Decriminalization or more treatment? Comparing 2 approaches to the drug overdose crisis

In early 2024, 2 of us summarized the recently initiated drug decriminalization program in the Canadian province of British Columbia.¹ The editorial highlighted the program’s potential but also expressed concerns about negative consequences if it was poorly implemented. Since few data were available, most of the commentary was based on limited experience. In the 16 months since then, preliminary data have been released. With this information, we now examine outcomes from the decriminalization program and compare them to a narrower, treatment-focused approach adopted by BC’s neighbouring province, Alberta.

In brief, there is a broad consensus among drug policy experts that criminalization has been a failed experiment. Based on the success of a multi-pronged decriminalization program in Portugal,² BC requested and received a 3-year exemption from the Controlled Drugs and Substances Act, effective Jan. 31, 2023.^3,4 Under this exemption, adults aged 18 years and older can possess up to 2.5 g of opioids, crack or powder cocaine, methamphetamine, and 3,4-methylenedioxy-methamphetamine (MDMA), corresponding to a few days’ supply for most heavy users. This decriminalization was to be accompanied by increased access to treatment, greater opportunities for job training and employment, and an expansion of harm reduction services (e.g., supervised consumption sites, needle exchange, and safe supply programs).³

For those with access to BC’s new services, there is evidence of positive effects. Drug convictions have plummeted, ⁵ supervised consumption sites have zero overdose-related deaths,⁶ and people using a regulated safe supply program have lower opioid mortality rates.⁷ Despite this, public health data from pre- and post-decriminalization⁵ indicate that BC’s decriminalization program was followed by an increase in opioid-related hospitalizations.⁸ This might reflect a greater willingness to use medical services, but drug-related deaths in BC also hit an all-time high in 2023.⁹ A more encouraging 12% decrease in overdose deaths was seen in 2024,⁹ but this shift was not specific to BC. During the same period, Canada and the United States had 12% and 24% reductions in opioid-related deaths, respectively. ^10,11 Given that decreases in overdose fatalities are seen in provinces and states without recent legal changes, the effects are hard to attribute to decriminalization. Reasons for the widespread decrease in illicit substance–related deaths in North America are unclear but could reflect several factors. These include evidence of less and lower-potency fentanyl in the drug supply.¹² Drug users may now be more likely to take drugs in the presence of others, increasing the likelihood that naloxone will be administered or medical services will be contacted. The most vulnerable might have succumbed already.¹³

The above social changes do not explain why BC has not observed larger-than-average decreases in drug use–related mortality. This is complex but plausibly reflects several factors. ⁴ Supervised consumption sites and regulated safe supply programs remain few and far between. The 2.5-g limit may have been too low, especially for those with severe addictions and living far from suppliers. Job training and employment opportunities rarely reached those most in need. And critical components of the Portuguese program are absent. In Portugal, when police identified an individual with drugs, the possessor met with a commission of mental health professionals in court.² If deemed addicted, they were given a choice between treatment and an education program. If they refused or were deemed non-dependent, they faced fines and community service. This feature was considered crucial for the marked decrease in HIV cases and drug-related deaths. Indeed, recent reductions in funding of these programs in Portugal have been associated with a resurgence of overdose problems.¹⁴ In BC, in comparison, these programs were never instituted. Instead, individuals are told what resources are available, placing the onus on the drug user to access treatment. Since publicly funded residential treatment facilities have wait-lists of several weeks,¹⁵ this lack of immediate lowor no-cost treatment likely counteracted any benefit decriminalization could have had on aiding individuals to access life-saving support.

Alberta has taken a different approach (Table 1). There are fewer supervised consumption sites and no plans to formally implement decriminalization (note: police services across Canada have been encouraged to deprioritize arrests since 2020, diminishing complications associated with criminal justice system involvement and potentially increasing willingness to seek help). Instead, the focus has been on expanding treatment access. Compared with the 3645 publicly funded residential treatment and detox beds in BC,¹⁸ Alberta has nearly 30 000 spaces.¹⁹ They have committed to opening 11 more residential recovery centres throughout the province, serving communities with the greatest need for low-barrier services. Alberta’s recovery model also includes a Virtual Opioid Dependency Program and the online My Recovery Plan tool, which allows individuals to assess, plan, and monitor their recovery in a way that is meaningful to them.¹⁶

Table 1.

Approaches to the overdose crises in British Columbia and Alberta

Feature	British Columbia	Alberta
Duration	2023–2026	Established 2019, with the first long-term treatment centre opened in May 202316
Basis for approach	Section 56 exemption from the Controlled Drugs and Substances Act from Health Canada	Recommendations from the provincial Mental Health and Addictions Advisory Council
Police involvement in response to possession	Police can offer information on health and social services; no criminal charges	Police can arrest the possessor on criminal charges
Focus on harm reduction	Large (e.g., prescribed safer supply, supervised consumption sites, naloxone kits)	Minimal (few supervised consumption sites)
Number of publicly funded detox and treatment beds17	3645 (64 per 100 000 British Columbians)	29 462 (635 per 100 000 Albertans)

Alberta’s focus on increased treatment access has been followed by encouraging changes. From 2023 to 2024, there was a 37% decrease in opioid-related fatalities,²⁰ a substantially greater reduction than in BC, the rest of Canada, and the US. Moreover, downward trends from 2023 to 2024 were reported not only for opioids, but also for methamphetamine, cocaine, and alcohol.²⁰ Although a less toxic drug supply could account, at least in part, for the reduction in illicit substance deaths, the decline in alcohol-related mortality suggests that improved access to same-day treatment is helping all substance users seek recovery.

Conclusion

The overdose epidemic poses an ongoing threat to individual life and public health. More time is needed to fully understand the effects of BC’s decriminalization program, but to fully realize the potential benefits, greater access to treatment seems critical. Although Alberta’s model might benefit from additional features too (e.g., more supervised consumption sites, needle exchange, naloxone distribution, and even safe supply and decriminalization), these are politically challenging for many constituencies. The primary lesson learned to date is that expanded treatment is superior to a multi-pronged approach that is poorly implemented.