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Reducing the Harms of Substance Use: Lessons From Abroad


Originally published on The Medical Care Blog, May 4, 2023. Reprinted with permission.

The way we’re addressing substance use and overdoses in the United States isn’t working.

Let’s be perfectly clear: the “war on drugs” isn’t, and never was, really a war on drugs. It's been a war waged on communities who are Black, Indigenous, and People of Color (BIPOC). The war on drugs started well before President Richard Nixon declared drug use to be “public enemy number one” and increased federal funding for drug-control agencies and drug-treatment efforts in June of 1971. It was, in fact, Harry Anslinger who launched the modern war on drugs nearly 100 years ago. From 1930-1962, Anslinger was the Commissioner of the Federal Bureau of Narcotics, now the Drug Enforcement Administration. His racist views and strict mentality toward drug laws and prison sentences catalyzed the prison-industrial complex that we have today. 

pile of a variety of pills and medications in various colors

As a result, the U.S. incarcerates more people than any other nation, with nearly half (45%) of incarcerated people in federal prisons held on drug charges. Drug laws were designed, and continue to be enacted, with racial bias. While the drug use rate is similar between African Americans and whites, the imprisonment rate of African Americans for drug charges is five times that of whites. Additionally, nearly 110,000 people died last year of drug overdoses in the United States. Yet there are stark racial differences in who receives life-saving treatment for overdoses. 


Most people who struggle with substance use, addiction, or overdoses have experienced one or more traumatic events. Trauma contributes to depression, anxiety, and loneliness. And people often use drugs as a self-soothing behavior to cope with or numb these feelings. The pivotal Adverse Childhood Experiences (ACEs) study showed that each adverse event that happened to a young person increased the likelihood of initiating substance use early in life by two to four times. And those who experienced five or more traumatic events in childhood were seven to ten times more likely to struggle with substance use and addiction. Many countries are aware of this link, and have implemented programs and measures that address trauma as a root cause of problematic substance use and overdoses. They also understand that the other social determinants of health, such as housing, employment, and education, are essential to recovery and preventing relapse.


We have much to learn from other countries that have reduced substance use and beat an overdose crisis. They have done this by placing the human, rather than drugs at the center of their approach. Let's take a look at five trailblazing countries who took a more public health-oriented approach to this problem. Each of the countries took risks and made controversial policy and service changes rooted in science to protect their residents. 

Portugal - In 2001, Portugal decriminalized the use and possession of all illicit substances, from cannabis to crack. In the fourteen years since, addiction rates have fallen and opioid overdose deaths have decreased. Portugal no longer spends resources on punishment, arrest, and imprisonment. Instead, people caught with a personal supply of substances are now offered treatment programs to help rebuild their lives. Not only did the opioid crisis stabilize with this policy change, so did overdose deaths, problematic drug use, and HIV and hepatitis infection rates. Drug-related crime and incarceration rates went down as well.

Two people holding hands, reaching out for supportUruguay - In 2012, then president José Mujica was the first president ever to fully legalize marijuana since 1930. This radical decision had positive outcomes, including a large decrease in overall drug trafficking and drug traffic systems, as well as helping poor and low-income people find healthier economic alternatives to participating in the drug trade.

Germany - Medically supervised opioid use and patient oversight are key to controlling the opioid epidemic. While Germany has a high rate of opioid use, it does not have an opioid epidemic. This is because in Germany, unlike in Canada and the U.S., prescriptions for chronic non-cancer pain are uncommon for people living outside of medical facilities. Rather, opioids are primarily used in institutional settings (e.g., fentanyl during inpatient surgery) where use is medically supervised. 

Canada - Vancouver, British Columbia has focused on harm reduction and compassionate care and seen a dramatic reduction in drug use, overdose deaths, and crime. Since 2005, the city has employed the Four Pillar Model to drug addiction, which includes harm reduction, prevention, treatment, and enforcement. This model also acknowledges trauma and poverty as underlying causes of substance use. Cities like Geneva, Zurich, Frankfurt, and Sydney also use this strategy with much success. The Downtown Eastside neighborhood of Vancouver was the first to open a supervised injection site in North America. Safe injection sites are a promising approach to saving lives and saving resources. The city of Vancouver has shown that harm reduction is what reduces illicit drug use and improves public safety. It's not punitive measures or a “war on drugs.”

Switzerland went from a heroin epidemic in the 1980s to effectively reducing deaths on legal heroin to nearly zero. This striking landscape change came about from radical policy changes, including decriminalizing substance use, offering 24-hour-a-day access to methadone programs and supervised injection sites, and offering heroin assisted treatment. Treatment is available and accessible to anyone who needs it. Between 1991 and 2010, overdose deaths in the country decreased by 50 percent, HIV and hepatitis infections decreased by 65 percent, and new heroin users decreased by 80 percent. There has also been a huge drop in crime related to buying and selling drugs. Plus, these changes have resulted in large cost savings from reduced incarceration. 


While Oregon has decriminalized drugs and other U.S. states have introduced drug decriminalization legislation, more infrastructure and resources are needed. We must work to build robust and accessible prevention and treatment systems. We must shift the task of addressing substance use from a criminal justice issue to a public health issue. Healing happens in community, building connections with other people. We know that punishment, shame, and imprisonment doesn’t work, and in fact, causes even more trauma. What does work is rational, humane, science-based harm reduction strategies. What does work is compassion, community, and comprehensive, holistic, and culturally specific treatment. As Johann Hari, the author of the book, Chasing the Scream: The First and Last Days of the War on Drugs, aptly says: "The opposite of addiction isn’t sobriety. It’s connection."