Pretending BC is Portugal won’t make it so

Written By Fran Yanor

The New Democrat government and its top medical health officers have heavily staked their decriminalization gambit on the drug policies of Portugal, Switzerland, Germany and elsewhere, using the European successes as a shield against criticism and proof the experiment will work in B.C. 

But the comparison is ill-informed and disingenuous.

Beyond the commonality of having actual or de facto decriminalization of drug possession for personal use in their jurisdictions, European practices bear little resemblance to what’s happening on the ground in B.C.

Four months ago, at the B.C. government’s request, the federal government green lit a three-year pilot project in the province decriminalizing personal possession of up to 2.5 grams of illegal drugs, including methamphetamine, crack and powder cocaine, fentanyl, heroin and ecstasy.  

Besides decriminalization, Portugal, Germany, Switzerland and B.C. all claim some form of a four or five-pillars drug strategy – prevention/education, harm reduction, treatment, enforcement and, in the case of Portugal, reintegration – but only the European nations have evenly funded and implemented them. 

Since the inception of Canada’s national drug strategy in 1987 (more on this later), B.C. and Canadian, policymakers have instead fixated almost singularly on either harm reduction or enforcement, neglecting prevention and treatment.  

Drug strategies done right

By comparison, the main goals of Germany’s 2012 national strategy on drug and addiction are weighted across the pillars – to counteract addiction before it develops (prevention), reduce risky consumption and premature deaths (harm reduction), help people break “the vicious cycle of addiction” (treatment) and protect the health of children and society at large from “particularly dangerous addictive substances and behaviours” (enforcement).

Switzerland’s four-pillar model from the 1990s introduced heroin-assisted treatment within a harm reduction framework that focussed squarely on preventing new drug users, treating people’s addictions through therapy and social integration, and improving the health of those who continued to consume opioids.

Similarly, Portugal’s universally venerated drug strategy includes harm reduction and enforcement but the anchor of the program is dissuasion, which relies on prevention, enforcement, treatment and reintegration to reduce the overall number of drug users by convincing them to get treatment or not to use drugs in the first place. This strategy simultaneously treats addiction as a health issue, trafficking as a crime and drug use itself as a socially unacceptable, harmful, unhealthy behaviour.

Yet Premier Eby, his ministers and public health officials appear loathe to even admit hard drug use has negative consequence, let alone that it might be dangerous. Which, it is. 

A reluctant concession

It took three months of pressure from the Opposition BC United and a steady stream of mayors beating a path to Eby’s door and all but begging for province-wide rules around hard drug use in public, before the premier finally broke his silence. Reluctantly, Eby conceded to Opposition Leader Kevin Falcon that people didn’t need to be consuming hard drugs in business alcoves, on sidewalks, and in children’s parks… as long as there was a safe injection site nearby.

In the run up to this admission, public health officers berated local governments for contemplating restrictions on hard drug use in public places. Health authority officials – not the minister of Health, he was silent – along with the minister of Mental Health and Addictions and B.C. government literature, contended that any prohibitions would hurt those who are unhoused. With few private places to use drugs, the homeless would be forced into the shadows where they couldn’t be revived from overdoses, they said.

Medical health officers further asserted to municipal councils that decriminalization would not increase drug use, deaths, crime or social costs, with some saying it would decrease the last three. As proof, they cited studies referencing the Portuguese outcomes predominantly, as well as data from Zurich, Germany and elsewhere, along with results from cannabis decriminalization in other countries. Which proves little in B.C.’s regard – apples to oranges – and accentuates how far we have to go to achieve any kind of similar success.

Eby has since promised his government will make sure “protections” are in place so public drug use doesn’t affect children, although he wouldn’t commit to a specific course of action, only that his ministers of public safety and mental health and addictions would consult with municipalities to come up with some kind of proposal.

Plea for common sense

Why did it take months to give way on such a minimal, common-sense concession?

Which drug strategy success model is the New Democrat government emulating by allowing unfettered public consumption of the most potent and addictive drugs on the planet?

Trying to reduce stigma for people who use drugs is a noble and overdue pursuit. But, surely as a society we have the emotional and intellectual dexterity to call out addiction to hard drugs for the health hazard it is, while acknowledging the public safety issues rampant public drug use can create, and at the same time, deliver empathic and responsive treatment to those caught in addiction’s grip. 

Ingesting methamphetamines, crack or powder cocaine, heroin, ecstasy and fentanyl is bad for you and people who are debilitated by addiction to these substances need health care. Full stop. 

Harm reduction: keep them alive… then what?

Instead of trying to mitigate harms and divert people from drug use as the European nations do, the B.C. approach has been mainly limited to helping drug users consume less dangerously, while preventing or reversing their overdoses. Most of us agree these measures are needed, but shouldn’t harm reduction mean much more than that?

In Germany, harm reduction efforts help people survive and stabilize as a necessary precondition for some individuals to advance to addictions treatment. This has been a common refrain by the provincial and federal mental health and addictions ministers, Premier Eby and various public health officials. 

“Keeping people alive is the first step in helping them access health care and treatment,” Jennifer Whiteside, minster of Mental Health and Addictions, has said many times in many ways.

While true and a worthy goal, it’s also a bit of misdirection. As numerous people have pointed out, including the chief coroner’s 2022 death review panel, there is no province-wide treatment system to stage people into. Until very recently, B.C.’s public health policy has been so consumed with reducing harms for drug users and preventing overdoses, barely any resources had been allocated for treatment of addictions and its underlying mental health causes. 

Harm reduction has become B.C.’s end game.

Without a comprehensive treatment and recovery system to link to, harm reduction efforts are not a steppingstone to anything, except continued breathing. 

Instead of being the entry point to a health care system that lifts people to get help for their addictions like it is in Portugal, Germany and Switzerland, harm reduction has become B.C.’s end game.

In the words of one addiction specialist: “Meet them where they’re at, but don’t just leave them there.” 

If harm reduction doesn’t open the door to a system of mental health and addiction care and it’s the only intervention in town, how will people find their way out of addiction?

If the system isn’t focussed on helping people get off drugs or preventing them from using them in the first place, how will we ever get in front of this crisis?

Portugal’s actual drug strategy

Decriminalization advocates most often point to Portugal for proof of concept because drug consumption and overdoses have plummeted in the two decades since the country decriminalized personal possession of hard drugs in 2001. 

But significantly – like, really significantly – Portugal only decriminalized simple possession after the country had established a robust, easily accessible, country-wide treatment and recovery system. 

Unlike B.C., public drug use remains illegal in Portugal. If caught consuming hard drugs in public, the drugs are confiscated, the person is issued an administrative fine, and they must appear before a dissuasion committee to have their drug consumption behaviour and life situation assessed. 

If their drug use is deemed a problem, they’re immediately channeled into a treatment system with a readily available range of options: from voluntary to coerced care; from low-barrier opioid replacement therapy, to out-patient addictions care, to residential therapeutic vocational communities. 

In Portugal, a person caught consuming in public has their drugs confiscated and their behaviour assessed to see if there’s a problem.

Decriminalization is only one aspect of a mature, nationwide treatment network designed to help people in all stages and circumstances overcome their addictions to become fully contributing members of society again. 

There are also two more critically important distinctions: all of Portugal’s treatment and recovery programs are free to access, and the services are regulated, with a medical professional in charge of each facility. 

B.C. on the other hand, has a hodgepodge of private and public treatment programs, ranging from free to financially exorbitant. The province not only lacks any uniform medical oversight requirements of treatment facilities, it doesn’t regulate, monitor or evaluate treatment programming at all. 

So how did we get to this place? 

Dr. Henry recommended five pillars

The rationale for the BC NDP 2020 election promise to decriminalize possession of hard drugs appears to have its roots in the Stopping the Harm report authored by BC Provincial Health Officer Dr. Bonnie Henry and her team in 2019. In it, Henry makes a single recommendation “to decriminalize people who possess controlled substances for personal use.”

But the line directly following her recommendation is the show-stopper: 

“Decriminalization is an evidence-based approach to drug policy that is effective in reducing harms related to substance use when reinforced with complementary measures of harm reduction, prevention, enforcement, social support, and treatment.”

Henry then immediately referenced Portugal’s five-pronged drug strategy, widely viewed as the most successful national drug strategy in the world. 

A national drug strategy is born

Ironically, while the City of Vancouver is often credited with introducing the four-pillar drug strategy in Canada in 2001, it was former Prime Minister Brian Mulroney’s Progressive Conservative government that first introduced the four-pillar concept in its Federal Drug Strategy in 1987 – almost 15 years before Portugal launched its strategy.

While B.C. has its own drug strategy and is responsible for health care delivery, the federal government funds health care and Health Canada administers the Controlled Drugs and Substances Act, regulating lawful access to otherwise illegal substances, such as cocaine, fentanyl, morphine. Drug-related crimes are prosecuted in federal courts.

Mulroney’s drug strategy was no doubt informed in part by the Le Bain Commission report in 1973 – delivered to Pierre Trudeau’s Liberal government – which recommended decriminalizing personal possession of marijuana and considering the harms to drug users, among many other findings that gathered dust for decades. In turn, the Le Bain report built on legislative initiatives and shifting public sentiment through the previous century.

But initial funding for Canada’s four pillars began under the conservatives in the late 1980s, and it was fairly balanced compared to what would follow. Of a record $210 million investment, 70 per cent went to prevention, treatment and rehabilitation, with 30 per cent to enforcement. The objectives of the day were to reduce supply and demand for drugs, and while specifically noting concern for harm to individuals, families and communities “from the abuse of drugs,” enforcement activities increased substantially, including for police involvement in anti-drunk driving campaigns.

The four pillars of Canada’s drug strategy was perhaps most equitably funded by Brian Mulroney’s conservative government.

At that time, most illicit drug overdoses involved heroin or cocaine, or a mix of more than one drug. A year after Jean Chretien’s Liberal Party won power in 1993, a federal government report on “substance abuse and public policy” noted the most abused drugs were psychotropic, and that while anyone could develop an addiction, young men, “street youths” and Indigenous people were most at risk. 

The same year, B.C.’s chief coroner Vince Cain recommended an alcohol and drug detox and treatment/recovery network be built out across the province with facilities in Prince George, Prince Rupert, Kelowna, Nanaimo, Campbell River and the Downtown Eastside in Vancouver. 

Nearly two decades later, the province picked up Cain’s thread, announcing its intention to set up regional treatment centres in three as-yet-undisclosed locations outside of Vancouver and the Lower Mainland, with about $1 billion allocated in its 2023-24 budget that promises to build up mental health and addictions services, including harm reduction, over the next three years. 

Jean Chretien’s government enabled Canada’s first legal safe injection site.

Back on Chretien’s watch, the Liberals continued a sort of hollowed out version of their predecessors’ drug strategy. Funding nosedived, and what little remained teetered disproportionately towards enforcement. The drug secretariat formed during Mulroney’s term disintegrated, causing some to refer to 1997 as the “sunset” of Canada’s drug strategy.  

Meanwhile, harm reduction measures made their first significant appearance on Canada’s drug policy scene. Health Canada issued a precedent-setting exemption under the Controlled Drugs and Substances Act allowing for the operation of Insite, North America’s first legally sanctioned supervised injection site. An experiment that succeeded in reducing HIV deaths from intravenous drug use. Insite also connected individuals to health and addiction services. Applications for similar exemptions in other cities followed.

‘Tough on crime’ era begins

Then in 2007, the federal conservatives, led by former Prime Minister Stephen Harper, swept to power. The new government incinerated the previous drug strategy and launched their own tough-on-crime National Anti-Drug Strategy

Among other things, the strategy paused new supervised consumption sites and flipped funding of the four pillars, directing 70 per cent towards enforcement, 17 per cent to treatment, and seven per cent to prevention and harm reduction, according to UBC researchers. The federal Department of Justice reported the funding more equally dispersed with 40 per cent going to enforcement, 37 per cent to treatment and 23 per cent for prevention, but the two sources agreed on one thing – harm reduction investments dropped to nearly zilch.

Under Stephen Harper’s conservative government, harm reduction funding dropped off a cliff.

Harper’s government also introduced the 2012 Safe Streets and Communities Act, which instituted mandatory minimum sentences for drug-related and other crimes. The war against drugs and crime was back on.

Then in 2016, public policy hit a hair-pin turn. 

Drug policy swings left

A year after Justin Trudeau and the Liberals formed a federal government, they chucked Harper’s National Anti-Drug Strategy and replaced it with the Canadian Drugs and Substances Strategy, which purports to support the four-pillars model, but which again summersaulted funding, this time in the harm reduction direction to combat the escalating illicit opioid overdose emergency. 

In 2019, the government also amended the Criminal Code. Bill C-75 instructs the court to give special consideration to marginalized individuals, including those suffering from mental illness or addiction, which resulted in fewer people being incarcerated for drug-related convictions, and is widely believed to have exacerbated the so-called ‘catch-and-release’ cycle of repeat offenders.

Four years later, on Jan. 31 of this year, the federal government went one step further when Health Canada exempted B.C. from the federal controlled drug act for a three-year pilot project decriminalizing personal possession of hard drugs.

The exemption was contingent on a vaguely worded letter of requirements that references the “readiness and capacity of the health and social systems,” building a “continuum of substance use services” and increasing access to prescribed safer supply, social housing and mental health supports, little of which, arguably, has been achieved.

B.C. is not Portugal

As it stands today in B.C., the decriminalization experiment is underway despite federal requirements for decriminalization not being fully met, despite the provincial health officer’s unmanifested recommendation that decriminalization be supported by five pillars, and despite the federal and provincial governments having known for decades that B.C. has an inadequate addiction and mental health treatment system. 

With Opposition Conservative Party of Canada Leader Pierre Poilievre leading in recent polls and threatening to redirect controversial safer supply resources to treatment and recovery services if his party wins a mandate in the next election, harm reduction could soon be on the chopping block again. If so, changes to the letter of requirements may follow.

If Eby wants his government to have a say on public drug use rules and safer supply policy, and wants decriminalization to find success, he and his ministers need to stop ignoring the critics and accept the ground truth of what’s happening in communities.

B.C. is not Portugal. If it was, public drug use would be illegal. As it stands, the province’s drug strategy is desperately flawed. Time for the Eby government to own it and adjust course. Otherwise, we’ll never get in front of the public health calamity destabilizing B.C. communities.

It’s a lead-the-parade-or-get-out-of-the-way moment.

Because the political pendulum dictating public health policy looks poised to swing, and if it does, it will swing hard.