandon D.L.a. The impact of syringe services program closure on the risk of rebound HIV outbreaks among people who inject drugs: a modeling study. AIDS 36(6):p 881-888, May 1, 2022. | DOI: 10.1097/QAD.0000000000003199 

25. UNAIDS: About Decriminalization

"In 2021, the world set ambitious law reform targets to remove criminal laws that are undermining the HIV response and leaving key populations behind. Recognising decriminalization as a critical element in the response, countries made a commitment that by 2025 less than 10% of countries would have punitive legal and policy environments that affect the HIV response. The Global AIDS Strategy set as a target that less than 10% of countries would criminalise sex work, possession of small amounts of drugs, same-sex sexual activity, and HIV exposure, non-disclosure and transmission."

UNAIDS. "About Decriminalization." Last accessed May 15, 2023.

26. Drug Policies and the Dark Web

"The increasing availability of potent substances such as opioids on the Dark Web indicates that the current drug policies are ineffective. Criminalizing drug use facilitates opportunities for illicit drug markets to operate both on the streets and online, including highly elusive spaces like the Dark Web. As found in this study, despite efforts to curb the availability of illicit substances on the Dark Web, cryptomarkets list these substances for sale in abundance. The harms associated with the illicit drug trade may be mitigated by decriminalization of substance use and the availability of a regulated safe supply of psychoactive substances."

Sudan HK, Tai AMY, Kim J, Krausz RM. Decrypting the cryptomarkets: Trends over a decade of the Dark Web drug trade. Drug Science, Policy and Law. 2023;9. doi:10.1177/20503245231215668.

27. No Relationship Between Drug Imprisonment Rates and States' Drug Problems

"One primary reason for sentencing an offender to prison is deterrence—conveying the message that losing one’s freedom is not worth whatever one gains from committing a crime. If imprisonment were an effective deterrent to drug use and crime, then, all other things being equal, the extent to which a state sends drug offenders to prison should be correlated with certain drug-related problems in that state. The theory of deterrence would suggest, for instance, that states with higher rates of drug imprisonment would experience lower rates of drug use among their residents.

"To test this, Pew compared state drug imprisonment rates with three important measures of drug problems — self-reported drug use (excluding marijuana), drug arrest, and overdose death — and found no statistically significant relationship between drug imprisonment and these indicators. In other words, higher rates of drug imprisonment did not translate into lower rates of drug use, arrests, or overdose deaths.

"State pairings offer illustrative examples. For instance, Tennessee imprisons drug offenders at more than three times the rate of New Jersey, but the states’ rates of self-reported drug use are virtually the same. (See Figure 3.) Conversely, Indiana and Iowa have nearly identical rates of drug imprisonment, but Indiana ranks 27th among states in self-reported drug use and 18th in overdose deaths compared with 44th and 47th, respectively, for Iowa.

"The results hold even when controlling for standard demographic variables, including the percentage of the population with bachelor’s degrees, the unemployment rate, the percentage of the population that is nonwhite, and median household income."

The Pew Charitable Trusts. More Imprisonment Does Not Reduce State Drug Problems: Data show no relationship between prison terms and drug misuse. March 2018.

28. The Future of Drug Policies in the EU

"Some participants noted that in their country there was a move towards greater recognition of the need for public health-oriented approaches to tackle drug problems accompanied by a shift in the goals of drug policies towards reducing drug-related harms. However, the relatively limited set of indicators that has historically been used to evaluate drug policy may have limited utility for informing on outcomes relevant to this perspective. Some drug policy experts have argued, for example, that a preoccupation with drug use prevalence as a primary outcome measure for drug policy is problematic, as it does not sufficiently consider the complexity of patterns of use or harms, nor distinguish sufficiently between different forms of drug use and the harm attributed to them. Taken together, trends suggest that moving towards drug policies that accentuate targeted approaches to reducing drug harms necessitates concomitant shifts in the focus and priorities of drug monitoring and evaluation systems. This would imply giving greater attention to indicators that monitor harm. In addition, approaches which can more holistically consider different patterns of use and how these may interact are likely to be necessary for informing future drug policy evaluations (Rhodes, 2019).

"A drug policy shift towards a focus on harms to target responses may also be accompanied by arguments for drug law reform. It is argued for example that there is evidence that suggests the criminalisation of drugs can increase some health, social and economic harms. Accordingly, there is a momentum towards seeking alternatives to criminalisation for simple possession and greater consideration in policy discourse on the possible unintended negative consequences of different policy options (Rhodes, 2019)."

European Monitoring Centre for Drugs and Drug Addiction (2023), The future of drug monitoring in Europe until 2030, Publications Office of the European Union, Luxembourg.

29. Use of Marijuana by Young People in Colorado Since Legalization

"Data on youth marijuana use was available from two sources. The Healthy Kids Colorado Survey (HKCS), with 47,146 high school and 6,704 middle school students responding in 2017, and the National Survey on Drug Use and Health (NSDUH), with about 512 respondents in 2015/16.

"HKCS results indicate no significant change in past 30‐day use of marijuana between 2013 (19.7%) and 2017 (19.4%). Also, in 2017, the use rates were not different from the national 30‐day use rates reported by the Youth Risk Behavior Survey.2 In 2017, 19.4% of Colorado high school students reported using marijuana in the past 30‐days compared to 19.8% of high school students nationally that reported this behavior.

"The 2017 HKCS found that marijuana use increases by grade level, with 11.0% of 9th graders, 17.7% of 10th graders, 23.7% of 11th graders, and 25.7% of 12th reporting use in the past 30‐days.

"The 2015/16 NSDUH, with many fewer respondents compared to HKCS, indicated a gradual increase in youth use from 2006/07 (9.1%) to 2013/14 (12.6%); however, the last two years showed decreased use, with 9.1% reporting use in 2015/16. The NSDUH showed that youth use of marijuana in Colorado (9.1%) was above the national average (6.8%)."

Impacts of Marijuana Legalization in Colorado: A Report Pursuant to Senate Bill 13-283. Colorado Department of Public Safety, Division of Criminal Justice, Office of Research and Statistics. October 2018, p. 5.

30. Impact of National Drug Policies on Drug Use Prevalence

"Differences in the prevalence of drug use are influenced by a variety of factors in each country. As countries with more liberal drug policies (such as the Netherlands) and those with a more restricted approach (such as Sweden) have not very different prevalence rates, the impact of national drug policies (more liberal versus more restrictive approaches) on the prevalence of drug use and especially problem drug use remains unclear. However, comprehensive national drug policies are of high importance in reducing adverse consequences of problem drug use such as HIV infections, hepatitis B and C and overdose deaths."

European Monitoring Center for Drugs and Drug Addiction, "2001 Annual Report on the State of the Drugs Problem in the European Union" (Brussells, Belgium: Office for Official Publications of the European Communities, 2001), p. 12.

31. Marijuana Legalization May Lead To Decreased Use By Young People

"Consistent with the results of previous researchers,2 there was no evidence that the legalization of medical marijuana encourages marijuana use among youth. Moreover, the estimates reported in the Table showed that marijuana use among youth may actually decline after legalization for recreational purposes. This latter result is consistent with findings by Dilley et al4 and with the argument that it is more difficult for teenagers to obtain marijuana as drug dealers are replaced by licensed dispensaries that require proof of age.6"

Anderson DM, Hansen B, Rees DI, Sabia JJ. Association of Marijuana Laws With Teen Marijuana Use: New Estimates From the Youth Risk Behavior Surveys. JAMA Pediatr. Published online July 08, 2019. doi:10.1001/jamapediatrics.2019.1720

32. The Future of Cannabis Policies in the Eu

"Globally, some recent changes in cannabis policies have experimented with different ways of regulating the sale and use of cannabis. Evolving cannabis policies raise numerous potential concerns about negative side-effects. These include increased commercialisation of legal cannabis; increased influence of the cannabis industry (similar to ‘big pharma’); possible increased use or more harmful patterns of use; complexities for regulatory approaches for the cannabis markets between countries that do not adopt the same policy; and tensions with UN international system for drug control and multi-national cooperation. There are also concerns related to the increased availability of products containing high levels of THC that may increase the risk of acute intoxication. There are also broader policy issues that may grow in importance should commercialised cannabis markets become established, such as what are the appropriate regulatory frameworks for addressing cannabis-impaired driving or restricting commercial availability to minors. Additionally, it was observed by some participants that an increased supply of the commercially available CBD products in some Europe countries raised concerns about possible negative effects on the consumers (EMCDDA, 2020). Possible emerging needs identified in the policy workshop included how to monitor quality assurance of cannabis-based products being produced legally in the European Union and how to identify and report on any potential risks associated with new policies and products.

"The debates about shifts in cannabis policies may also require us to make a clearer distinction between legalisation of cannabis for medical purposes and for recreational use. This is likely to require reliable information and timely monitoring of the health effects of cannabis use (medical and recreational) from the countries or regions where cannabis regulations have been changed."

European Monitoring Centre for Drugs and Drug Addiction (2023), The future of drug monitoring in Europe until 2030, Publications Office of the European Union, Luxembourg.

33. Arrests of Young People on Marijuana Charges in Colorado Since Legalization

"The number of juvenile marijuana arrests decreased 16%, from 3,168 in 2012 to 2,655 in 2017. The rate of juvenile marijuana arrests per 100,000 decreased from 583 in 2012 to 453 in 2017 (‐22%).

"The number of White juvenile arrests decreased from 2,146 in 2012 to 1,703 in 2017 (‐21%).

"The number of Hispanic juvenile arrests decreased from 767 in 2012 to 733 in 2017 (‐4%).

"The number of Black juvenile arrests decreased from 202 in 2012 to 172 in 2017 (‐15%)."

Impacts of Marijuana Legalization in Colorado: A Report Pursuant to Senate Bill 13-283. Colorado Department of Public Safety, Division of Criminal Justice, Office of Research and Statistics. October 2018, p. 5.

34. Drug Checking

"Results from samples expected to be stimulants were divergent between testing groups. Crystal methamphetamine samples tested using take-home drug checking were reported as fentanyl positive more often than on-site samples (27.6% vs. 5.2%). The same pattern was seen for cocaine samples tested using take-home drug checking (17.2% vs. 1.1%). However, the study was underpowered to evaluate equivalence between these testing groups. A small portion of the test strips (3.8%) yielded an unclear or illegible response. It is unclear what the participants did in these cases, but the inclusion of multiple test strips would have allowed for repeat testing.

"Notably, when the results of take-home drug checking were stratified based on previous experience with fentanyl test strips, there was a trend towards a smaller difference between the results of take-home drug checking and on-site drug checking. For opioids, when only results from those who were using fentanyl test strips for the first time were included, there was a difference of 1.6% between take-home drug checking and on-site drug checking. This difference was reduced to 0.6% when only including samples from those who had self-reported prior experience with using fentanyl test strips. Similar results were seen for crystal methamphetamine (28.9% to 15.2%) and cocaine (28.3% to 7.8%)."

Klaire, S., Janssen, R. M., Olson, K., Bridgeman, J., Korol, E. E., Chu, T., Ghafari, C., Sabeti, S., Buxton, J. A., & Lysyshyn, M. (2022). Take-home drug checking as a novel harm reduction strategy in British Columbia, Canada. The International journal on drug policy, 106, 103741. doi.org/10.1016/j.drugpo.2022.103741

35. Marijuana Use by Young People in Washington State Following Legalization

"More schools and students are captured in the HYS [Washington Healthy Youth Survey] than MTF [Monitoring The Future Survey] (Table). The MTF included fewer low–socioeconomic status and nonwhite youth in the prelegalization vs postlegalization period.

"Estimates from the MTF show statistically nonsignificant change in the prevalence of cannabis use for 8th graders (from 6.2% [95% CI, 4.4%-8.7%] to 8.2% [95% CI, 6.3%-10.7%];P = .16), and a significant increase for 10th graders (from 16.2% [95% CI, 14.0%-18.6%] to 20.3% [95% CI, 16.9%-24.1%]; P = .02). In contrast, the HYS shows statistically significant declines in prevalence from 2010-2012 to 2014-2016 among both 8th graders (from 9.8% [95% CI, 9.1%-10.5%] to 7.3% [95% CI, 6.6%-8.0%]; P < .001) and 10th graders (from 19.8% [95%CI, 18.6%-21.0%] to 17.8% [95%CI, 16.7%-18.9%]; P = .01). Neither MTF nor HYS analysis showed changes among 12th graders (Figure). Findings from HYS comparisons to 2014 alone were of less magnitude but similar direction."

Dilley JA, Richardson SM, Kilmer B, Pacula RL, Segawa MB, Cerdá M. Prevalence of Cannabis Use in Youths After Legalization in Washington State. JAMA Pediatr. 2019;173(2):192–193. doi:10.1001/jamapediatrics.2018.4458

36. Drug Checking Study In Vancouver, BC

"Based on our findings, distributed fentanyl test strips would be reliable for the testing of samples identified as opioids and should be more widely distributed. There is growing evidence that fentanyl test strips may help prevent overdose when included with other evidence-based strategies (Peiper, 2019). Other informal techniques such as visual inspection of a substance have been applied by PWUD, but may not be effective in substances that contain traces of fentanyl (Peiper et al., 2019). Our study situated fentanyl test strips within sites that provide naloxone kits, drug use supplies such as syringes, supervised consumption of substances, and drug checking using both test strips and more sophisticated technologies. In contrast to the potential for behaviour change from drug checking results, analysis of several cohort studies within Vancouver during the period of increasing fentanyl contamination in late 2016 showed that a majority of PWUD did not change their drug use behaviours nor translate the knowledge of a changing drug supply to an increased risk of overdose (Brar et al., 2020; Moallef et al., 2019). These findings indicate the need for targeted education and harm reduction interventions for those at risk. Distribution of testing supplies provides an opportunity for further engagement. In BC, an expansion of this pilot program, including continuation at sites included in this evaluation, has occurred to distribute fentanyl test strips labelled with instructions for use. Notably, the described positive behaviour changes rely on an individual possessing knowledge around safer ways to use substances, including knowledge around using a small amount (“test dosing”) and using with others or not alone to avoid overdose and allow for naloxone administration. Furthermore, participants identified using at an OPS/SCS as a potential behaviour, which necessitates that these services exist. Our findings around behaviour change in response to a positive fentanyl result underscore the need for comprehensive harm reduction services and education."

Klaire, S., Janssen, R. M., Olson, K., Bridgeman, J., Korol, E. E., Chu, T., Ghafari, C., Sabeti, S., Buxton, J. A., & Lysyshyn, M. (2022). Take-home drug checking as a novel harm reduction strategy in British Columbia, Canada. The International journal on drug policy, 106, 103741. doi.org/10.1016/j.drugpo.2022.103741

37. Police Seizures of Drugs in Vancouver Despite "De Facto" Decriminalization

"Among 995 participants who were interviewed in 2019–2021, 63 (6.3%) had their drugs seized by police at least once in the past 6 months. In multivariable analyses, factors significantly associated with drug seizure included: homelessness (adjusted odds ratio [AOR]: 1.98; 95% confidence interval [CI] 1.09–3.61), working in the unregulated drug market (AOR: 4.93; 95% CI 2.87–8.49), and naloxone administration (AOR: 2.15; 95% CI 1.23–3.76). In 2009–2012, 67.8% reported having obtained new drugs immediately after having their drugs seized by police. Odds of drug seizure were not significantly different between the two time periods (2019–2021 vs. 2009–2012) (AOR: 0.93; 95% CI: 0.64–1.35)."

Hayashi K, Singh Kelsall T, Shane C, et al. Police seizure of drugs without arrest among people who use drugs in Vancouver, Canada, before provincial 'decriminalization' of simple possession: a cohort study. Harm Reduct J. 2023;20(1):117. Published 2023 Aug 30. doi:10.1186/s12954-023-00833-7

38. Police Seize Drugs Without Making Arrests Under So-Called "De Facto" Decriminalization

"During the 16-month study period between June 2019 and November 2021 (June 2019–mid-March 2020 and June 2021–November 2021), 6% of our sample of people who used drugs daily in Vancouver reported having had their drugs seized by police without arrest at least once in the past 6 months. When examining the historical trends of annual prevalence, we found a declining trend in reports of drug seizure from 7% in 2009 to 3% in 2012, while the prevalence between June 2019 and mid-March 2020 and between June and November of 2021 (4–5%) remained essentially the same as the annual prevalence in 2011–2012. However, overall, the odds of drug seizure were not significantly different between the two time periods (2019–2021 vs. 2009–2012).

"The low documented numbers of recommended charges for simple possession by the VPD are often cited to indicate success of VPD’s de facto depenalization policy [24]. Certainly, recommended charges for simple possession and drug seizure without arrest are two distinct practices and not directly comparable; however, given that statistics regarding the former are almost the only data used to assess the extent of depenalization, it is worth examining the potential discrepancy between the two to deepen our understanding of street-level drug law enforcement activities. For example, in 2019, VPD recommended 36 charges for simple possession to Crown Counsel [7]. In contrast, in our study, participants reported experiencing at least 35 drug seizures by police during the 6 months prior to their interview date between June and December 2019. The number of unique events was much higher than 35 given that a substantial portion of participants (approx. 45% of those who reported the number of occurrences of police seizure of drugs) experienced having their drugs seized more than once during the same 6-month period. These findings corroborate previous anecdotal reports [8] and show that drug seizure without arrest occurs more frequently than the VPD’s recommended charges for simple possession.

"Some negative consequences of criminal justice involvement may be avoided by police not recommending charges for simple possession. However, we found that more than two-thirds of PWUD who were interviewed in 2009–2012 obtained more drugs immediately after police seized their drugs. These findings suggest that this policing practice may still lead to health and safety harms for PWUD. For example a previous qualitative study that interviewed PWUD in 2017 described that police seizure of drugs inadvertently promoted the creation of drug debts and increased the risk of drug market violence among PWUD [11]. Some PWUD were also forced to refill their drug supply hastily from an unknown unregulated drug market worker especially when experiencing withdrawal [11, 25]. Each time an individual has to return to the unregulated market, especially if accessing drugs from an unknown source, they are increasing their risk of fatal or non-fatal overdose. In this regard, drug seizure essentially ‘mimics the health and safety harms associated with criminalization’ [15], undermining the intended benefits of the VPD’s depenalization policy. Of concern, a previous qualitative study reported that some police officers in BC believed that seizure of drugs is ‘beneficial for preventing harms, including overdose’, though it was not made clear whether it referred to VPD officers or other officers in BC or both [26]."

Hayashi K, Singh Kelsall T, Shane C, et al. Police seizure of drugs without arrest among people who use drugs in Vancouver, Canada, before provincial 'decriminalization' of simple possession: a cohort study. Harm Reduct J. 2023;20(1):117. Published 2023 Aug 30. doi:10.1186/s12954-023-00833-7

39. Vancouver's "De Facto" Decriminalization of Drugs Prior To Actual Decriminalization of Possession

"In 2006, the Vancouver Police Department (VPD), the police force within the city of Vancouver in British Columbia (BC), Canada, formalized its drug policy and endorsed harm reduction as a core pillar of its strategy, alongside prevention, treatment, and law enforcement [5]. The policy encouraged the de facto depenalization of simple possession by restricting enforcement to circumstances where people are engaged in public drug use or other behaviour that the VPD believed may harm others [5], which would notably sustain roles for policing in the lives of PWUD. Similarly, in August 2020, the Public Prosecution Service of Canada released guidelines that direct prosecutors to limit the criminal prosecution of simple possession offences to the most serious manifestations of the offence (e.g. where there is a safety risk to others) [6]. Although the VPD’s published data are limited, available data indeed indicate low and declining levels of enforcement between 2016 and 2019, with recommended charges for simple possession having decreased by 67% from 109 to 36 cases [7].

"Despite VPD’s depenalization policy regarding simple possession, officers are still afforded broad enforcement discretion, including with respect to drug possession [5]. For example officers may use their ‘professional judgement’ to enforce drug seizures with or without making an arrest [5]. While anecdotal reports suggest that the police practice of drug seizure is commonplace and a driver of harm among people who use drugs (PWUD) [8], such discretionary practice is not fully captured in the VPD’s published data [9], limiting our understanding of how VPD’s policy of depenalization has been implemented at the street level."

Hayashi K, Singh Kelsall T, Shane C, et al. Police seizure of drugs without arrest among people who use drugs in Vancouver, Canada, before provincial 'decriminalization' of simple possession: a cohort study. Harm Reduct J. 2023;20(1):117. Published 2023 Aug 30. doi:10.1186/s12954-023-00833-7

40. Decriminalization of Possession and Low Threshold Limits

"The study’s findings emphasize that although some participants expect decriminalization to result in positive outcomes and felt as though the 2.5g threshold was appropriate, the majority of participants foresaw a number of significant limitations due to the defined threshold quantity. Our findings offer insights into what those limitations are. This is in line with the research and consultation process that was conducted by BC’s Ministry of Mental Health and Addiction to inform the exemption request, and by the many advocates who continue to recommend a higher threshold limit that more accurately reflects people who use drugs’ substance use profiles in BC [20]. Participants in our study proposed a number of factors that may undermine the effectiveness of the 2.5g threshold, such as continued need to purchase substances in smaller quantities, which has the potential to be “stomped” or contaminated with other substances, thus potentially increasing overdose risk. Additionally, with a threshold limit so low, it could create a market for substances to become more adulterated, which could make them increasingly dangerous for people to use. As research in other jurisdictions has shown, drug policy interventions that target drug markets can have severe impacts on the safety of the drug market and can increase overdose risk and other harms for people who rely on it [2830]. People in our study who relied on purchasing drugs in bulk suggested that the threshold could result in additional financial costs and increased overdose risk. As well, police discretion to arrest and charge above the 2.5g threshold could result in the unintended consequence of increasing drug-related arrests, such as through targeted search and seizures and increased surveillance of drug trafficking.

"The implementation and enforcement of the policy, and particularly the 2.5g threshold, will likely be of utmost importance when evaluating whether the policy is meeting its proposed objectives, as the threshold will be used to delineate between those who will be criminalized versus those who will not. Currently, there is no publicly available information regarding what types of information police will take into consideration when deciding what amount above the 2.5g threshold will be considered possession for personal use versus for trafficking purposes, and whether a criminal or health response will be taken. This therefore has significant implications for law enforcement who are tasked with enforcing the policy. Data from Australia suggest that based on individual drug use patterns, even when there are clear threshold limits for personal possession/use versus trafficking, some people who use drugs are still at risk of being criminalized for possession and/or trafficking if their personal use exceeds current thresholds [16]. Recognizing this, it has been suggested that in BC, the threshold should be considered a ‘floor’ not a ‘ceiling’ [19], meaning that people who possess over the 2.5 g threshold should not automatically be considered as carrying for trafficking purposes and that law enforcement should be guided by explicit direction to avoid criminalizing people who use drugs. Such a broad interpretation would recognize that people who use drugs who have varying patterns of use might need to possess over the 2.5g limit but would not necessarily be doing so for trafficking purposes."

Ali F, Russell C, Greer A, Bonn M, Werb D, Rehm J. "2.5 g, I could do that before noon": a qualitative study on people who use drugs' perspectives on the impacts of British Columbia's decriminalization of illegal drugs threshold limit. Subst Abuse Treat Prev Policy. 2023;18(1):32. Published 2023 Jun 15. doi:10.1186/s13011-023-00547-w

41. Good Samaritan and Naloxone Access Laws Save Lives

"GAO found that 48 jurisdictions (47 states and D.C.) have enacted both Good Samaritan and Naloxone Access laws. Kansas, Texas and Wyoming do not have a Good Samaritan law for drug overdoses but have a Naloxone Access law. The five U.S. territories do not have either type of law. GAO also found that the laws vary. For example, Good Samaritan laws vary in the types of drug offenses that are exempt from prosecution and whether this immunity takes effect before an individual is arrested or charged, or after these events but before trial.

"GAO reviewed 17 studies that provide potential insights into the effectiveness of Good Samaritan laws in reducing overdose deaths or the factors that may contribute to a law’s effectiveness. GAO found that, despite some limitations, the findings collectively suggest a pattern of lower rates of opioid-related overdose deaths among states that have enacted Good Samaritan laws, both compared to death rates prior to a law’s enactment and death rates in states without such laws. In addition, studies found an increased likelihood of individuals calling 911 if they are aware of the laws. However, findings also suggest that awareness of Good Samaritan laws may vary substantially across jurisdictions among both law enforcement officers and the public, which could affect their willingness to call 911."

"Most States Have Good Samaritan Laws and Research Indicates They May Have Positive Effects," US General Accountability Office, March 2021, GAO-21-248.

42. Police Attitudes, Enforcement, and Decriminalization of Possession

"Our study also underscores the importance of recognizing the long history of uncertainty, punitive actions, and negative experiences with police among people who use drugs. Decriminalization in BC and implementation among police has important implications regarding building trust between people who use drugs, the community, and law enforcement. While there is the potential to reduce stigmatization and criminalization against people who use drugs, the discretionary power of law enforcement will play a large role in achieving these outcomes. Given the fear of police discretion and subsequent criminalization, the enforcement of the 2.5g threshold by police will be pivotal in reducing criminal penalties for people who use drugs in BC. Participants feared that some cities, particularly rural and remote or Northern and more isolated locations, would still experience criminalization for their drug use, and this was especially noted for marginalized and racialized populations and rural/remote communities. These sentiments have been noted in previous qualitative research on decriminalization where people who use drugs in Australia expressed concerns about how discretionary practices by police would impact the ways in which the policy is implemented, and called for clearly defined law enforcement measures to eliminate any discrepancies or grey areas in enforcement [31]. In Canada, previous reforms to drug policy, such as the Good Samaritan Drug Overdose Act, were ultimately undermined by a lack of knowledge and implementation among police, who continued to arrest individuals for possession despite the decriminalization of simple possession at overdose events [32, 33]. This policy had a number of shortcomings, such as ambiguity around police’s discretion when encountering people with drug paraphernalia on them or those who had outstanding warrants for their arrest, demonstrating the importance of recognizing the potential harms that shortsighted policies combined with continued use of police discretion may result in.

"Although study participants, people who use drugs and their allies have called for a more hands-off approach and an overall decentralization of police involvement in drug use, citing major concerns in relation to police use of discretion, as it stands, the policy and the 2.5g threshold will continue to be enforced by police [34]. Therefore, police knowledge on decriminalization and its goals, as well as training, will likely play a direct role in how police apply their discretion during enforcement of the policy. As part of the policy implementation plan, the BC MMHA have incorporated different phases of robust police training starting with Phase 1 in November 2022, and Phase 2 launching in Summer 2023 [35]. While the specifics of the training modules are not publicly available yet, the implementation paths allude to the importance and need for tailored and targeted police training measures. These training measures should incorporate awareness and education on different substance use practices and profiles that may criminalize people who use drugs who are polysubstance users, or who carry more than the allocated threshold because of location, tolerance, need, or accessibility. Frontline law enforcement officers must be made aware of established service pathways to be able to support people who use drugs, and adjunct health system improvements will need to be implemented to strengthen these connections and the capacity of services to provide support. Furthermore, under the MMHA plan, it is imperative that appropriate resources, training, and education are provided to inform police on how to engage with people who use drugs from different communities, guided by a public health and anti-stigma lens. If law enforcement officers are trained on how to identify different drugs, the ways in which drugs are commonly sold and packaged, and the various patterns of use among polysubstance users, then they may be able to exercise more appropriate discretion when applying the 2.5g threshold during an interaction with people who use drugs. As part of the policy, police will be mandated to provide resource cards with information on local health and social services to people who use drugs who request them, and provide referrals to these organizations upon request [35]. These connections will also be key to the policy’s objectives, and if done correctly and appropriately, can reduce stigma, and facilitate access to treatment or harm reduction services [36]. However, extant research suggests that even in situations where police have de-penalized simple possession, the ways in which this is enforced can vary and can result in significant inconsistencies, inequities, and harms, including net widening effects [37]."

Ali F, Russell C, Greer A, Bonn M, Werb D, Rehm J. "2.5 g, I could do that before noon": a qualitative study on people who use drugs' perspectives on the impacts of British Columbia's decriminalization of illegal drugs threshold limit. Subst Abuse Treat Prev Policy. 2023;18(1):32. Published 2023 Jun 15. doi:10.1186/s13011-023-00547-w

43. Safe Supply Works

"Among residents of a COVID-19 isolation hotel shelter for people experiencing homelessness, we found that an emergency, provisional safe supply program (i.e., prescribing pharmaceutical-grade medications and beverage-grade alcohol) was associated with low rates of adverse events and high rates of successful completion of the 14-day isolation period. No shelter residents experienced an overdose during their stay. We identified medication dosage ranges that generally fell within those recommended in “risk mitigation” prescribing guidelines, which were urgently produced in response to evolving risks of COVID-19."

Brothers, T. D., Leaman, M., Bonn, M., Lewer, D., Atkinson, J., Fraser, J., Gillis, A., Gniewek, M., Hawker, L., Hayman, H., Jorna, P., Martell, D., O'Donnell, T., Rivers-Bowerman, H., & Genge, L. (2022). Evaluation of an emergency safe supply drugs and managed alcohol program in COVID-19 isolation hotel shelters for people experiencing homelessness. Drug and alcohol dependence, 235, 109440. doi.org/10.1016/j.drugalcdep.2022.109440

44. Child-Centered Harm Reduction

"This term, which we hope can over time be employed as a keyword in the literature, is intended to foreground children under the age of majority and for whom child rights laws apply in harm reduction theory, policy and practice. Child-centred harm reduction draws attention to the specificities of childhood in harm reduction work. Existing theories of harm reduction may need adaptation to the sociology and psychology of childhood, including the interconnected relationship between parent and child, family-centred care, and attention to children’s rights (see Maynard et al., 2019). Some interventions may not be practical, effective or ethical for children (Watson et al., 2015). Research on existing harm reduction services that work with minors – including those that may not strictly be permitted to do so - may place those children or the service at risk. Issues of consent, identity, agency and maturity, as well as the child’s ‘best interests’ may challenge the assumptions and premises upon which ‘low threshold’ harm reduction services are delivered (Barrett, Petersson, & Turner, 2022). Different legal and human rights standards are engaged, from drug laws to family law to child rights. Child protection laws may require duties of reporting that affect harm reduction service provision and research (ibid). In some cases both parent and child can be legal minors, leading to further challenges and complications regarding assessments of best interests. National, regional and international policy frameworks may need renewed scrutiny through a child-centred harm reduction lens (see for example Barrett, 2015).

"The term is not perfect. For example, ‘child’ may conjure the image of only very young children, when the majority of drug use would involve older adolescents. Few seventeen year-olds would refer to themselves as children. However, those under the age of 18 are legal minors in most contexts, and are ‘children’ for the purposes of child rights. Other terms, such as ‘youth harm reduction’ reproduce the problem of age ranges noted above, while ‘adolescent harm reduction’ omits younger children. ‘Adolescence’ can also extend beyond the age of majority. ‘Paediatric harm reduction’ was considered, but implied an overly medical approach.

"The word ‘centred’ is critical. Our view of child-centred harm reduction extends from neonates to adolescents, with all of the challenges and differing capacities and relationships that arise at these stages of development. Centring the child is key and draws our attention also, for example, to dependent children in adult harm reduction work. We believe that ‘child-centred’ focuses on the specificities of childhood in harm reduction and captures a holistic, rights-based, and person-centred approach."

Barrett, D., Stoicescu, C., Thumath, M., Maynard, E., Turner, R., Shirley-Beavan, S., Kurcevič, E., Petersson, F., Hasselgård-Rowe, J., Giacomello, C., Wåhlin, E., & Lines, R. (2022). Child-centred harm reduction. The International journal on drug policy, 109, 103857. Advance online publication. doi.org/10.1016/j.drugpo.2022.103857

45. Law Enforcement Disruption of Drug Markets and Overdose

"Our population-based study provides evidence that police seizures of substances identified as opioids or stimulants are significantly associated with increased spatiotemporal clustering of overdose events in the immediate surrounding geographic area (radii of 100 m, 250 m, and 500 m) over 1-, 2-, and 3-week periods. Importantly, the difference in spatiotemporal clustering of all 3 overdose event rates before and after opioid-related seizures was higher than expected under the estimated null distribution across all radii and time intervals although this pattern of association was less consistent among stimulant-related seizures. This is consistent with our hypothesized mechanism because persons with opioid use disorder who lose their supply will experience both diminishing tolerance and withdrawal, whereby even the anticipation of painful symptoms may lead them to seek a new supply while discounting risks that stem from the differences in potency inherent in an illicit opioid market; this results in unknown tolerance, uncertainty about a safe dose, and increased overdose risk."We were unable to assert a causal relationship between law enforcement drug market disruptions and overdose, and our study was not designed to, but our results are consistent with other evidence of this association.18,19,2224 Moreover, federal agencies already recognize the harms that emerge from these disruptions; for example, the Centers for Disease Control and Prevention developed the Opioid Rapid Response Program, an interagency effort designed to reduce overdose by rapidly increasing access to treatment of chronic pain and substance use disorder in the wake of enforcement actions against pain clinics and opioid prescribers.25,26 Routine supply-side interdictions among police may merit similar efforts to prevent resulting overdose in the surrounding community—but with more frequent need, given the prevailing volume of seizures."Officers might also use the considerable discretion at their disposal when interacting with persons who use drugs, particularly in enforcing misdemeanors or nonviolent felonies that regulate drugs to reduce harms that might come from disrupting an individual’s drug supply.27 Additionally, our study suggests that information on drug seizures may provide a touchpoint that is further upstream than other postoverdose events, providing greater potential to mitigate harms. For example, although the role of law enforcement in overdose remains a topic of debate,28 public safety partnerships could entail timely notice of interdiction events to agencies that provide overdose prevention services, outreach, and referral to care.25"

Ray, B., Korzeniewski, S. J., Mohler, G., Carroll, J. J., Del Pozo, B., Victor, G., Huynh, P., & Hedden, B. J. (2023). Spatiotemporal Analysis Exploring the Effect of Law Enforcement Drug Market Disruptions on Overdose, Indianapolis, Indiana, 2020-2021. American journal of public health, 113(7), 750–758. doi.org/10.2105/AJPH.2023.307291

46. Lessons from Opening the US's First Legally-Recognized Supervised Consumption Sites: Local Engagement

"NYC engaged in a series of discussions with local, state, and federal stakeholders to gauge the viability of opening OPCs in the absence of clear authorization. Strong political engagement of local stakeholders—including the New York City Police Department (NYPD), district attorneys, and local elected officials—was critical to not only mitigate risks of local enforcement against OPC operations but also to ensure successful service provision. Education and engagement of city agencies and elected officials have been ongoing since the release of the feasibility report in 2018. In the ensuing years, the NYC Health Department facilitated multiple visits to OPCs in Europe and Canada to allow local leaders, including senior NYPD officials and some district attorneys, to witness OPC operations and community health and safety impacts. Following the city’s renewed commitment to OPCs in 2021, the NYC Health Department conducted briefings for local elected officials and NYC District Attorneys to secure support for or, at minimum, neutrality toward OPCs.

"One significant component of the NYC Health Department’s local political engagement strategy was to consistently advocate for OPCs as the evidence-based, structural response to not only prevent overdose deaths but also reduce public drug use and syringe litter—neighborhood quality of life issues that were particularly salient for community members, local businesses, visitors, elected officials, and city agencies during the summer of 2021. For example, NYC framed OPCs as one intervention to address public drug use in the city’s “joint operations” initiativeFootnote4, a collaboration among the NYC Health Department, Department of Homeless Services, Police Department, health + hospitals, and the Department of Sanitation. By consistently citing the strong evidence base for OPCs, the NYC Health Department was able to develop buy-in across agencies in support of OPCs as an actionable strategy to address the overdose epidemic and reduce public drug use.

"In addition to discussions at the local level, extensive engagement with federal and state officials was necessary to assess and mitigate the risk of interference, particularly in the absence of clear endorsements of OPC operations from the federal and state governments. NYC Health Department and the de Blasio administration informed leadership at the NYS Governor’s Office, NYS DOH, and NYS Office of Addiction Services and Supports (OASAS) of NYC’s intention to implement OPCs in NYC as well as federal leaders at Health and Human Services (HHS), Substance Abuse and Mental Health Services (SAMHSA), and the Office of National Drug Control Policy (ONDCP)Footnote5. Ultimately, in response to the unprecedented number of fatal overdoses reported in 2020, Mayor de Blasio made the decision to endorse OPCs in NYC without explicit support or legal authorization from the federal or state government."

Giglio, R.E., Mantha, S., Harocopos, A. et al. The Nation’s First Publicly Recognized Overdose Prevention Centers: Lessons Learned in New York City. J Urban Health (2023). doi.org/10.1007/s11524-023-00717-y

47. Lessons from Opening the US's First Legally-Recognized Supervised Consumption Sites: Community Engagement

"As with any service provided to the public, NYC Health Department viewed community engagement and education as critical to the success of OPCs, particularly given the stigma that substance use providers and participants often face. Prior to implementation, the NYC Health Department conducted general educational briefings with local community groups and leaders in neighborhoods across the city, including those where the OPCs would be located. This entailed conducting broad public education and engagement about harm reduction as an effective and life-saving approach to drug use and the overdose crisis while incorporating information about OPCs as an additional proven public health strategy to prevent fatal overdoses. Similar to political engagement strategies, materials used for community engagement further emphasized the strong evidence supporting the impact of OPCs in improving public safety and addressing concerns about syringe litter and public drug use.

"Through our education efforts, including attendance at Community Board and other community group meetings, the city emphasized the value that an OPC could bring to directly address many of these quality-of-life-related concerns, including syringe litter and public drug use. Furthermore, it was beneficial that OPC services were slated to open in existing SSP facilities, which also house wraparound health and social services, avoiding the need to site a new location."

Giglio, R.E., Mantha, S., Harocopos, A. et al. The Nation’s First Publicly Recognized Overdose Prevention Centers: Lessons Learned in New York City. J Urban Health (2023). doi.org/10.1007/s11524-023-00717-y

48. Criminalization Does More Harm Than Good

"Our study adds to a growing body of literature that suggests drug criminalization and supply-side interdiction might produce more public harm than public good. This casts doubt on the core assumption of state and federal drug policy and suggests that police officers intending to protect the public’s health and safety may be inadvertently exacerbating harms such as fatal overdose. Policymakers need to revisit the role drug policies play in perpetuating an overdose epidemic that is negatively affecting the nation’s life expectancy. This should include careful consideration of the population-level consequences from decades of interdiction efforts that have not resulted in any meaningful reduction in the price or availability of drugs in the community over any substantial period and may contribute to increased risk of overdose and its sequelae, including death."

Ray, B., Korzeniewski, S. J., Mohler, G., Carroll, J. J., Del Pozo, B., Victor, G., Huynh, P., & Hedden, B. J. (2023). Spatiotemporal Analysis Exploring the Effect of Law Enforcement Drug Market Disruptions on Overdose, Indianapolis, Indiana, 2020-2021. American journal of public health, 113(7), 750–758. doi.org/10.2105/AJPH.2023.307291

49. Lessons from Opening the US's First Legally-Recognized Supervised Consumption Sites: Ongoing Engagement

"Once OPCs were operating in NYC, local Community Board members and other local leaders were invited to tour the sites and see the services firsthand. This has been a powerful tool to demystify OPCs and educate observers about harm reduction. It was helpful, in terms of building community support, that OnPoint already had strong community relationships developed over more than 20 years of operating an SSP. As a result of OnPoint NYC’s consistent community engagement, many community leaders and elected officials have grown to appreciate their work and now serve as strong advocates for OPC services. Some have even called for the expansion of OPC services to other boroughs.

"The city also faced opposition from community boards and several advocacy groups in East Harlem and Washington Heights. In East Harlem, in particular, the local community board felt that the opening of an OPC in their community would contribute to an existing “oversaturation” of social and addiction services in the area. Below is an excerpt from a letter to the NYC Health Department, Community Board 11, regarding oversaturation concerns, May 17, 2022:

"Like, so many other low-income communities of color, East Harlem has been burdened with hosting more than its fair share of social service facilities, including an oversaturation of mental health and substance abuse treatment and prevention programs. Individuals from not just the five boroughs but as far as Westchester and Long Island participate in programs in our community. This has created a strain on resources and contributed to a range of quality of life and public safety concerns for years on end.

"It has remained critical that the NYC Health Department continue to highlight the connection to services/care provided at OPCs, including provision of substance use disorder treatment on-site or through referrals. Since the OPCs opened, briefings for community stakeholders have continued and now include information about the benefits and successes of the OPCs while providing a forum to respond to community questions."

Giglio, R.E., Mantha, S., Harocopos, A. et al. The Nation’s First Publicly Recognized Overdose Prevention Centers: Lessons Learned in New York City. J Urban Health (2023). doi.org/10.1007/s11524-023-00717-y

50. Safe Supply

"The prescribing practices described in this evaluation – safe supply medications and managed alcohol, for unwitnessed consumption – are a recent development. While the relative safety of medications and alcohol dispensed for unwitnessed consumption has not been previously well-described in the literature, the practice is an extension of the evidence from witnessed consumption settings (Bonn et al., 2021; Brothers et al., 2022; Tyndall, 2020; Hales et al., 2020; Bonn et al., 2021). Witnessed injectable OAT (iOAT) with liquid hydromorphone or diacetylmorphine (Heroin) has a robust evidence-based and has been incorporated into Canadian clinical practice guidelines for opioid use disorder (Oviedo-Joekes et al., 2016; Fairbairn et al., 2019). Qualitative studies have evaluated the benefits of witnessed hydromorphone tablet consumption, which is more flexible and less resource-intensive than witnessed iOAT (Ivsins et al., 2021; Ivsins et al., 2020). A recent study from Ottawa, Canada, describes positive outcomes for people with severe opioid use disorder who are provided hydromorphone iOAT along with supported housing (Harris et al., 2021). Benefits of managed alcohol programs are also clearly established for people with severe alcohol use disorder, and particularly people who drink non-beverage alcohol (Stockwell et al., 2021; Stockwell et al., 2018; Crabtree et al., 2018). Some existing managed alcohol programs include once-daily alcohol dispensing and/or unwitnessed ingestion (Pauly et al., 2018)."

Brothers, T. D., Leaman, M., Bonn, M., Lewer, D., Atkinson, J., Fraser, J., Gillis, A., Gniewek, M., Hawker, L., Hayman, H., Jorna, P., Martell, D., O'Donnell, T., Rivers-Bowerman, H., & Genge, L. (2022). Evaluation of an emergency safe supply drugs and managed alcohol program in COVID-19 isolation hotel shelters for people experiencing homelessness. Drug and alcohol dependence, 235, 109440. doi.org/10.1016/j.drugalcdep.2022.109440

51. Harm Reduction Approach To Drug Policy

"Harm reduction is an influential approach to drug policy and practice that ‘encompasses interventions, programmes and policies that seek to reduce the health, social and economic harms of drug use’ (Rhodes & Hedrich, 2010 p. 19). While a universal definition is lacking, harm reduction is distinguished by its focus on incremental positive change regarding targeted harms, which neither presupposes nor precludes abstinence as a goal. NGOs further emphasise a commitment to human rights and social justice, necessitating the separation of drug use harms from drug policy harms, and highlighting the role of policy and legal frameworks as a driver of vulnerability (e.g. HRI, n.d; HRC, n.d). Harm reduction is a cornerstone of HIV and overdose prevention, endorsed by every relevant UN agency in this regard (United Nations, 2019). It is also increasingly influential for other forms of drug use and drug related harms. However, harm reduction has primarily developed around adult drug use, obscuring theoretical, practical, ethical and legal issues pertaining to children and adolescents under the age of majority – both relating to their own use and the effects of drug use among parents or within the family."

Barrett, D., Stoicescu, C., Thumath, M., Maynard, E., Turner, R., Shirley-Beavan, S., Kurcevič, E., Petersson, F., Hasselgård-Rowe, J., Giacomello, C., Wåhlin, E., & Lines, R. (2022). Child-centred harm reduction. The International journal on drug policy, 109, 103857. Advance online publication. doi.org/10.1016/j.drugpo.2022.103857

52. Association of Opioid Overdose Laws with Opioid Use and Mortality

"• Naloxone access laws that ease restrictions on naloxone possession and distribution are associated with a 20% reduction overdose deaths among African-Americans.

"• Good Samaritan laws, providing immunity from prosecution for those calling emergency services, are associated with broad reductions in overdose deaths, reducing overdose deaths by 13% overall.

"• None of these harm reduction measures result in increase in opioid or heroin use.

"• These laws are effective at reducing overdose mortality without creating additional opioid use. Correspondingly, these measures should be considered an important part of the strategy used to address the opioid epidemic."

McClellan, Chandler, Lambdin, Barrot H., et al. Opioid-overdose laws association with opioid use and overdose mortality. Addictive Behaviors. March 19, 2018.

53. State and Federal Changes Prior to Opening the US's First Legally-Recognized Supervised Consumption Sites

"In 2021, NY State and the USA elected executive branch leaders who publicly supported harm reduction as a public health approach to reducing overdose deaths. In April 2021, the Biden administration explicitly listed “enhancing evidence-based harm reduction efforts” as a drug policy priority for its first year in office, which NYC interpreted as potentially aligned with the concept of OPCs. Similarly, members of President Biden’s senior leadership team, including Secretary of Health and Human Services Xavier Becerra, voiced harm reduction as a priority, although they did not go so far as to endorse OPCs as a strategy. At the state level, NYS ushered in a new administration in 2021, including newly appointed health leadership who had previously contributed to efforts to explore OPCs in prior roles and was on record as supporting OPCs. Although NYS was not on an immediate path to formally authorize OPCs through executive or legislative action, it appeared that NYS would not interfere if an OPC were to open in NYC."

Giglio, R.E., Mantha, S., Harocopos, A. et al. The Nation’s First Publicly Recognized Overdose Prevention Centers: Lessons Learned in New York City. J Urban Health (2023). doi.org/10.1007/s11524-023-00717-y

54. Alcohol Use v Marijuana Use - Young People and "The Displacement Hypothesis"

"Alcohol and marijuana are the two most commonly used substances by teenagers to get high, and a question that is often asked is to what extent does change in one lead to a change in the other. If the substances co-vary negatively (an increase in one is accompanied by a decrease in the other) they are said to be substitutes; if they co-vary positively, they are said to be complements.

"Interestingly, the answer may differ by historical era. Before 2007 patterns of use for the two substances suggested they acted as complements. When marijuana use increased in the late 1970s, so too did alcohol use. Between 1979 and 1992 marijuana use declined and a parallel decline took place in annual, monthly, and daily alcohol use, as well as in binge drinking among 12th graders. As marijuana use increased again in the 1990s, alcohol use again increased with it, although not as sharply. In sum, before 2007 there was little evidence from MTF to support what we have termed “the displacement hypothesis,” which asserts that an increase in marijuana use will lead to a decline in alcohol use, or vice versa.8

"However, since 2007 a new trend has emerged that would be consistent with the “displacement” hypothesis. From 2007 through 2019 alcohol use declined markedly, reaching historic lows in the life of the study. Meanwhile, for most of this time period marijuana use has stayed steady or increased for all age groups. For the first time trends in alcohol and marijuana use are substantially diverging, suggesting that the historical relationship between these two drugs may have changed."

Miech, R. A., Johnston, L. D., O’Malley, P. M., Bachman, J. G., Schulenberg, J. E., & Patrick, M. E. (2020). Monitoring the Future national survey results on drug use, 1975–2019: Volume I, Secondary school students. Ann Arbor: Institute for Social Research, The University of Michigan.

55. Decriminalization and Enforcement of Possession Laws In Rural and Urban Communities

"Regarding the potential for inconsistent application and enforcement of the 2.5g threshold, participants suggested that smaller, Northern, or isolated communities could be particularly vulnerable to police use of discretion, which could result in important jurisdictional disparities. For instance, many participants believed that police in rural and remote settings were more likely to criminalize and discriminate against people who use drugs. Additionally, participants suggested there may be stark differences in policing culture, ideologies, and practices between urban and rural police departments. Many participants proposed that police officers in larger, urban police departments, such as the Vancouver City Police Department (VPD), were more likely to ignore personal possession of small amounts of drugs compared to smaller or rural areas."

Ali F, Russell C, Greer A, Bonn M, Werb D, Rehm J. "2.5 g, I could do that before noon": a qualitative study on people who use drugs' perspectives on the impacts of British Columbia's decriminalization of illegal drugs threshold limit. Subst Abuse Treat Prev Policy. 2023;18(1):32. Published 2023 Jun 15. doi:10.1186/s13011-023-00547-w

56. Overdose Crisis In Canada

"Canada is in the midst of a devastating overdose crisis that has been further exacerbated by the COVID-19 pandemic and, in particular, the subsequent increased toxicity of the drug supply [1]. Between January 2016 and June 2022, close to 33,000 people died from an overdose in Canada, with the provinces of British Columbia, Ontario, and Alberta accounting for 88% of those deaths [2]. Fentanyl, and to a lesser extent fentanyl analogues, have contributed to a sharp rise in the toxicity of the unregulated drug supply and fatal overdoses [2]. Between January and June 2022, fentanyl was detected in 76% of overdose deaths in Canada [2]. In Ontario, fentanyl is involved in 88% of fatal overdoses [3]. In Toronto, this number rises to 93% [3]."

Gagnon, M., Rudzinski, K., Guta, A. et al. Impact of safer supply programs on injection practices: client and provider experiences in Ontario, Canada. Harm Reduct J 20, 81 (2023). doi.org/10.1186/s12954-023-00817-7

57. Development of Safer Supply Programs In Canada

"Scaling-up interventions such as naloxone distribution programs, supervised consumption services, and opioid agonist treatment have averted thousands of overdose-related deaths in Canada, but the persistent predominance of fentanyl in the unregulated drug supply continues to fuel overdose-related deaths [4]. To complement existing interventions, many have pointed out that providing an alternative to the unregulated toxic drug supply in the form of safer supply is critical to preventing overdose-related deaths and addressing the needs of people for whom current treatment models do not work or are not a good fit [5,6,7,8,9,10,11]. This approach builds on the premise that harms caused by the unregulated drug supply can be averted by providing access to a regulated drug supply [12].

"Over the past few years, there has been a rapid scale up of safer supply programs in Canada [13]. Ontario is home to a dozen safer supply programs where primary care physicians and/or nurse practitioners work with other health care and service providers to embed safer supply prescribing within a broader model of care and supports for clients with complex health and social needs [14]. At the time of the study, safer supply medications in this province consisted of take-home hydromorphone tablets and directly observed slow-release morphine tablets, dosed and titrated to meet clients’ needs. Some programs required both medications to be directly observed for high-risk clients, such as those who report high-volume alcohol consumption or benzodiazepine use. Early evidence suggests that clients enrolled in safer supply programs have significantly reduced emergency room visits and hospitalizations, improved health care engagement, fewer overdoses and overdose-related deaths, reduced drug-related harms, and improved health and social outcomes [14,15,16,17,18,19,20,21,22]."

Gagnon, M., Rudzinski, K., Guta, A. et al. Impact of safer supply programs on injection practices: client and provider experiences in Ontario, Canada. Harm Reduct J 20, 81 (2023). doi.org/10.1186/s12954-023-00817-7

58. Cornerstones of Drug Policy in the Netherlands

"All recent policy documents state that the Dutch drug policy has two cornerstones - and this was confirmed by the Minister of Health, Welfare and Sport during the major drug debate in the House of Representatives in March 2012: to protect public health and to combat public nuisance and drug-related crime (TK 24077-259; TK Handelingen 69-28 maart 2012). In the current Opium Act Directive the objective of the drug policy is described as: 'The [new] Dutch drugs policy is aimed to discourage and reduce drug use, certainly in so far as it causes damage to health and to society, and to prevent and reduce the damage associated with drug use, drug production and the drugs trade' (Stc 2011-11134)."

Van Laar, M.W., Cruts, A.A.N., Van Ooyen-Houben, M.M.J., Van Gageldonk, A., Croes, E.A., Meijer, R.F., et al. (2013). The Netherlands drug situation 2012: report to the EMCDDA by the Reitox National Focal Point. Trimbos-instituut/WODC, Utrecht/Den Haag.

59. Safer Supply and Injection Practices

"Safer supply programs are not designed or implemented with the explicit goal of changing injection practices. However, the experiences of clients and providers help us understand how a structural intervention, such as safer supply, can impact other aspects of IDU (e.g., frequency of injection) and its associated health risks (e.g., HIV, HCV, etc.). As Perlman and Jordan [37] point out, structural interventions are important because “structural factors contribute potently to creating the context that renders individuals and areas vulnerable to the syndemic of [overdose, HCV, and HIV]” (p.109). These interventions work upstream, to change the “risk environment” [38, 39], rather than solely focusing on mitigating the downstream consequences at the level of the individual. Our study findings suggest that changing the “risk environment,” by providing an alternative to the toxic drug supply, creates more opportunities for risk reduction. Changes in injection practices identified in this analysis offer a compelling example.

"Our findings suggest that clients enrolled in safer supply programs changed their injection practices in three intersecting ways: (1) they changed how often they injected, (2) they changed what they injected, and (3) they changed their mode of consumption (from injecting to swallowing or snorting). These findings add to existing research [16,17,18] by providing a more dynamic understanding of injection practices in the context of safer supply programs and further supporting the idea that safer supply can contribute to reducing injection-related health risks in addition to overdose risks [40]. We posit that safer supply programs have the potential to address disease prevention and health promotion gaps that other stand-alone downstream harm reduction interventions (e.g., needle and syringe programs) cannot address, by working upstream and providing a safer alternative to fentanyl. As Rhodes [38] reminds us, harm reduction interventions such as needle and syringe exchange programs are crucial, but their effectiveness at preventing injection-related health risks can be undermined by a particular “risk environment.” For example, if a particular shift in the drug supply results in people injecting more frequently, such is the case with fentanyl, an HIV outbreakFootnote1 could occur even in jurisdictions where needle and syringe exchange programs are available [38].

"It is important to note, however, that not all changes in injection practices could be attributed directly to safer supply programs. We identified several indirect factors, such as poor venous access and having to inject hydromorphone tablets not intended for intravenous administration (for more on this, see study by Ivsins and colleages [17] and guidance by the British Columbia Centre on Substance Use [42]), which shaped the decision to stop injecting. Having the option of taking safer supply medications orally made this decision possible, but it is unclear if all clients who stopped injecting would have done so if they had access to a range of injectable safer supply medications and/or had better venous access. Moreover, it is unclear to what extent clients continued to inject because the safer supply medications dosage/potency was not meeting their needs, as suggested by clients who spoke of the need to supplement with fentanyl, and/or because they wanted to continue injecting. Future research should aim at exploring these nuances because safer supply programs are not intended as interventions to stop clients from injecting. If clients want to inject, they should be able to do so and access injectable safer supply medications (including injectable hydromorphone) as well as sterile supplies and supervised safer consumption services—a priority echoed in a recent report on substance use patterns and safer supply preferences of PWUD in British Colombia [43]."

Gagnon, M., Rudzinski, K., Guta, A. et al. Impact of safer supply programs on injection practices: client and provider experiences in Ontario, Canada. Harm Reduct J 20, 81 (2023). doi.org/10.1186/s12954-023-00817-7

60. Public Health Approaches To Substance Use

"Proponents of public health approaches differ in their general views of substance use, ranging from broad disapproval (Gostin & Lazzarini, 1997) to the suggestion of potential benefits (Jonas, 1994); accordingly, some calls for a public health approach focus on prevention and treatment (McLellan, 2017), while others emphasize harm reduction (Sweanor et al., 2007). Even among calls for a public health approach to opioids in North America, definitions range from those narrowly focused on population-level prevention via surveillance and research (Joranson & Gilson, 2006) to expansive ones that include a commitment to the principles of social justice, human rights, and equity (Emerson & Haden, 2021). So while public health approaches to substance use are frequently called for, what they are—or should be—remains unclear."

Crépault JF, Russell C, Watson TM, Strike C, Bonato S, Rehm J. What is a public health approach to substance use? A qualitative systematic review and thematic synthesis. Int J Drug Policy. 2023;112:103958. doi:10.1016/j.drugpo.2023.103958

61. Characteristics of a Public Health Approach to Drug Use

"Among the synthesized articles, the five most frequently cited characteristics and components of a PHA were the following (also see Table 6 for illustrative quotes):

  • "A PHA includes regulation (n=70). Some articles simply mentioned that a PHA involves regulating psychoactive substances, while others gave specific examples; the most commonly cited types of regulation were price controls (n=36), limits on availability (n=33), and advertising restrictions (n=29).
  • "A PHA includes substance use disorder treatment (n=63). Most articles mentioned that treatment generally is a part of PHAs, but others specified certain types, e.g. medication-assisted or psychosocial treatment.
  • "A PHA includes education (n=58). This category consists of interventions intended to communicate information to the public, for example through media campaigns, public service announcements, or school-based education. Most often the desired content of this education was not discussed, but 21 articles stated that PHAs involve targeting social norms around substance use and promoting “healthy behaviours.”
  • "Prevention efforts are part of a PHA (n=55). Prevention is a broad category.5 Most articles mentioned only broad types of prevention (e.g. primary or secondary) that they envision as part of a PHA, but a few also offered examples, e.g. early detection of substance use disorders as a form of secondary prevention.
  • "A PHA is distinct from a criminal justice approach (n=54). Here, articles presented PHAs as a contrast or alternative to drug policies that are centred around criminalization and incarceration."

Crépault JF, Russell C, Watson TM, Strike C, Bonato S, Rehm J. What is a public health approach to substance use? A qualitative systematic review and thematic synthesis. Int J Drug Policy. 2023;112:103958. doi:10.1016/j.drugpo.2023.103958

62. Types Of Offenses Covered by Good Samaritan Laws

"Of the 47 laws that provide criminal immunity to individuals who call for medical assistance, 44 cover drug possession offenses. The other three laws (Iowa’s, South Carolina’s, and Vermont’s) cover both drug possession offenses as well as more serious drug delivery offenses, such as selling, dispensing, or possessing drugs with an intent to sell or dispense.25 The 47 laws vary in the specific drug possession and drug delivery offenses covered by criminal immunity (immunized offenses). At the broadest level, Vermont’s law provides immunity for any drug offense.26 In comparison, the other 46 laws limit immunity to a subset of drug offenses. For example, in regards to immunized drug possession offenses, Alabama’s law limits immunity to misdemeanor drug offenses, such as possession of marijuana for personal use, whereas Illinois’s law includes some felonies, such as possession of less than 3 grams of heroin or morphine.27 In regards to immunized drug delivery offenses, Iowa’s law provides immunity if the drugs were delivered without profit, while South Carolina’s law provides immunity if the drugs were delivered to the overdose victim."

"Most States Have Good Samaritan Laws and Research Indicates They May Have Positive Effects," US General Accountability Office, March 2021, GAO-21-248.

63. A Decentralized Model for Supervised Consumption Services

"A growing body of data supports the need to deliver HIV prevention in low-barrier settings where PWUD already access services [9]. With opioid use disorder (OUD) increasingly recognized as a chronic and relapsing disease, evidence-based treatment (including medications for OUD [MOUD], harm reduction services, and others) should be integrated into primary care, pharmacies, methadone clinics, social services organizations, fire stations, or other settings alongside other chronic conditions. For example, a clinic may designate a clinic room as their OPS, with injection supplies, peer support, and healthcare personnel available to respond in case of an overdose. To patients, this could signal a non-stigmatizing culture, acknowledge that clinicians should support a patient when their substance use disorder is most active, and may facilitate discussions on MOUD during ongoing use. Drawing on successes of syringe exchange and other peer-based approaches to harm reduction, PWUD should be meaningfully included throughout program development and implementation.

"A decentralized model may have additional benefits. A majority of clients may travel only 1 mile or less to use an OPS [10], meaning that any single location may be inaccessible to some. Decentralized services would assist regions without geographically concentrated drug use. Additionally, the current epidemics, driven by illicitly manufactured fentanyl and stimulants, require frequent injection events—suitable to a decentralized model allowing multiple access points throughout the day. Finally, as federal approval or funding for OPS operation is unlikely in the near future, a decentralized model using existing healthcare infrastructure may minimize costs and improve feasibility."

Braun, H. M., & Rich, J. D. (2022). A Decentralized Model for Supervised Consumption Services. Journal of urban health : bulletin of the New York Academy of Medicine, 99(2), 332–333. doi.org/10.1007/s11524-022-00621-x

64. Prenatal Healthcare After Sentencing Reform

"Our examination of the effects of Pennsylvania’s criminal sentencing reform showed that after the policy was implemented, early prenatal care increased on average and inadequate prenatal care declined. Our fixed effects interrupted time series design used multiple points of comparison to assess whether reductions in incarceration improved racial and socioeconomic health equity. First, we found the benefits for prenatal care were largely limited to counties where prison admission rates declined the most after the policy. Second, we found that improvements were primarily observed among groups that are more likely to be affected by prison admissions, Black birthing people and those with lower levels of education, thus decreasing prenatal care inequities across these dimensions. Both points of comparison bolster confidence in the conclusion that changes in prenatal care were due to the policy and not to secular trends that affected these groups equally.

"These findings underscore the importance of contextual conditions of incarceration for preventative health care access and utilization. Prior research has largely examined individual or household-level effects of incarceration on prenatal care, [21] but prenatal care has not been examined in the prior epidemiologic literature on incarceration as a contextual effect across geographies. Moreover, previous research on incarceration as a contextual predictor of adverse birth outcomes [20, 31] has thus far not tested criminal justice reform policies as potential interventions to reduce exposure to high rates of incarceration in communities.

"Our findings also shed light on how criminal justice reforms may have spillover effects for healthcare utilization and health equity. However, the uneven implementation of the policy across counties underscores that incremental changes to criminal justice policy are unlikely to have broad effects for health equity. Several factors likely contributed to the heterogeneous implementation of the Pennsylvania’s policy, including judicial discretion and adherence to the revised sentencing guidelines. Indeed, policies like the one in Pennsylvania have been critiqued for making a small or negligible reduction in incarceration rates, and for further investing in criminal justice institutions instead of community-based services [28]. Moreover, even in counties where prison admissions declined the most, the magnitude of many of these improvements was small."

Jahn, J.L., Simes, J.T. Prenatal healthcare after sentencing reform: heterogeneous effects for prenatal healthcare access and equity. BMC Public Health 22, 954 (2022). doi.org/10.1186/s12889-022-13359-7

65. Uruguay Legalizes Marijuana

“President José Mujica has quietly signed into law the government’s plan to create a regulated, legal market for marijuana, the president’s spokesman said Tuesday. The presidential secretary Diego Canepa said Mr. Mujica signed the legislation on Monday night. That was the last formal step for the law to take effect. Officials now have until April 9 to write the fine print for regulating every aspect of the marijuana market, from growing to selling in a network of pharmacies. They hope to have the whole system in place by the middle of next year. But as of Tuesday, growing marijuana at home was legal, up to six plants per family and an annual harvest of 480 grams, or about one pound.”

Source: Associated Press, “Uruguay: Marijuana Becomes Legal,” in the New York Times, December 24, 2013.

66. Supply Reduction Has Little Or No Impact On Substance Use

"Overall, supply reduction—that is, reducing the availability of drugs—does not appear to have played as major a role as many had assumed in four of the five most important downturns in illicit drug use that have occurred to date, namely, those for marijuana, cocaine, crack, and ecstasy (see, for example, Figures 8-4, 8-5, and 8-6). The case of cocaine is particularly striking, as perceived availability actually rose during much of the period of downturn in use that began in the mid- 1980s. (These data are corroborated by data from the Drug Enforcement Administration on trends in the price and purity of cocaine on the streets.8) For marijuana, perceived availability has remained very high for 12th graders since 1976, while use dropped substantially from 1979 through 1992 and has fluctuated considerably thereafter. Perceived availability for ecstasy did increase in parallel with increasing use in the 1990s, but the decline phase for use appears to have been driven much more by changing beliefs about the dangers of ecstasy than by any sharp downturn in availability. Similarly, amphetamine use declined appreciably from 1981 to 1992, with only a modest corresponding change in perceived availability. Finally, until 1995, heroin use had not risen among 12th graders even though availability had increased substantially.

"• What did change dramatically were young peoples’ beliefs about the dangers of using marijuana, cocaine, crack, and ecstasy. We believe that increases in perceived risk led to a decrease in use directly through their impact on young people’s demand for these drugs and indirectly through their impact on personal disapproval and, subsequently, peer norms. Because the perceived risk of amphetamine use was changing little when amphetamine use was declining substantially (1981–1986), other factors must have helped to account for the decline in demand for that class of drugs—quite conceivably some displacement by cocaine. Because three classes of drugs (marijuana, cocaine, and amphetamines) have shown different patterns of change, it is highly unlikely that a general factor (e.g., a broad shift in attitudes about drug use) can explain their various trends.

"• The increase in marijuana use in the 1990s among 12th graders added more compelling evidence to this interpretation. It was both preceded and accompanied by a decrease in perceived risk. (Between 1991 and 1997, the perceived risk of regular marijuana use declined 21 percentage points.) Perceived peer disapproval dropped sharply from 1993 through 1997, after perceived risk began to change, consistent with our interpretation that perceived risk can be an important determinant of disapproval as well as of use. Perceived availability remained fairly constant from 1991 to 1993 and then increased seven percentage points through 1998.9

"• We do think that the expansion in the world supply of heroin, particularly in the 1990s, had the effect of dramatically raising the purity of heroin available on the streets, thus allowing for new means of ingestion, such as snorting and smoking. The advent of new forms of heroin, rather than any change in respondents’ beliefs about the dangers associated with injecting heroin, very likely contributed to the fairly sharp increase in heroin use in the 1990s. Evidence from this study, showing that a significant portion of the self-reported heroin users in recent years are using by means other than injection, lends credibility to this interpretation. The dramatic decline in LSD use in the early to mid 2000s is also not explainable by means of concurrent changes in perceived risk or disapproval; but availability did decline sharply during this period and very likely played a key role in reducing the use of that drug.

"We should also note that other factors, such as price, could play an important role for some drugs. Analyses of MTF data have shown, for example, that price probably played an important role in the decline of marijuana use in the 1980s, and in changes in cigarette use in the 1990s.10,11 However, price does not appear to have the same influence in all periods for all drugs, as the dramatic reduction in cocaine prevalence during the late 1980s took place at the same time that the price of cocaine decreased,12 contrary to the supply/demand model."

Miech, R. A., Johnston, L. D., O’Malley, P. M., Bachman, J. G., Schulenberg, J. E., & Patrick, M. E. (2018). Monitoring the Future national survey results on drug use, 1975–2017: Volume I, Secondary school students. Ann Arbor: Institute for Social Research, The University of Michigan.

67. Drug Decriminalization In Portugal Reduced Problematic Drug Use

"The information we have presented adds to the current literature on the impacts of decriminalization. It disconfirms the hypothesis that decriminalization necessarily leads to increases in the most harmful forms of drug use. While small increases in drug use were reported by Portuguese adults, the regional context of this trend suggests that they were not produced solely by the 2001 decriminalization. We would argue that they are less important than the major reductions seen in opiate-related deaths and infections, as well as reductions in young people’s drug use. The Portuguese evidence suggests that combining the removal of criminal penalties with the use of alternative therapeutic responses to dependent drug users offers several advantages. It can reduce the burden of drug law enforcement on the criminal justice system, while also reducing problematic drug use."

Hughes, Caitlin Elizabeth and Stevens, Alex, "What can we learn from the Portugese decriminalization of drugs?" British Journal of Criminology (London, United Kingdom: Centre for Crime and Justice Studies, November 2010), Vol. 50, Issue 6.

68. Drug Decriminalization Could Lead To Less Violent Crime

"Generalizing from the findings on Prohibition, we can hypothesize that decriminalization would increase the use of the previously criminalized drug, but would decrease violence associated with attempts to control illicit markets and as resolutions to disputes between buyers and sellers. Moreover, because the perception of violence associated with the drug market can lead people who are not directly involved to be prepared for violent self-defense, there could be additional reductions in peripheral settings when disputes arise (see Blumstein & Cork, 1997; Sheley & Wright, 1996)."

Jensen, Gary F., "Prohibition, Alcohol, and Murder: Untangling Countervailing Mechanisms," Homicide Studies, Vol. 4, No. 1 (Sage Publications: Thousand Oaks, CA, February 2000), pp. 33-4.

69. Temporary Scheduling Authority of the US Attorney General and the DEA

"Because policymakers were concerned about the effects of pharmaceutically created and other modified drugs, Congress gave the Attorney General the authority to temporarily place a substance onto Schedule I of the CSA to “avoid imminent hazards to public safety.”14 When determining whether there is an imminent hazard, the Attorney General (through the DEA) must consider the drug’s history and current pattern of abuse; scope, duration, and significance of abuse; and risk to public health.

"Once scheduled through this temporary scheduling process, a substance may remain on Schedule I for two years. The Attorney General then has the authority to keep the substance on Schedule I for an additional one year before it must be removed or permanently scheduled. The Synthetic Drug Abuse Prevention Act of 2012—Subtitle D of Title XI of the Food and Drug Administration Safety and Innovation Act (P.L. 112-144)—extended the DEA’s temporary scheduling authority. Prior to enactment of this act on July 9, 2012, the DEA was able to temporarily place a substance on Schedule I of the CSA for one year, with a potential extension of six months."

Sacco, Lisa N. and Finklea, Kristin M., "Synthetic Drugs: Overview and Issues for Congress," Congressional Research Service, Washington, DC: Library of Congress, May 3, 2016.

70. Origin of the Controlled Substances Act

"With increasing use of marijuana and other street drugs during the 1960s, notably by college and high school students, federal drug-control laws came under scrutiny. In July 1969, President Nixon asked Congress to enact legislation to combat rising levels of drug use. Hearings were held, different proposals were considered, and House and Senate conferees filed a conference report in October 1970. The report was quickly adopted by voice vote in both chambers and was signed into law as the Comprehensive Drug Abuse Prevention and Control Act of 1970."

Eddy, Mark, "Medical Marijuana: Review and Analysis of Federal and State Policies," Congressional Research Service (Washington, DC: March 31, 2009), p. 3.

71. Failure of Law Enforcement Interventions

"Based on the available English language scientific evidence, the results of this systematic review suggest that an increase in drug law enforcement interventions to disrupt drug markets is unlikely to reduce drug market violence. Instead, from an evidence-based public policy perspective and based on several decades of available data, the existing scientific evidence suggests drug law enforcement contributes to gun violence and high homicide rates and that increasingly sophisticated methods of disrupting organizations involved in drug distribution could paradoxically increase violence. In this context, and since drug prohibition has not achieved its stated goals of reducing drug supply, alternative regulatory models for drug control will be required if drug market violence is to be substantially reduced."

Werb, Dan; Rowell, Greg; Guyatt, Gordon; Kerr, Thomas; Montaner, Julio; Wood, Evan, "Effect of drug law enforcement on drug market violence: A systemic review," International Journal of Drug Policy (London, United Kingdom: International Harm Reduction Association: March 2011) Vol. 22, Issue 2.

72. Legalization, Decriminalization, and Police Priorities

"Some experts propose easing certain laws to allow the government to concentrate its limited resources on the most pressing criminal activities. For example, some advocate decriminalizing the possession of small amounts of marijuana. Others, concerned that the government may be overwhelmed, have proposed legalizing some counterfeit products and easing certain piracy restrictions. Intellectual property-related legal changes would probably require contentious negotiations with affected U.S. industries. Approaches such as these can be controversial and politically difficult; critics believe they risk sending society an inappropriate message. But some argue that similar strategies are already employed. The United States, for example, has taken steps to regularize the status of certain illegal immigrants. Many foreign countries have reduced legal penalties for marijuana possession. Some experts propose more funding for studies on various policies’ economic and social effects."

Wagley, John R., "Transnational Organized Crime: Principal Threats and U.S. Responses," Congressional Research Service (Washington, DC: Library of Congress, March 20, 2006), p. CRS 14.

73. Commissions and Reports Have For Decades Recommended Marijuana Decriminalization or Legalization

"The identification of cannabis as a potentially dangerous psychoactive substance did not, however, prevent a substantial number of these enquiries to explore the issue of whether current legislation reflected the real dangers posed by cannabis. Already in 1944, the La Guardia Committee Report on Marihuana concluded that ‘the practice of smoking marihuana does not lead to addiction in the medical sense of the word’ and that ‘the use of marihuana does not lead to morphine or heroin or cocaine addiction’ (Zimmer and Morgan, 1997). In 1968 the Wootton Report stated that ‘the dangers of cannabis use as commonly accepted in the past and the risk of progression to opiates have been overstated’ and ‘cannabis is less harmful than other substances (amphetamines, barbiturates, codeine-like compounds)’. A similar conclusion was arrived at 34 years later in 2002 when the Advisory Committee on Drug Dependence proposed the reclassification of cannabis from Class B to Class C (enforced by law in 2004 and confirmed in 2005). These views were reiterated by other enquiries, such as the Baan Committee in the Netherlands, which affirmed in 1971 that ‘cannabis use does not lead directly to other drug use’ (16) or by the US National Commission on Marihuana and Drug Abuse, which in 1973 stated that ‘the existing social and legal policy is out of proportion to the individual and social harm engendered by the use of the drug [cannabis]’ (17). The Canadian Le Dain Commission saw ‘the UN Single Convention of 1961 as responsible’ for such a situation which ‘might have reinforced the erroneous impression that cannabis is to be assimilated to the opiate narcotics’. The same commission, however, suggested that the UN Convention did ‘not prevent domestic legislation from correcting this impression’ (18)."

EMCDDA (2008), "A cannabis reader: global issues and local experiences," Monograph series 8, Volume 1, European Monitoring Centre for Drugs and Drug Addiction, Lisbon.

74. Federal Controlled Substances Act of 1970

"Enacted in 1970, the CSA [Controlled Substances Act] establishes a statutory framework through which the federal government regulates the lawful production, possession, and distribution of controlled substances.7 The CSA places various plants, drugs, and chemicals (such as narcotics, stimulants, depressants, hallucinogens, and anabolic steroids) into one of five schedules based on the substance’s medical use, potential for abuse, and safety or dependence liability.8 Further, the act requires persons who handle controlled substances or listed chemicals (such as drug manufacturers, wholesale distributors, doctors, hospitals, pharmacies, and scientific researchers) to register with the Drug Enforcement Administration (DEA) in DOJ, which administers and enforces the CSA.9 Registrants must maintain detailed records of their respective controlled substance inventories, as well as establish adequate security controls to minimize theft and diversion.10"

Garvey, Todd, "Medical Marijuana: The Supremacy Clause, Federalism, and the Interplay Between State and Federal Laws," Congressional Research Service (Washington, DC: Library of Congress, March 6, 2012), p. 2.

75. NIH Expert Panel Conclusions Regarding Methadone Treatment

"• Vigorous and effective leadership is needed within the Office of National Drug Control Policy (ONDCP) (and related Federal and State agencies) to inform the public that dependence is a medical disorder that can be effectively treated with significant benefits for the patient and society.

"• Society must make a commitment to offering effective treatment for opiate dependence to all who need it.

"• The panel calls attention to the need for opiate-dependent persons under legal supervision to have access to MMT [methadone maintenance treatment]. The ONDCP and the U.S. Department of Justice should implement this recommendation.

"• The panel recommends improved training of physicians and other health care professionals in diagnosis and treatment of opiate dependence. For example, we encourage the National Institute on Drug Abuse and other agencies to provide funds to improve training for diagnosis and treatment of opiate dependence in medical schools.

"• The panel recommends that unnecessary regulation of MMT and all long-acting agonist treatment programs be reduced.

"• Funding for MMT should be increased.

"• We advocate MMT as a benefit in public and private insurance programs, with parity of coverage for all medical and mental disorders.

"• We recommend targeting opiate-dependent pregnant women for MMT.

"• MMT must be culturally sensitive to enhance a favorable outcome for participating African American and Hispanic persons.

"• Patients, underrepresented minorities, and consumers should be included in bodies charged with policy development guiding opiate dependence treatment.

"• We recommend expanding the availability of opiate agonist treatment in those States and programs where this treatment option is currently unavailable."

"Effective Medical Treatment of Opiate Addiction," NIH Consensus Statement 1997, Nov 17-19 (Washington, DC: National Institutes of Health), 15(6), p. 24.

76. Efforts Are Needed to Overcome Opposition to Opioid Agonist Treatment

"The wide international variation in the availability of opioid agonist treatment for opioid-dependent injection drug users, despite documented scientific evidence in support of its efficacy, highlights the impact of political and philosophical forces that determine the availability of this treatment. Few proven therapies for medical conditions are restricted in this fashion. Therefore, efforts to address the political and philosophical opposition to opioid agonist treatment are needed to meet the global needs to prevent HIV transmission."

Sullivan, Lynn, David S. Metzger, Paul J. Fudala & David A. Fiellin, "Decreasing International HIV Transmission: The Role of Expanding Access to Opioid Agonist Therapies for Injection Drug Users," Addiction, February 2005, Vol. 100, No. 2, p. 153.

77. Incarceration for Drug Crimes Both Ineffective and Counterproductive

"The potency of incarceration is further diminished by three other forces, researchers have found. The first, sometimes referred to as the 'replacement effect,' applies largely to crimes that occur as part of a market, such as fencing stolen property or, most notably, drug transactions. Once incarcerated, drug dealers tend to be quickly replaced by new dealers and, as during the crack epidemic, the new recruits can be younger and more prone to violence than their predecessors.57 Thus while drug dealers no doubt deserve punishment, most leading researchers, and many law enforcement officials, now agree that incarcerating the foot soldiers in drug gangs, not to mention drug users, has a negligible impact on crime.58 Moreover, by creating job openings in drug-dealing organizations, it draws more people into criminal lifestyles and may in certain cases exacerbate crime.59"

Pew Center on the States, "One in 31: The Long Reach of American Corrections" (Washington, DC: The Pew Charitable Trusts, March 2009), p. 19.

78. Former Drug Czar Gen. Barry R. McCaffrey: "We have created an American gulag."

"We must have law enforcement authorities address the issue because if we do not, prevention, education, and treatment messages will not work very well. But having said that, I also believe that we have created an American gulag."

Gen. Barry R. McCaffrey (USA, Ret.), Director, ONDCP, Keynote Address, Opening Plenary Session, National Conference on Drug Abuse Prevention Research, National Institute on Drug Abuse, September 19, 1996, Washington, DC.

79. Drug Free Policies and Growing Underclass

"But while drug-free schools remain a fantasy, their policies are contributing to an uneducated underclass that just gets larger, more despairing, and more entrenched. This underclass now includes five million young adults between sixteen and twenty-four who are both out of school and out of work, with few skills and fewer prospects. It includes most ex-prisoners, half of whom lack a high school education, and most of whom are jobless one year after release. And it includes Black Americans and other racial minorities who have never remotely attained the standard of well-being common throughout the developed world."

Eric Blumenson, Eva S. Nilsen, "How to Construct an Underclass, or How the War on Drugs Became a War on Education," The Journal of Gender, Race & Justice, (May 2002), p. 76.

80. Marijuana Tax Act of 1937 and Federal Prohibition

"Marijuana essentially became illegal in 1937 pursuant to the Marijuana Tax Act.39 The use of marijuana required the payment of a tax for usage; failure to pay the tax resulted in a large fine or stiff prison time for tax evasion.40 Drug prohibition was elevated to another level by targeting 'marijuana,' a plant that had never demonstrated any harm to anyone.41

"Anslinger’s [Harry J. Anslinger, the first Commissioner of the Federal Bureau of Narcotics] efforts to eradicate marijuana continued when Anslinger sought similar anti-narcotic laws against marijuana at the state level.42 Guided by Anslinger’s policy direction, states began passing their own laws or adopting more strident versions of federal laws.43 By 1952, nearly all states had anti-narcotic laws in place.44"

Gilmore, Brian, "Again and Again We Suffer: the Poor and the Endurance of the 'War on Drugs,'" University of the District of Columbia Law Review (Washington, DC: The University of the District of Columbia David A. Clarke School of Law, 2011) Volume 15, Number 1, p. 64.