The Cost of Criminalization: Why California Needs a Public Health Approach to Substance Use

California’s Proposition 36 has reignited debates about how to address drug use and addiction. The measure reclassifies possession of certain substances as a felony, introduces harsher penalties for other drug-related offenses, and mandates court-ordered drug treatment for certain repeat offenders. Supporters argue that this will expand access to treatment, but the reality tells a more troubling story - one that risks further destabilizing vulnerable communities and perpetuating the failures of punitive drug policies.

The Flaws in Court-Mandated Treatment

Proposition 36 relies on the assumption that court-mandated treatment will reduce substance use. However, court-mandated programs are based on faulty premises: that drug courts effectively prevent relapse, that treatment is widely accessible, and that judges and prosecutors can determine who qualifies for treatment and what defines successful treatment.

In reality, effective treatment for substances like methamphetamine requires long-term residential care - at least six months - followed by outpatient support. Yet, in California, access is limited. Medi-Cal, the state’s Medicaid program, covers only one month of residential treatment, and 22 counties lack facilities altogether.[i] Proposition 36 does not offer funding to address this capacity gap, leaving those in need without options. A statewide study[ii] showed that 20% of unhoused individuals want treatment for substance use but cannot access it due to exclusions based on Medicaid status, chronic illnesses, or prior justice system involvement.[iii]

Instead of addressing these systemic barriers, Proposition 36 doubles down on criminalization, reviving a decades-long “war on drugs” strategy that has consistently failed to improve public health or reduce substance use.

Criminalization’s Cost: Lives and Livelihoods

The war on drugs has disproportionately harmed communities of color, eroded public health, and drained resources that could have addressed the root causes of addiction. In 2020, over one million arrests related to substance use occurred in the U.S., mainly for personal possession. Black Americans, who represent just 13% of the population, accounted for 24% of these arrests despite similar drug use rates across racial groups.[iv]

Meanwhile, incarceration does little to deter drug use. It often worsens addiction by isolating individuals from support systems, exposing them to high-risk environments, and significantly increasing the likelihood of overdose deaths after release. Between 2001 and 2018, drug- and alcohol-related deaths in prisons surged by 600% and 400%, respectively.[v] In the first two weeks post-release, individuals are 129 times more likely to die from an opioid overdose compared to the general population.[vi] Beyond health risks, having a criminal record creates lasting barriers to employment and housing - two critical factors for breaking cycles of substance use and poverty.

A Public Health Approach: Lessons from Portugal and Oregon

Evidence from across the world demonstrates that treating drug use as a public health issue leads to better outcomes. In 2001, Portugal decriminalized drug possession for personal use, redirecting resources from enforcement to treatment and harm reduction. Contrary to fears, drug use declined, and Portugal’s previously high rate of HIV among people who inject drugs dropped dramatically. By 2017, new HIV cases linked to drug use plummeted from 907 in 2000 to just 18 annually.[vii] Furthermore, several European countries, including Switzerland, the Netherlands, the Czech Republic, and Norway, have achieved similar success in addressing substance use by adopting a public health-centered approach.

In 2020, Oregon decriminalized drug possession, adopting a public health approach that yielded promising results, even though it was reversed in 2024. During this period, screenings for substance use disorders surged by 298%,[viii] and crime rates dropped by 14%.[ix] While overdose rates increased, studies indicated[x] the rise wasn’t a result of decriminalization and was lower than in neighboring states like Washington. The financial benefits were also substantial: incarcerating someone for a drug misdemeanor costs up to $35,000 annually, compared to $9,000 for treatment.[xi] Redirecting funds to health care, housing, and social support not only saves money, but also addresses the root causes of substance use. Many individuals turn to drugs in response to unmet basic needs like shelter and clean water. Oregon’s experiment highlighted how investing in these areas can effectively reduce substance use and its associated harms.

A Better Way Forward

Proposition 36 misses the opportunity to embrace evidence-based solutions. Harm reduction strategies such as syringe programs, overdose prevention centers, and opioid agonist therapy have proven to save lives and reduce risky behaviors. Research[xii] among injection drug users in the U.S. shows that participants in syringe service programs are five times more likely to enter methadone treatment and nearly three times more likely to reduce or stop injecting compared to non-participants. These programs also play a crucial role in combating the HIV epidemic, as people who inject drugs accounted for 8% of California’s new HIV infections in 2022.[xiii] Alarmingly, while new HIV diagnoses are declining in most groups, there was a 5% increase in diagnoses among drug users between 2018 and 2022.[xiv]

Rather than intensifying criminalization, California could invest in solutions that tackle the root causes of addiction. Housing, mental health support, and expanded access to treatment and harm reduction are more effective strategies for reducing substance use and its associated harms. Portugal and Oregon provide compelling models: shift away from addressing drug use through policing and the courts, invest in health and social services, and prioritize solutions rooted in human dignity and public health. By doing so, California can move beyond outdated, harmful policies and create a future that uplifts its most vulnerable communities.

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