Compassionate Coercion: Mandatory Health Diversion Programs
With the Citizen Assembly up and running, we have repeatedly heard references to Portugal’s success in decriminalising personal possession of drugs and highlighting their health diversion programme as a sound policy choice to truly embrace a health-led approach to personal drug consumption in Ireland. While we cannot disagree that Portugal’s decriminalisation has had a significant impact in some areas of drug use, such as the drop in overdose deaths and a drop in people testing positive for consumption-related illnesses such as HIV, in my opinion, it has done more damage than good for the majority of drug consumption, namely non-problematic adult use.
Diversion schemes are police-led programmes that divert people who are caught committing a minor offence such as personal possession of cannabis, away from the criminal justice system, and in the case of drug possession, they are referred to the health services for an assessment and intervention.
In 2001 Portugal broke the mould by decriminalising personal drug possession. The strategy incorporated a range of measures rather than focusing on decriminalisation alone. The government’s mains focus on the implementation of this strategy is on education, harm reduction and improving treatment and any other relevant programmes that would aid drug users to restore their family, work and social connections in society. This strategy was hailed as “a humanistic, pragmatic and health-orientated approach explicitly recognising the addict as a sick person rather than a criminal and acknowledging the inefficacy of criminal sanctioning in reducing drug use“.
The removal of criminal sanctions for individuals who are found with drugs that would constitute personal use is now treated as an administrative violation, which results in no criminal record, instead, the sanction available is limited to a monetary fine and recommended treatment options are given. The removal of criminal sanctions does not mean the removal of all contact with the criminal justice system. Police still retain a role in the discrimination framework. The police remain the main source of detection and referral, those officers that witness drug use or possession are now required to issue a citation to begin the administrative process by diverting the individual to the Drugs Dissuasion Commission, but they are not permitted to make an arrest.
The Commission operate independently from the criminal justice system and consists of legal experts, doctors and social workers. The Commission is set in an informal way to distance themselves from the Court system, usually, these take place in a room similar to a large office or meeting room, with parties sitting around a large table. The sanctions that can be imposed by the commission range from a monetary fine, a warning, a ban on visiting certain places or from associating with certain people, or drug users can be directed to seek professional help, advice or treatment. The Commission does not have the power to mandate treatment or to impose imprisonment.
In the absence of any evidence of addiction, the Commission’s role is to provide the individual with information about treatment and harm reduction that is available to support them. In addition, the Commission is mandated to suspend sanctions once the non-addicted person agrees to undergo and complete treatment. If an individual does not agree to treatment or fails to complete the treatment, the Commission can impose sanctions such as a monetary fine or impose certain restrictions. Despite the heroin epidemic being the main driving force behind the radical policy shift, the majority of citations that have been issued have been to non-problematic cannabis users. Year on year, an estimated 80% of cases that came before the Commission are suspended due to no evidence of addiction.
In August 2019 the Minister for Health and Minister for Justice announced a health diversion approach would be introduced on a phased basis in Ireland, with funding of a meagre €200,000 for the programme. There are two components to the Health Diversion Approach whereby a person in possession of drugs, determined by An Garda Síochána to be for personal use, on the first occasion would be referred by An Garda Síochána on a mandatory basis to the Health Service Executive for a health screening and brief intervention. On the second occasion, An Garda Síochána would have the discretion to issue an Adult Caution.
Minister with responsibility for the National Drug Strategy stated “Drug addiction is an illness and touches many families and communities. That is why it is so important to break down the stigma associated with drug use and to show compassion in difficult circumstances.” While we can see the good intentions behind the introduction of a health diversion programme here in Ireland, there are many concerns regarding the effectiveness of this approach.
One concern is that these programs may perpetuate the criminalisation of drug use and addiction, despite being framed as a health-focused approach. By diverting individuals into a health program as an alternative to criminal punishment, it may send the message that drug use is still a criminal and shameful activity, albeit one that can be treated as a health issue. This can further stigmatise drug users and contribute to the harmful societal attitudes that often drive punitive drug policies. By framing drug use as a health issue, these programs can reinforce the idea that drug use is something to be ashamed of and something that should be hidden from society. This stigma towards drug use is not unlike the stigma that has historically been attached to mental illness. For many years, mental illness was stigmatised and misunderstood, with people who experienced mental health problems being labelled as "crazy" or "insane." This stigma created a barrier for individuals in accessing help and support when they needed it, as they may have been reluctant to seek help for fear of being labelled as "mentally ill."
By treating drug use as a health issue, there is a risk that we may simply be replacing one form of stigma with another. Rather than labelling people who use drugs as criminals, we may be labelling them as "sick" or "diseased." This can create a new form of stigma that may make it difficult for individuals who use drugs to access help and support when they need it. As such, it is important that health diversion programs are implemented in a way that is sensitive to the needs and experiences of people who use drugs, and that recognizes the importance of reducing stigma and promoting access to health services for all.
Another concern is that these programs may not go far enough in addressing the systemic issues that contribute to drug use and addiction. While providing health services and social support can certainly help individuals overcome addiction, these programs may fail to address the root causes of drug use, such as poverty, trauma, and social exclusion. Finally, some proponents of drug reform may argue that health diversion programs can distract from the need for broader drug policy reform. By focusing on individual health outcomes, these programs may fail to address the larger systemic issues and political factors that drive drug use and addiction, such as the failed War on Drugs, racial and class disparities in drug policy enforcement, and the economic forces that perpetuate drug-related crime.
While health diversion programs can be an improvement over traditional punitive drug policies, they may still fall short of addressing the deeper issues and structural inequalities that underpin drug use and addiction. A truly effective drug policy would aim to address these underlying issues and provide comprehensive support to individuals who use drugs.
For health diversion programs to be successful, they must be designed to provide comprehensive and integrated support to individuals who use drugs. However, many health diversion programs may fall short in this regard, particularly in terms of the availability of wrap-around services and support for individuals with dual diagnoses. Wrap-around services are those that provide holistic, individualized support to individuals who use drugs. These services may include housing support, employment services, education and training, and access to legal support. However, many health diversion programs may not have the resources or capacity to provide these services, which can limit their effectiveness in addressing the underlying issues that contribute to drug use.
In addition, many individuals who use drugs also experience mental health problems or other co-occurring conditions. This is known as dual diagnosis, and it requires a specialized approach to treatment that addresses both mental health and substance use issues concurrently. However, many health diversion programs may not have the capacity or expertise to provide this kind of integrated support, which can limit their effectiveness in addressing the underlying issues that contribute to drug use. Without access to comprehensive wrap-around services and support for dual diagnosis, health diversion programs may fall short in their ability to support individuals in overcoming drug use and addiction. As such, it is important that health diversion programs are designed to provide a comprehensive and integrated approach to support, that recognizes the importance of addressing the underlying issues that contribute to drug use, including mental health problems, social exclusion, and poverty.
There is a growing recognition that health diversion programs may not be necessary or appropriate for individuals who use cannabis, particularly those who use cannabis recreationally and non-problematically. The vast majority of cannabis users fall into this category, with around 90% of all cannabis use considered non-problematic. Given this, I believe that it is not necessary to design drug policies around the small minority of cannabis users who may experience problematic use. Instead, resources should be directed towards harm reduction initiatives and public education campaigns that promote safe and responsible cannabis use. Furthermore, mandatory health diversion programs may be counterproductive for non-problematic cannabis users, as they may stigmatise and marginalise individuals who use cannabis recreationally. By treating cannabis use as a health issue, even when it is non-problematic, we risk reinforcing the idea that cannabis use is something that should be hidden from society and treated with shame. While health diversion programs may have a role to play in addressing problematic drug use, they may not be necessary or appropriate for individuals who use cannabis recreationally and non-problematically. Instead, drug policies should focus on promoting harm reduction and public education initiatives that recognize the safety and responsible use of cannabis by the majority of users.