A few weeks ago, Oregon voters passed Ballot Measure 110, the Drug Decriminalization and Addiction Treatment Initiative. The measure eliminates criminal penalties for the possession of small quantities of drugs such as heroin, cocaine, and methamphetamine. It was one of several drug reform victories on Election Day, but Oregon’s decision is of particular interest to public health experts and recovery advocates, many of whom have pointed to decriminalization as a necessity for any widespread reduction of substance use disorders, drug-related diseases, and overdoses.

“Our drug laws are a major driver of health outcomes,” says Leo Beletsky, director of the Health in Justice Action Lab. Though existing drug laws are ostensibly about public health, “if you unroll the tape,” he says, “it’s clear that they were never really designed with health interests at the center.” Instead, he says, they have been motivated by racism and other oppressive systems — leaving health concerns surrounding drug use by the wayside.

National and global health organizations have proposed decriminalization for years. Framing people with substance use disorders as people in need of health care and social services, rather than as criminals, opens paths to getting them the help they need. The American Public Health Association (APHA) recommended “ending the criminalization of drugs and drug consumers” in a 2013 policy statement, calling the war on drugs a “severely flawed” approach.

More recently, in 2017, the Global Commission on Drug Policy called for drug decriminalization in order to effectively address the opioid epidemic. With increased numbers of people dying of overdose during the COVID-19 pandemic, “there’s never been a more apt time to rethink our approach,” says Beletsky.

Oregon, like many other states, is in need of a new approach. From 2008 to 2018, there was a dramatic increase in hospitalizations in Oregon for serious bacterial infections associated with injection drug use, according to a recent study. The authors of the study say their findings highlight a crucial need for harm reduction services, such as clean needle programs, safe injection sites, and social support for people with substance use disorders.

Because decriminalization is rare in the United States, local governments often have to look outside the country to see how these programs might work. Portugal, which decriminalized all drugs in 2001, has served as an example of what happens when a nation focuses on harm reduction rather than punishment. Since 2001, Portugal has had decreases in the numbers of new HIV cases from drug injection, Hepatitis C and B cases in drug treatment centers, and deaths from drug overdose.

While many look to the Portugal model as a successful example of decriminalization, there are key differences between Portugal and the United States that will present challenges for Oregon’s new initiative. Portugal already had lax enforcement of drug laws in contrast to the United States, which invests more heavily in carceral systems than in health and support systems. “If we’re talking about deflecting people from systems of coercion and oppression into systems of care and support,” says Beletsky, “there are no systems of care and support in many communities.” Oregon, and any states that follow its lead, will have to invest in building those systems.

The initiative calls for the establishment of more addiction recovery centers, and it requires that services at the centers be provided free of charge. People with substance use disorders, in addition to being fearful of criminal charges if they seek help, are often unable to afford the price of costly treatment. According to the measure, all services must be “evidence-informed, trauma-informed, culturally responsive, patient-centered, non-judgmental, and centered on principles of harm reduction.”

These requirements are especially significant considering the exploitative practices of many existing addiction treatment centers across the country. Funding for public treatment centers will come from both marijuana tax revenue and the reallocation of money that would otherwise be used for the costs of arrests and incarceration.

Decriminalization still does not make these drugs legal, and possession of larger quantities will still lead to penalties, though they will be reduced to misdemeanors. Possession of one or two grams, depending on the substance, will now be considered a non-criminal Class E violation. Anyone who is found with these substances will have a choice between a $100 fine or a health assessment with an addiction treatment professional.

If drug users are no longer criminalized, those who need treatment will be more likely to get it. The hope is that, with greater access to health and social services and less fear of punishment, fewer people will contract drug-related illnesses, be involved in drug-related violence, or die of overdoses. “From a public health perspective, the basic premise is that the way that we do things now drives lots of health harms,” says Beletsky, “and so there’s an opportunity to do things better.”

Supporters hope this initiative, as with the legalization of marijuana, will start a domino effect of decriminalization in more states. Kassandra Frederique, executive director of the Drug Policy Alliance, said in a press release, “We expect this victory to inspire other states to enact their own drug decriminalization policies that prioritize health over punishment.”