The overdose crisis continues to escalate. In Canada and the United States, more than 120 000 people now die annually, twice the toll in 2015. 1,2 In the global epicentre, the Canadian province of British Columbia, this corresponds to 7-8 deaths each day.The first wave of increased mortality was prompted by excessive and poorly overseen opioid prescribing. The more recent escalations reflect changing street drug markets, including the sale of, and growing appetite for, extremely potent, cheap-to-produce synthetic opioids, benzodiazepines, and amphetamines. [3][4][5] Since most policy experts agree that criminalizing these activities has failed to help, 6-9 some have proposed a decriminalization-based approach. The effectiveness of this strategy depends on how well it is executed. Some of the challenges are illustrated in the following composite cases.
Vignette 1For much of her early childhood, "Julie" was sexually abused by her father. At age 15, he sold her into slavery where she was trafficked around the world and forced to have sex with several men each day. In her early 20s, she escaped and found a supportive community. Both antidepressants and trauma therapy were provided. Both were helpful. And yet, the horrors of her past did not disappear. Instead, Julie found that the best way to achieve some peace and not kill herself was by using opioids. Methadone and buprenorphine were, for her, unpleasant, but a combination of heroin, psychotherapy, and anti depressants allowed her to get through the day and experience some happiness. When heroin was easily available, she reported, she could maintain a job and life that felt constructive, productive, and protected from the worst emotional pain.