British Columbia will be the first Canadian province to allow adult possession of small amounts of illegal drugs. Starting in January 2023 and continuing through January 2026, it will no longer be a criminal offense to possess up to 2.5 mg of crack or powder cocaine, MDMA (3,4 methylenedioxymethamphetamine), methamphetamine, or opioids (including heroin, morphine, and fentanyl) under an exemption of the federal Controlled Drugs and Substances Act.

The exemption “is not legalization,” according to the provincial government. “These substances remain illegal, but adults who have 2.5 grams or less of certain illicit substances for personal use will no longer be arrested, charged, or have their drugs seized.”

The move “will reduce stigma and harm and provide another tool for British Columbia to end the overdose crisis,” said Carolyn Bennett, minister of mental health and addictions and associate minister of health, in a statement.

Highest Death Toll

Canada is experiencing a national overdose crisis. British Columbia is among the provinces on the front line, with a “disproportionately higher rate of deaths attributed to illicit drug overdoses, at 31.2 per 100,000 population (age-adjusted), relative to 11.9 for the whole of Canada,” according to a report published in Frontiers in Communication.

In 2016, the province declared a public health emergency to address the issue, but over the past 6 years, the death rate has risen by more than 400%, hitting a record of 2224 deaths last year, up 26% from the previous year. This rate equates to an average of 6.1 deaths per day.

According to a federal government report, “toxicity of supply continues to be a major driver of the crisis.” Ensuring a safe supply is an essential step toward saving lives, and achieving that goal requires taking the prior step of decriminalization, Eugenia Oviedo-Joekes, PhD, an addictions expert at the University of British Columbia’s School of Population and Public Health in Vancouver, told Medscape Medical News.

“We have to reduce the stigma,” she said. “How are you going to reach for help if you are scared of the police? Evidence shows that using substances involves many other issues that have nothing to do with the legal system. It has to do with early trauma, with families breaking down, low income, or sometimes the other way round: a lot of money in the house. So, let’s take the legal aspect out so we can work on those things.”

Safe Supply

Oviedo-Joekes hopes for a day when people who use drugs “can just go to a physician, a prescriber, and they can access any medication.” in this context, she is referring to illegal drugs, which she says society should consider to be medications for a patient with an illness. “Folks that have issues with substances deserve the same kind of treatment that you and I deserve for lung disease, COVID, or chronic headaches,” she explained. “Sometimes the medication is the only thing sustaining the person. So, you don’t touch the medication, you leave it stable, well-dosed, and then you give the person time to work.”

Buying illegal drugs on the street leaves people vulnerable to contaminated supplies and the risk of jail time. “Where is the evidence that putting people in jail works?” asked Oviedo-Joekes. “The system has been putting people in jail for years, and nothing has improved. On the contrary, everything has gotten worse. And who goes to jail? The people who are the poorest, the ones with the darkest skin, the marginalized groups. Those of us who work in addiction care and harm reduction know that putting people in jail does not work.”

Yet ensuring a safe supply of illegal drugs is an uphill battle. Oviedo-Joekes was the lead investigator of SALOME (Study to Assess Longer-Term Opioid Maintenance Effectiveness), the results of which contributed to the establishment of North America’s first program to provide diacetylmorphine (“medical-grade heroin”) and hydromorphone to chronic substance use patients under clinical supervision. But getting the cooperation of regulatory and law enforcement organizations to expand access and to put these drugs in the hands of prescribers is extremely difficult, she said.

Opening the Conversation

“The regulations from the College of Pharmacists are so archaic that even when people want these medications, they can’t access them,” said Oviedo-Joekes. “The people have spoken, these are the medications they want, and it’s almost ridiculously impossible to get them into the hands of these folks because of the paperwork, the regulations. We are talking about people who require low-barrier services, and we made it super high-barrier.” This situation underscores the need for decriminalization, she added.

Once illicit drugs are regulated the same way that alcohol and tobacco are, people who use them and want help can make a choice about treatment, said Oviedo-Joekes. “Rehab has very, very low efficacy, but it has to exist, because for some people, that’s their choice, and personal choice is very important. What we do know is that offering a wide spectrum of medications with person-centered care is very, very effective. We are trying to make it easier for people to decide what treatment and medications they think are best for them. For some, the goal might be not using any medication at all; for others, it might be using a medication that is prescribed daily so they can function.”

Kate Johnson is a Montreal-based freelance medical journalist who has been writing for more than 30 years about all areas of medicine.

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