Toronto’s Model of Decriminalizing Drugs for Personal Use

Introduction
In 2021, the Toronto Board of Health directed the Medical Officer of Health to begin a process with Health Canada to decriminalize the possession of controlled drugs and substances for personal use within the City of Toronto.
As outlined in the initial submission to Health Canada on January 4, 2022, the goal of decriminalization is to reduce the mental, physical and social harms associated with criminalizing people for possessing drugs for their personal use, and it has the potential to meaningfully improve the health and wellbeing of all Torontonians.
After over a year of further community discussions and partnership building with a diverse range of stakeholders, including people with lived and living experience of drug use, service providers and first responders, Toronto Public Health recommends a Toronto model of decriminalization that includes voluntary referrals to services and creates an exemption to Section 4(1) of the Controlled Drugs and Substances Act (i.e. simple possession) for:
• All controlled drugs and substances in possession for personal use; • The whole City of Toronto, with specific exclusions; and,
• All people in Toronto, including youth.
The mandate of Toronto Public Health is to reduce health inequities and improve the health of the whole population. In addition to recommending the decriminalization of possession of controlled drugs and substances for personal use, Toronto Public Health continues to call on federal and provincial government partners to provide additional funding for a range of mental health and substance use services to improve the health and wellbeing of everyone living in the city.

Decriminalization and the Continuum of Care
Decriminalization is an upstream population health response to the drug toxicity crisis that will be accompanied by a full continuum of downstream mental health, harm reduction, and treatment services. In partnership with community providers, Toronto is taking a data-driven approach to providing critical health services in hotspot areas – places in the city where overdoses are most likely to occur, and where services are needed to save lives.
Toronto intends to have several new health and treatment services in place by the time decriminalization is implemented, including: at least one location in the downtown core offering 24/7 health and social supports, to serve as an effective alternative to emergency departments; and, an expanded Community Crisis Service, the four crisis response services for Toronto residents staffed by health and social service providers and peers. Toronto is leading the way with innovative service delivery, including the recently announced historic partnership to provide supervised consumption services in collaboration with acute care hospitals.
The future of mental health and substance use services will offer a full range of programs and health interventions to individuals, and improve the health and wellbeing of the Toronto population. This will create the downstream foundational supports to effectively implement upstream population health responses, including decriminalization.

Decriminalization: What is it and what does it mean for community safety?
Decriminalization has the potential to reduce stigma and discrimination against people who use drugs. It will make it easier for people to ask for and access a range of health and social supports, while eliminating the fear and harms of criminalization.
Although decriminalization alone will not fully improve the social determinants of health, such as access to housing, or make the unregulated drug supply safer, it will reduce the negative impact of criminalization. Without a criminal record, it will be easier for people who use drugs to find a job and a safe place to live.
Decriminalization is not legalization. It does not mean that all drugs will be legally available, which is the case with alcohol and cannabis. If Toronto’s exemption request is approved by Health Canada, the simple possession provision of the Controlled Drugs and Substances Act prohibiting the possession of controlled drugs and substances would not apply to persons in Toronto. It would no longer be criminal to possess controlled drugs and substances in Toronto for personal use — instead, individuals will be offered a voluntary referral to a range of health and social supports.
Decriminalizing the possession of drugs for personal use requires a cultural transformation in
our thinking: shifting drug use from an issue of criminal behaviour to an opportunity to advance health and human rights. Decades of stigma about drug use has led to an assumption that decriminalization might have a negative impact on community safety. However, possessing drugs for personal use does not directly cause harm to others. Available evidence on the impact of decriminalization on drug use patterns is mixed; however, a 2020 systematic review of evaluations of decriminalization and legalization in other jurisdictions found that in the majority of jurisdictions that have implemented decriminalization or legalization, drug use trends did not change and drug use did not increase.1
Toronto Public Health is working closely with community service providers and the Toronto Police Service, and will monitor a range of indicators together to ensure safety for everyone throughout the implementation of the Toronto model. We plan to establish key performance measures to allow for continuous assessment on the status of the model, since the main goal of the exemption request is to improve public health and preserve public safety.

Guiding Principles for the Toronto Model of Decriminalization

Members of Toronto’s Decriminalization Working Groups co-developed a set of principles to guide discussions on the details and goals of a Toronto model of decriminalization. There was consensus that the model and the process should:
• Centre local experience;
• Be informed by people who use drugs and who are vulnerable to criminalization;
• Recognize that the unregulated drug market is dynamic and potentially toxic;
• Reduce criminalization of people who use drugs;
• Reduce stigma and discrimination associated with drug use;
• Be clear, implementable, and measureable;
• Be easy to communicate to those in the justice system, people who use drugs, and the broader community;
• Promote equity for people who have been marginalized by criminalization;
• Ensure that decriminalization is equitably applied;
• Reduce and improve interactions between first responders and all people who use drugs in all areas of the City of Toronto;
• Be accompanied by wraparound health and social supports; and,
• Minimize unintended consequences.

Proposed Approach: Toronto Model of Decriminalization
All drugs and substances listed in the Controlled Drugs and Substances Act
In a city as diverse as Toronto, with many different patterns of drug use and communities, the model of decriminalization should apply to all drugs. Consistent rules for all unregulated drugs creates a fair legal environment and ensures that all communities and people who use drugs are equitably protected from criminal charges, regardless of which drug they use. In addition to equity considerations, a model that includes all drugs will be easier to implement and for everyone to understand.
In Toronto, the unregulated drug supply is extremely toxic, unpredictable, and dynamic – it changes all the time. Laboratory results from Toronto’s Drug Checking Service and investigations from the Office of the Chief Coroner for Ontario reveal that the unregulated drug supply continues to be more contaminated since the beginning of the drug toxicity crisis.2 Different types of drugs are often mixed together, and it is difficult for people who use drugs, the police, and healthcare providers to immediately know what is in a particular substance at any given time. Decriminalizing the personal possession of all drugs provides clarity for people who use drugs and makes it easier for law enforcement to do their jobs.

Additional information about the drugs included in the model can be found in the Frequently Asked Questions (FAQ) section.
City-wide, with some exclusions
To avoid creating unfair rules based on where someone may live or work in the city, the Toronto model should apply to all areas of the city, except for the entire premises of following locations:
• Child Care Facilities • K-12 Schools
• Airports
The exclusion of child care facilities and schools is intended to maintain alignment with provincial legislation intended to prevent alcohol, cannabis, and unregulated drug use in these settings. Airports are excluded because they fall under federal laws.
All drugs for personal use, but not for trafficking, or production
Drug use and purchasing patterns in Toronto are exceptionally diverse. Drugs in possession for personal use can vary considerably depending on the type of drugs being used, or an individual’s tolerance to a substance. For the anticipated benefits of decriminalization to be available to all Torontonians, the model should apply to all drugs in possession if they are for personal use.
Under the made-in-Toronto model, Section 4(1) of the Controlled Drugs and Substances Act, which states that no one shall possess a controlled drug or substance, would not apply to those possessing those substances in Toronto and therefore could not result in a criminal charge. However, individuals will still be investigated for and charged with trafficking and/or possession for the purpose of trafficking, exporting, or producing a controlled substance where there are reasonable grounds for any such charge.
The proposed Toronto model is expected to eliminate the harms of drug criminalization for the greatest number of people and centre the experience of people who use drugs. Toronto Police Service data demonstrates that charges for personal possession have declined since 2019, and under the Toronto model, they would drop to zero.
Toronto Public Health is working closely with partners, including the Toronto Police Service to further examine the issues associated with confiscating controlled drugs and substances from exempted persons, unless there is evidence of trafficking or another offence captured under the CDSA, such
as production. Confiscating drugs increases a range of substantial health risks for people who use drugs. For example, people may go into withdrawal if their drugs are taken from them. Withdrawal can lead to a higher risk of overdose when people use drugs again, and can pose serious danger to health on its own depending on the drug, such as an increased pulse rate, bone and joint aches, discomfort, or risk of death.

Evidence further demonstrates that confiscating drugs does not lead people to stop using drugs,
but encourages them to replace those drugs – often in less safe ways such as buying new drugs from an unknown supplier, which can also increase the risk of overdose.3 Ensuring everyone’s health and safety is of upmost importance, and Toronto Public Health and the Toronto Police Service will continue to work through the considerations relating to confiscation with partners.
All people in Toronto, including youth
Criminalization does not effectively deter youth substance use. The data show that youth in Toronto between the ages of 12 and 17 use unregulated drugs and are vulnerable to the same harms associated with criminalization as adults. In 2019, one in five (22.9%) Toronto students (grade 9-12) reported use of one or more of the following drugs in the past 12 months: heroin, fentanyl, ecstasy (MDMA), non-medical use of tranquillizers/sedatives, prescription opioids, ADHD drugs, cough/cold medicine, LSD, cocaine, mushrooms/mescaline, and methamphetamine.4 Sadly, there were eight accidental opioid toxicity deaths in the 12-17 age group from 2019-2021 in Toronto.5
There is limited evidence available to suggest that decriminalization leads to an increase in drug use behaviours, but there is substantial evidence that tells us that youth in Toronto are using unregulated drugs.6 The Toronto model of decriminalization should remove the harms associated with criminalization for as many people as possible, which includes youth.
Connecting People with the Support They Need
Many people use drugs without experiencing health-related harms or developing a substance use disorder. For those at risk of drug overdose, or in need of social services, evidence-based harm reduction services or treatment, the criminalization of drugs discourages them from seeking the support they may need due to fear, and reduces the quality of care they receive in the healthcare system.
The Toronto model proposes replacing criminal charges for the possession of drugs for personal use with voluntary referrals through the offer of a referral card. The referral card will contain information for adults and youth to help connect them to a range of health and social supports, and these multiple touch points will help to ensure that individuals are both aware and able to take advantage of all of the services available.
The referral card will include navigational support offered through 211. The card will also include information about legal rights, and specific programming for youth, available through partners like the Youth Wellness Hubs to ensure that youth and their families receive support to access youth-specific services as an alternative to criminalization.
Ongoing Work with Population Groups
African, Caribbean, and Black communities are heterogeneous, have a rich diversity of strengths and are vital to the social, cultural, and economic fabric of the city; but are also disproportionately affected by the criminalization of drugs, which has a range of negative health and social implications. The African, Caribbean, and Black Decriminalization Working Group is documenting these disparities in
a report that they will soon release. The African, Caribbean & Black Decriminalization Working Group also contributed valuable expertise and perspectives related to population-specific considerations for the proposed Toronto model.
Toronto Public Health is also building relationships with urban Indigenous partners that provide health and social services in the city. This work involves developing a shared understanding of harm reduction and the decriminalization of drugs for personal use. Relationship building is a process that Toronto Public Health will continue to work on with Indigenous partners to support Indigenous-led referral supports, seek additional funding for Indigenous-specific harm reduction and healthcare services, and collectively address the drug toxicity crisis impacting urban Indigenous communities.
Toronto Public Health is also participating in an ongoing dialogue with Treaty partners including the Mississaugas of the Credit First Nation about what decriminalization will mean for their First Nation and the actions required to ensure a meaningful relationship with Toronto Public Health and the city as a whole.
Next Steps
The proposed Toronto model reflects a balance of public health and public safety considerations, advances equity for those most impacted by the harms of criminalization, and is fully endorsed by Toronto Public Health and the Toronto Police Service.
It reflects extensive stakeholder engagement, with experts on drug use policy, including focused roundtable sessions with people with lived and living experience of drug use. It is informed by available evidence, and aims to remove harms associated with criminalization for the whole population, and specifically those populations who are most vulnerable. Within the model, the Toronto Police Service also maintain the legal tools they need to ensure community safety for everyone.
Toronto Public Health will continue to work with Health Canada on a range of implementation considerations, including a robust monitoring and evaluation framework, and looks forward to continued partnership in this work.
For additional details on the proposed Toronto model, please see the attached FAQs.

References
1 Scheim, A. I., Maghsoudi, N., Marshall, Z., Churchill, S., Ziegler, C., & Werb, D. (2020). Impact evaluations of drug decriminalisation and legal regulation on drug use, health and social harms: A systematic review. BMJ Open, 10(9), e035148.
2 Office of the Chief Coroner for Ontario. (2017-2022). Coroner’s Opioid Investigative Aid, Confirmed opioid toxicity deaths, May 2017 to September 2022.
3 Werb, D., Wood, E., Small, W., Strathdee, S., Li, K., Montaner, J., & Kerr, T. (2008). Effects of police confiscation of illicit drugs and syringes among injection drug users in Vancouver. International Journal of Drug Policy, 19(4), 332-338.
4 Boak, A., Elton-Marshall, T., Mann, R. E., & Hamilton, H. A. (2020). Drug use among Ontario students, 1977-2019: Detailed findings from the Ontario Student Drug Use and Health Survey (OSDUHS). Centre for Addiction and Mental Health. Retrieved from: https://www.camh.ca/-/media/files/pdf--- osduhs/drugusereport_2019osduhs-pdf
5 Office of the Chief Coroner for Ontario. (2017-2022). Coroner’s Opioid Investigative Aid, Confirmed opioid toxicity deaths, May 2017 to September 2022.
6 Scheim, A. I., Maghsoudi, N., Marshall, Z., Churchill, S., Ziegler, C., & Werb, D. (2020). Impact evaluations of drug decriminalisation and legal regulation on drug use, health and social harms: A systematic review. BMJ Open, 10(9), e035148.