Drug Decriminalization: A Co-Designed Study Outlining the Implications for Providers of Youth Services

Drug Decriminalization: A Co-Designed Study Outlining the Implications for Providers of Youth Services | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Drug Decriminalization: A Co-Designed Study Outlining the Implications for Providers of Youth Services Nicole Morgan, Jennifer Suen, Joyce Liao, Sarah Adair, Lyn Heinemann, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6378624/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 21 Oct, 2025 Read the published version in Harm Reduction Journal → Version 1 posted 10 You are reading this latest preprint version Abstract Background Death by drug toxicity is now the leading cause of death among youth in British Columbia (BC). In January 2023, BC implemented decriminalization for personal possession (2.5 grams) of certain substances for individuals 18 and over. The purpose of this study was to gain a deeper understanding of service providers who work with youth (ages 15–24). Specifically, the study aimed to explore: 1) their attitudes and beliefs regarding drug decriminalization, and 2) the knowledge and resources they need to effectively discuss drug decriminalization with their clients. Methods Community-based participatory research and interpretive description were used to co-design an interview guide and recruitment strategy with leaders at a BC integrated youth services initiative. Fifteen semi-structured interviews were conducted with service providers and data were coded using reflexive, inductive semantic thematic analysis. Results The thematic analysis revealed that while decriminalization was perceived as a “step in the right direction,” it remains insufficient to address the needs of youth in BC. Service providers expressed a significant disconnect between the policy and practical support required for youth clients. Despite their strong understanding of youth’s needs, providers reported a lack of involvement in the policy development process. Conclusion Service providers said that decriminalization is “a step in the right direction, but not enough.” Additional youth-centred policies and services are needed to address the drug toxicity crisis in BC, and service providers and people who use drugs need a seat at the table to inform, design, and implement policies that will impact youth who use drugs. adolescents young adults youth toxic drug crisis drug decriminalization integrated youth services Figures Figure 1 Introduction Canada is the world’s second highest opioid prescribing nation, behind only the United States [ 1 ]. While the toxic drug crisis affects all of Canada, one of the most affected provinces is British Columbia (BC) [ 1 ]. With increasing deaths due to drug toxicity, BC declared a public health emergency in 2016 [ 2 ]. However, the death rate from the unregulated drug supply has increased, despite expansion of harm reduction and treatment services across BC [ 3 , 4 ]. Since 2016, more than 13,300 individuals have died from the unregulated drug supply [ 5 ]. As this public health emergency continues to kill people who use drugs (PWUD), it becomes clearer that simple solutions do not address high death rates [ 4 ]. One group of particular concern is youth. Death by drug toxicity is now the leading cause of death among youth in BC; for instance, children and youth accounted for 1.3% of deaths due to unregulated drug toxicity between 2016 and 2023[ 4 ]. Canadian youth ages 15–24 are the fastest growing population requiring hospital care from opioid overdoses [ 6 ]. With these factors considered, the Government of BC requested an exemption from the federal government regarding the Controlled Drugs and Substances Act to decriminalize the possession of small amounts of illicit drugs for people over 18 years old [ 7 ]. According to the initial exemption, from January 31, 2023–2026, individuals in possession of less than 2.5 cumulative grams of cocaine, ecstasy, heroin, fentanyl, or morphine cannot be arrested, charged or have their drugs confiscated by law enforcement [ 7 ]. Decriminalization has been proposed as a matter of public health and justice and equity [ 8 ], along with destigmatizing drug use and possession and connecting people to care where and when they needed it [ 1 , 9 – 12 ]. Traditionally, reaching youth early in their mental health and substance use trajectory has been challenging [ 13 ] and youth in BC have consistently been found to face barriers to accessing and sustaining opioid treatment services [ 14 – 18 ]. In BC, an integrated youth services (IYS) initiative, the BC-IYS, has been established to improve youth’s access to mental health and substance use services [ 19 ]. IYS initiatives provide multiple services at a single access point, thereby facilitating collaboration among various team members [ 20 ]. With the decriminalization of simple possession in BC, it was uncertain what youth who use drugs (YWUD) and their service providers understood about the exemption and how it would impact service delivery, outcomes, and experiences among youth accessing the BC-IYS. Therefore, this study aimed to better understand 1) What are the attitudes and beliefs of service providers at the BC-IYS around drug decriminalization? and 2) What knowledge and tools would service providers like to be equipped with to discuss the topic of decriminalization with youth? The researchers defined service providers as healthcare professionals and front desk staff that support the delivery of IYS at an urban centre where toxic drug deaths have been consistently high. Methods Study design The methodology of this qualitative study was rooted in reflexive thematic analysis and the outlines of Thorne and colleagues [ 21 ] for interpretative description. The researchers chose interpretative description due to its accessibility, theoretical flexibility, and prevalence in healthcare research [ 22 ]. Interpretive description was merged with reflexive thematic analysis because these methodologies synergistically highlight the variety of participant experiences and translate these experiences into a story arch of various realities and meanings [ 23 ]. Given the fact that reflexivity is a vital component of interpretative description and reflexive thematic analysis, the researchers JS, NM, and JL tracked decision making and met regularly to discuss how potential research biases, impressions, and assumptions might impact their interpretation of the data. Community-based participatory research (CBPR) was woven into all stages of this research. CBPR is a collaborative research approach that aims to improve the health and social equity of communities by striving for equitable knowledge generation among multiple parties and building on the existing strengths of communities (Wallerstein & Duran, 2006). This study was also rooted in co-design, a human-centred way of conducting research that is increasingly adopted within healthcare research due to its focus on improving healthcare experiences and outcomes [ 24 – 26 ]. Taken together, CBPR and co-design prioritize “end users” (i.e., service providers) and iterative co-creation [ 25 , 27 ] The researchers prioritized service providers by incorporating their feedback into their thematic analyses. The researchers engaged in co-design by using iterative collaboration with BC-IYS leadership and other members of the research team to create the interview guide and analyze themes. Ethics approval was obtained from the University of British Columbia (#H23-02800). Setting The BC-IYS initiative where this study took place has a provincial central office to support backbone operations, virtual services, and 17 physical centres located across BC (with 18 more in development). The initiative’s core services include care for physical and sexual health, mental health, substance use health, peer support, and social services, which are youth- and family-driven to meet the needs of youth [ 19 ]. After consultation with BC-IYS leadership, participants were recruited from one BC-IYS centre that provides substance use services to a high number of youth in downtown Vancouver, a metropolitan city (2021 population: 2,642,825) with a high rate of illicit drug toxicity deaths [ 28 , 29 ]. Recruitment and sampling The researchers engaged in purposive sampling to recruit participants. Participants were recruited during fall 2023 through posters displayed at the BC-IYS centre and through word of mouth from other staff members. Service providers met the study inclusion criteria if they worked at the office for at least one month, spoke English, and could verbally consent to participation. The inclusion criteria were kept broad to account for the widest representation of service providers working at the centre. Various roles were encouraged to participate in the study, such as occupational therapists, social workers, registered nurses, clinic support assistants, nurse practitioners, peer support workers, physicians, and case managers. These professionals were encouraged to partake given that they are all involved in service provision. To maintain confidentiality, each participant chose or was assigned a pseudonym. Procedures Following CBPR and co-design, the initial interview questions were proposed by three BC-IYS staff members in positions of leadership; then, four different staff in leadership positions provided feedback on the initial questions during virtual interviews. The researchers (NM, JS, JL) utilized this feedback to develop the next iteration of the interview guide, which was then refined based on the content of the first three interviews with participants. Each interview question was developed to explore three topics: 1) experience providing substance use services, 2) personal knowledge of recent decriminalization policy, and 3) impact of decriminalization policy on service provision to youth. Some of the interview questions included: “How, if at all, did drug decriminalization affect the substance use care you provide to youth?”, “What lessons regarding decriminalization would you share with service providers who work in this field?”, and “How, if at all, has the topic of decriminalization come up in your day-to-day work?”. The interviews took place between September-November 2023; thus, data were gathered seven months after decriminalization. Interested participants were informed about the aim of the study, the procedures, data privacy and the professional background of the research team. After giving verbal consent, each participant completed a semi-structured interview. With the implementation of the aforementioned research approaches, researchers NM, JL, and JS conducted 15 semi-structured interviews in a manner that centred participants’ expertise. Participants were each interviewed once. NM, JS, and JL are Occupational Therapy graduate students with experience conducting qualitative interviews and using qualitative research. They are not employees of the BC-IYS initiative and had no prior connection to participants before interviewing them. Interviews were conducted either by Zoom (n = 6) or in-person in a private office (n = 9), depending on participant preferences. For in-person and video interviews, the researchers monitored participants’ tone of voice, facial expressions, and body language. Interviews ranged from 15–45 minutes and averaged a total of 26.85 minutes. Interviews were audio-recorded and transcribed verbatim on Zoom. Transcripts were de-identified, and data was stored on a password-protected file in a secure research environment, in accordance with applicable regulations. Researchers SA and SB supervised data generation and provided feedback during data analyses. 2.5 Data analysis The de-identified transcripts were analyzed in accordance with Braun and Clarke’s (2019) reflexive thematic analysis. Before coding, researchers JS and NM familiarized themselves with the data by re-listening to audio-recordings and re-reading transcripts. They used NVivo 14 [ 30 ] to organize and code the semantic content of their transcribed data, using inductive thematic analyses. They independently coded two of the richest de-identified transcript data and met three times over a period of three weeks to review quotes that were challenging to code. They coded remaining transcripts independently. This research involved two coders because the researchers completed this qualitative data analysis as part of their studies. Following the initial round of coding, researchers JS and NM brainstormed preliminary themes by determining common patterns across the data. They shared a file of combined codes with researcher JL, and all three engaged in theme generalization. To ensure their themes represented the data, they reviewed emerging themes at the level of coded data extracts. These researchers met weekly to organize their codes into preliminary themes, distilling and amalgamating the strongest supporting quotes for each theme. To maintain their commitment to co-design, the researchers NM, JS, and JL presented preliminary themes to their BC-IYS leadership partners and integrated their feedback accordingly. Next, they engaged in triangulation by sharing their thematic analyses with three participants and revising their analyses. Preliminary results were presented to the rehabilitation team at BC-IYS and the research team at the BC-IYS central office. Results Demographic Characteristics Fifteen interviews were conducted with occupational therapists (n = 2), social workers (n = 3), registered nurses (n = 3), rehabilitation assistants (n = 2), clinic support assistants (n = 2), a nurse practitioner (n = 1), a physician (n = 1), and a case manager (n = 1). Participants had worked at the BC-IYS initiative for a minimum of two months and maximum of 9.5 years; however, many participants had prior experience in substance use and harm reduction prior to working at the BC-IYS. Participants spoke to their experiences of working with PWUD and the impact of decriminalization on their work with this population; however, it is important to note that participants work with youth, therefore these findings are applicable to YWUD. Our thematic analysis revealed a significant disjunction between the decriminalization policy framework and the actual needs of youth in BC. Service providers expressed a robust understanding of the requirements of this demographic; however, they reported a lack of involvement in the policy development process and inadequate guidance on its practical implementation. During discussions, participants swiftly transitioned to proposing solutions aimed at enhancing support for youth and integrating forthcoming policies into practices that address the needs of young individuals who use drugs. Figure 1 describes the three main themes that were identified. Participants said that BC needs: (1) A safe, regulated supply that better addresses the toxic drug supply, (2) Service providers and PWUD, especially youth, having a seat at the table, and (3) Upstream interventions that address cycles of oppression and substance use. The overarching take-away from the findings was that drug decriminalization is a step in the right direction but not enough. Participants consistently used this language to refer to the ways that the decriminalization policy was the right direction by aiming to support PWUD but that the policy lacked the potential to positively impact the lives of YWUD. Theme 1: A safe, regulated supply that better addresses the toxic drug supply This theme refers to calls from service providers for increased access to a safe and regulated drug supply to prevent youth death by drug toxicity. As “Taylor” (Registered Nurse) noted, “I definitely think that the government needs to come in and create the safe, regulated drug supply and start saving lives because what we're doing now just ain't it.” The BC Centre on Substance Use (2023) defines safe supply as “a legal and regulated supply of psychoactive substances that traditionally have been accessible only through the illicit drug market”. While some participants were hopeful that decriminalization would reduce the number of individuals in the justice system, participants consistently noted that youth and adults who use drugs are still dying from the toxic drug supply. Participants questioned the importance of decriminalization within the context of BC’s toxic drug crisis. In reference to the youth they work with, “Bruce” (Social Worker) said, “The big concern is, is the person I'm seeing going to die tomorrow based on the drugs that are in their pocket right now, whether or not those drugs are criminalized or not is kind of irrelevant.” Participants emphasized the critical importance of early intervention in the provision of youth substance use care. However, there was a prevailing sense of hopelessness among participants who shared that the absence of a safe drug supply significantly undermined their possibility of achieving positive outcomes. For example, “Jane” (Nurse Practitioner), noted: I think what we do is, a lot of what we see is very sad and the reality is just, you know, is decriminalization really gonna change how people are overdosing and dying? I don't – I'd like to see the stats. I don't think it's going to… Theme 2: Service providers and PWUD, especially youth, having a seat at the table This theme addresses the implications of not incorporating the perspectives of people who provide and access substance use services in the decriminalization policy. “At the table” refers to the discussions that contributed to the establishment and implementation of drug decriminalization. The findings of this study suggest that service providers who care for youth wanted to take part in policy creation and wanted PWUD to be included in these discussions. Participants argued that these parties needed to be involved in the policy creation because their relevant knowledge, education, professional experience working with youth, and personal experience may have impacted the outcomes of drug decriminalization. For instance, “Chester” (Addictions Medicine Physician) said, “I feel like, I feel like – I wish I knew the different options that were being discussed at the table because I, you know, I learned all about decriminalization pretty much like as it was being rolled out and all the decisions had been made.” Participants consistently noted that drug decriminalization had minimal impact on their substance use services. “Chester” noted, “I don’t think it’s really changed how I practice. I think I’ve practiced more or less the same way before and after.” Similarly, “Karmel” (Registered Nurse) said, “There hasn’t really been a huge shift in the way we’ve provided care because that’s always the lens we’ve looked at it through.” Participants also noted that drug decriminalization was not coming up in their conversations with youth and families; as a result, they felt that they did not require additional training or tools to navigate conversations around decriminalization. For instance, “Taylor” (Registered Nurse) said: It hasn’t at all – changed anything that I do. Because I think again, I will say, like the people that are in it, like working for a line in it like my colleagues that are in the Downtown Eastside [an area of Vancouver with a high number of street-entrenched individuals who experience barriers to participation in the community, such as substance use] and my colleagues here, I think we all very much understand that just decriminalizing doesn't do anything for supporting the youth out of addiction. Participants also discussed how the details in the policy were not aligned with what was actually happening on the ground with diverse youth. This was particularly discussed in relation to the 2.5-gram requirement of possession. Each participant shared that they worked with youth who commonly use more than 2.5 grams in one sitting. Participants consistently agreed that 2.5 grams was not large enough to reflect the purchasing or use patterns of all YWUD. For instance, “Taylor” (Registered Nurse) said, “2.5 is a joke. I've got clients that do that in a single shot in a day. How, how is this helpful?” They also said: Then really, like, the goal should be ending overdose death, right? Like it should be – and 2.5 grams, like limiting like an amount, it doesn't stop the poison drug supply, right? Like ‘cause that's the problem is the poison drug supply, not how much drugs. Additionally, “Jimmy” (Social Worker) shared: [The 2.5 gram limit] really, I don't know if – like for lack of a better term [context] like imprisons, the people who are using with these guidelines that are not conducive to supporting them in their lifestyle, not conducive to making sure they're getting what they need in a safe way. Participants underscored the necessity for equitable partnership among policymakers, YWUD, families, service providers, and other stakeholders in the decision-making processes that affect youth in BC. While some PWUD were engaged in the formulation of BC decriminalization policies, participants felt that their recommendations were not adequately incorporated. For instance, "Taylor" (Registered Nurse) remarked that PWUD advocated for a decriminalization exemption limit of five grams, based on their insights into substance use patterns, yet the perspectives of other stakeholders, such as law enforcement and government, were prioritized by policymakers. Several participants expressed the view that the decriminalization policy should have centered the voices of PWUD and individuals who access substance use services. They noted that youth and those who work closely with them are frequently excluded from critical discussions and planning activities. Participants highlighted their commitment to providing care within a system that is increasingly focused on upstream and tailored interventions for youth. In alignment with these principles, they asserted that youth voices must be included at all levels of policy development and intervention. Theme 3: Upstream interventions that address cycles of oppression and substance use The third theme speaks to the need for prevention-based interventions, such as early interventions for mental health and substance use, reworking the foster care system, and other interventions that meet the basic needs of children, youth, and families. “Cycles of oppression” refers to the cycle of poverty, incarceration, and unemployment that can occur among intersectional, equity-deserving populations, such as people who are unhoused, street-entrenched, and/or using drugs. Participants in each interview emphasized that decriminalization does not address social determinants of health. Several participants noted the need for additional policies that address the social determinants of health that can contribute to poor health outcomes among youth and adults who use drugs, such as social inclusion and non-discrimination, early childhood experiences, and access to housing, education, employment, and income. For example, “Marigold” (Occupational Therapist) shared: But I feel like in general, like the intervention needs to happen like way upstream from that. Because typically people who wind up using a ton of substances, and that being like the primary thing in their lives or one of the primary things in their lives, it's because the system has failed them multiple times before that, especially in this work. And so, you know, like they had a family that probably failed them. They had a health system that failed them. They had probably an education system that failed them. They probably had – they probably had maybe a justice system that failed them, they probably had a foster care system that failed them. And, many of the people that I've worked with through my career have had all those systems fail them. And some, it doesn't even take that you know, like sometimes it just takes one like you know, you're abused by your family and maybe everything else is hunky dory and eventually you know the trauma of that winds up leading to substance use. You so I just think that, you know, if we're going to really focus resources any place it just needs to be way, way upstream from, from that. Participants consistently shared that additional policies are needed to address the complex intersectional social determinants of health that contribute to substance use and addiction. For instance, Marigold (Occupational Therapist) said: It's just like the system is not really set up to succeed, right? So I just feel like if you want to really make big changes in terms of substance use patterns, you need to look at the causes of those patterns and then like, and then spend money appropriately there and it's actually not that radical. Similarly, Taylor (Nurse) said: Like housing is a great way to support people that use substances into not using substances, right? Like safe, dignified housing or you know education, right? The social determinants of health really are what actually supports people out of addiction and out of substance use and away from death, right? And really this policy doesn't address any of that. Finally, participants noted that decriminalization does not address the stigma of drug use. They acknowledged that the intention behind decriminalization was to reduce the stigma around drug use (BC Centre for Disease Control, 2024). However, none of the participants reported that decriminalization destigmatized drug use. Glen, an occupational therapist, shared, “If anyone has stigma or had that stigma, it’s not going to go away just because it was decriminalized.” Similarly, another participant noted that more time is needed to destigmatize drug use and PWUD. “Bruce” (Social worker) shared: “[…] I think that if we wanted to see significant change in stigma that it’s years and years away. Like that's, I'll be lucky to see it in my lifetime”. Discussion Government policies are instrumental in shaping the healthcare landscape, directly influencing the provision and accessibility of clinical care for patients, including youth. In light of recent decriminalization, this study aimed to explore its impact on service providers delivering care to youth in BC. The findings revealed a significant disconnect between the actions of service providers and the actual implementation of the policy. Specifically, service providers engaged in substance use care for youth expressed feelings of exclusion from both the decision-making process and the implementation of the policy. While they acknowledged the policy as a positive step forward, they regarded it as insufficient in its current form. It is noteworthy that the decriminalization policy has undergone revisions since the commencement of this research, trending toward a re-criminalization approach. Despite these developments, the findings of this study retain their relevance for future policymakers and service providers involved in substance use care for youth and families in BC and beyond. These themes align with Duong’s perspective [ 31 ] that, while many British Columbians support decriminalization, the potential success of the current decriminalization policy is compromised by several missing components. They note that the success of decriminalization depends on whether service providers are able to provide PWUD with alternatives and divert them to other services [ 31 ]. Duong, as well as Bonn and colleagues [ 32 ], argue that decriminalization must be implemented alongside access to social supports and safe, regulated drugs. In addition, in a report to the Chief Coroner of BC, it is noted that unregulated toxic drugs are driving the current drug toxicity emergency and that increased access to safe, regulated drug supply is needed to save lives [ 4 ]. The finding that service providers and PWUD need a seat at the table is supported by other researchers’ work that the policy’s 2.5-gram exemption is seen as too low and not conducive to the buying practices of many PWUD [ 31 ]. Although service providers and advocates called for a higher exempted amount [ 33 ], the amount was set at 2.5 grams. Research in BC has shown that low thresholds have not been impactful [ 34 ]. Consequently, participants felt that decriminalization did not protect PWUD who are most at risk of poor health outcomes related to substance use, such as youth; for instance, street-entrenched individuals who buy drugs in bulk do not often carry small amounts for personal use [ 31 ]. Insights from Portugal’s decriminalization underscore the importance of establishing objective, substance-specific limits that align with people’s needs [ 34 ]. Service providers can play a pivotal role in collaborating with youth to clarify these established limits, offer psychoeducation regarding consumption levels, and deliver pertinent harm reduction support and treatment. The importance of upstream interventions that address cycles of oppression is consistent with the findings of existing research that the social determinants of health, such as income, unemployment, and housing, are highly associated with the health outcomes of people who use opioids [ 35 ]. This research, in the youth context, articulates that health policies need to address the social determinants of health to effectively support the needs of YWUD [ 31 ]. Participants highlighted that these health policies are missing from BC’s response to the toxic drug crisis. Canadian youth aged 15–24 are the fastest-growing demographic requiring hospitalization for opioid use [ 36 ], yet BC’s decriminalization policy excludes YWUD under 18. Participants noted that this exclusion contradicts literature indicating that, without access to a safe, regulated drug supply, youth face increased risks of death and non-fatal drug toxicity, particularly given their existing barriers to opioid treatment [ 15 , 16 ]. Therefore, policies must include and protect youth in BC, with upstream interventions having significant impacts on YWUD. Participants also stressed that current policies often overlook youth’s needs by excluding them from co-design processes and failing to create developmentally and culturally relevant implementation strategies. The findings suggest that service providers who work with youth are uniquely positioned to advocate for their needs and ensure their representation in policy decision making. Professionals with clinical experience in substance use, especially with youth, have the capacity to influence policy and advocate for the inclusion of individuals with lived experiences in the policy-making process. As the re/decriminalization policy in BC evolves [ 37 ], meaningful, evidence-based, and co-designed policies are crucial to prevent mortality and empower individuals to lead fulfilling lives. This research highlights the importance of maximizing collaboration in policy development to improve health outcomes for all community members. Limitations This study has several limitations. First, the sample size may not fully represent the diverse perspectives of all service providers working with youth, potentially limiting the findings’ generalizability. Second, the study relies on self-reported data, which may bias the findings. Third, the evolving nature of BC’s decriminalization policy may also impact the relevance of the findings over time. Finally, the exclusion of youth under 18 from the decriminalization policy presents a significant gap in understanding the needs of this vulnerable population. Conclusion To the researchers’ knowledge, this is one of the first known studies to strategically combine the complementary features of interpretive description, CBPR, and co-design to understand the impact of drug decriminalization on service provision at an IYS centre. The qualitative findings revealed that while drug decriminalization is a step in the right direction, it is not enough to support the needs of YWUD. Service providers highlighted that additional policies and social services are needed to support this population effectively. Although drug decriminalization aims to reduce the stigma of drug use and encourage access to life-saving services, the findings suggest that stigma persists, contributing to ongoing fatalities and incidents of drug toxicity. The service providers indicated that, in addition to decriminalization, BC requires a safe, regulated drug supply, active involvement of service providers and PWUD in policy decision-making, and upstream interventions that address systemic cycles of oppression and substance use. Addressing the limitations of drug decriminalization and proposing viable integrated solutions is crucial for the health and well-being of YWUD. Declarations Data Availability. The dataset generated during and/or analyzed during the study are not publicly available due to pseudo anonymity of research participants, but are available from the corresponding author on reasonable request. Ethics approval. This research was subject to institutional behavioural research ethics through the harmonized research ethics review and approval process at the University of British Columbia (Study ID: #H23-02800). Participants provided informed consent before all data generation. Funding sources. This research was not funded by any specific grants from funding agencies in the public, commercial, or not-for-profit sectors. Declaration of Competing Interest. The researchers declare no known competing financial interests or personal relationships that appeared to have influenced the research reported in this paper. CrediT authorship contribution statement. Nicole Morgan: Writing – review & editing, Writing – original draft, Formal analysis, Data curation, Conceptualization, Project Administration. Jennifer Suen: Writing- original draft, Formal analysis, Data curation, Conceptualization, Project Administration. Joyce Liao: Writing – original draft, Formal analysis, Data curation, Conceptualization, Project Administration. Sarah Adair: Writing – review & editing, Formal analysis, Data curation, Conceptualization, Project Administration. Lyn Heinemann: Conceptualization, Project Administration. Sylvia Lai: Conceptualization. Kirsten Marchand: Writing – review & editing, Formal analysis. Skye Barbic: Writing – review & editing, Writing – original draft, Formal analysis, Conceptualization, Project administration, Methodology Acknowledgements. The researchers are grateful to the service providers who were willing to co-create this research project as well as the stewards of the unceded, ancestral, and traditional lands upon which this research was conducted: the xʷməθkʷəy̓əm (Musqueam), səlilwətaɬ (Tsleil-Waututh), and Sḵwx̱wú7mesh (Squamish) Peoples. References Belzak, L. and J. Halverson, The opioid crisis in Canada: a national perspective. Health Promot Chronic Dis Prev Can, 2018. 38 (6): p. 224-233. BC Ministry of Health, Provincial health officer declares public health emergency . 2016. Ackermann, E., et al., Awareness and knowledge of the Good Samaritan Drug Overdose Act among people at risk of witnessing an overdose in British Columbia, Canada: a multi-methods cross sectional study. Subst Abuse Treat Prev Policy, 2022. 17 (1): p. 42. BC Coroners Service Death Review Panel, An urgent response to a continuing crisis . 2023. Slaunwhite, A., et al., Effect of Risk Mitigation Guidance opioid and stimulant dispensations on mortality and acute care visits during dual public health emergencies: retrospective cohort study. Bmj, 2024. 384 : p. e076336. Canadian Institutes for Health Information. Child and Youth Mental Health in Canada . 2018 [cited 2018 November 20th, 2018]; Available from: https://www.cihi.ca/en/child-and-youth-mental-health-in-canada-infographic. Government of BC., Decriminalizing people who use drugs in B.C. 2024. Virani, H.N. and R.J. Haines-Saah, Drug Decriminalization: A Matter of Justice and Equity, Not Just Health. Am J Prev Med, 2020. 58 (1): p. 161-164. Bratberg, J.P., et al., Support, don't punish: Drug decriminalization is harm reduction. J Am Pharm Assoc (2003), 2023. 63 (1): p. 224-229. Vicknasingam, B., et al., Decriminalization of drug use. Curr Opin Psychiatry, 2018. 31 (4): p. 300-305. van Boekel, L.C., et al., Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: systematic review. Drug Alcohol Depend, 2013. 131 (1-2): p. 23-35. Kolla, G., et al., Canada's overdose crisis: authorities are not acting fast enough. Lancet Public Health, 2019. 4 (4): p. e180. Kidd, S.A., K.J. McKenzie, and G. Virdee, Mental health reform at a systems level: widening the lens on recovery-oriented care. Can J Psychiatry, 2014. 59 (5): p. 243-9. Barbic, S., et al., Implementing Foundry: A cohort study describing the regional and virtual expansion of a youth integrated service in British Columbia, Canada. Early Interv Psychiatry, 2024. 18 (10): p. 877-887. Giang, V., et al., Opioid agonist therapy trajectories among street entrenched youth in the context of a public health crisis. SSM Popul Health, 2020. 11 : p. 100609. Hadland, S.E., T.W. Park, and S.M. Bagley, Stigma associated with medication treatment for young adults with opioid use disorder: a case series. Addict Sci Clin Pract, 2018. 13 (1): p. 15. Marchand, K., K.M. Pellatt, and S. Barbic, Centering Young People's Perspectives, Needs, and Preferences in Researching Barriers to Medications for Opioid Use Disorder. JAMA Pediatr, 2022. Turuba, R., et al., A qualitative study exploring how young people perceive and experience substance use services in British Columbia, Canada. Subst Abuse Treat Prev Policy, 2022. 17 (1): p. 43. Mathias, S., et al., Foundry: Early learnings from the implementation of an integrated youth service network. Early Interv Psychiatry, 2022. 16 (4): p. 410-418. Hetrick, S.E., et al., Integrated (one-stop shop) youth health care: best available evidence and future directions. Med J Aust, 2017. 207 (10): p. S5-s18. Thorne, S., S.R. Kirkham, and K.O. Flynn-Magee, The analytic challenge in interpretive description. International Journal of Qualitative Methods, 2004. 3 (1): p. 1-11. Burdine, J.T., S. Thorne, and G.b. Sandhu, Interpretive description: A flexible qualitative methodology for medical education research. Medical Education, 2020. 55 (3): p. 336-343. Braun, V. and V. Clarke, Reflecting on reflexive thematic analysis. Qualitative Research in Sport, Exercise, and Health, 2019. 11 (4): p. 589-597. Bate, P. and G. Robert, Experience-based design: from redesigning the system around the patient to co-designing services with the patient. Qual Saf Health Care, 2006. 15 (5): p. 307-10. Chen, E., et al., Enhancing Community-Based Participatory Research Through Human-Centered Design Strategies. Health Promot Pract, 2020. 21 (1): p. 37-48. Marchand, K., et al., Improving Treatment Together: a protocol for a multi-phase, community-based participatory, and co-design project to improve youth opioid treatment service experiences in British Columbia. Addict Sci Clin Pract, 2021. 16 (1): p. 53. Greenhalgh, T., et al., Achieving Research Impact Through Co-creation in Community-Based Health Services: Literature Review and Case Study. Milbank Q, 2016. 94 (2): p. 392-429. BC Centre for Disease Control, Distribution of illicit drug toxicity deaths (2015-2024). 2025. Statistics Canada, Focus on geography series, 2021 census of population: Vancouver, census metropolitan area. 2021. Lumivero, NVivo . 2023. Duong, D., British Columbia trials drug decriminalization. Cmaj, 2023. 195 (7): p. E281. Bonn, M., et al., "The Times They Are a-Changin'": Addressing Common Misconceptions About the Role of Safe Supply in North America's Overdose Crisis. J Stud Alcohol Drugs, 2021. 82 (1): p. 158-160. Ali, F., et al., "2.5 g, I could do that before noon": a qualitative study on people who use drugs' perspectives on the impacts of British Columbia's decriminalization of illegal drugs threshold limit. Subst Abuse Treat Prev Policy, 2023. 18 (1): p. 32. Henry, B., Stopping the harm decriminalization of people who use drugs in B.C. . 2019. Alsabbagh, M.W., et al., Stepping up to the Canadian opioid crisis: a longitudinal analysis of the correlation between socioeconomic status and population rates of opioid-related mortality, hospitalization and emergency department visits (2000-2017). Health Promot Chronic Dis Prev Can, 2022. 42 (6): p. 229-237. Canadian Institute for Health Information, Opioid-related harms in Canada . 2017. Xavier, J., et al., "There are solutions and I think we're still working in the problem": The limitations of decriminalization under the good Samaritan drug overdose act and lessons from an evaluation in British Columbia, Canada. Int J Drug Policy, 2022. 105 : p. 103714. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 21 Oct, 2025 Read the published version in Harm Reduction Journal → Version 1 posted Editorial decision: Revision requested 08 Aug, 2025 Reviews received at journal 08 Aug, 2025 Reviewers agreed at journal 16 Jul, 2025 Reviews received at journal 15 Jul, 2025 Reviewers agreed at journal 27 Jun, 2025 Reviewers agreed at journal 01 May, 2025 Reviewers invited by journal 30 Apr, 2025 Editor assigned by journal 07 Apr, 2025 Submission checks completed at journal 07 Apr, 2025 First submitted to journal 04 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6378624","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":451124695,"identity":"5118afce-1b96-4517-a493-30cc5d498e4b","order_by":0,"name":"Nicole Morgan","email":"","orcid":"","institution":"University of British Columbia","correspondingAuthor":false,"prefix":"","firstName":"Nicole","middleName":"","lastName":"Morgan","suffix":""},{"id":451124696,"identity":"ec640a9a-a977-4d87-8ba4-3c1041a51692","order_by":1,"name":"Jennifer Suen","email":"","orcid":"","institution":"University of British Columbia","correspondingAuthor":false,"prefix":"","firstName":"Jennifer","middleName":"","lastName":"Suen","suffix":""},{"id":451124697,"identity":"d9cb02ca-bfeb-4dd7-acdc-3fe85b40fa4c","order_by":2,"name":"Joyce Liao","email":"","orcid":"","institution":"University of British Columbia","correspondingAuthor":false,"prefix":"","firstName":"Joyce","middleName":"","lastName":"Liao","suffix":""},{"id":451124698,"identity":"ce6bbec5-8844-45bf-acad-c8ae419594b1","order_by":3,"name":"Sarah Adair","email":"","orcid":"","institution":"University of British Columbia","correspondingAuthor":false,"prefix":"","firstName":"Sarah","middleName":"","lastName":"Adair","suffix":""},{"id":451124699,"identity":"3cbb1376-eb33-4981-a8f2-2c5f6d43a79e","order_by":4,"name":"Lyn Heinemann","email":"","orcid":"","institution":"Providence Health Care","correspondingAuthor":false,"prefix":"","firstName":"Lyn","middleName":"","lastName":"Heinemann","suffix":""},{"id":451124700,"identity":"a579da9c-6cff-429b-aac1-1943cb187860","order_by":5,"name":"Sylvia Lai","email":"","orcid":"","institution":"Providence Health Care","correspondingAuthor":false,"prefix":"","firstName":"Sylvia","middleName":"","lastName":"Lai","suffix":""},{"id":451124701,"identity":"3a0ac062-79f4-46ec-bcd0-e185fa5cf0be","order_by":6,"name":"Kirsten Marchand","email":"","orcid":"","institution":"University of British Columbia","correspondingAuthor":false,"prefix":"","firstName":"Kirsten","middleName":"","lastName":"Marchand","suffix":""},{"id":451124702,"identity":"cb32afe9-e3c9-4d81-a8df-77aa0d1dc306","order_by":7,"name":"Skye Pamela Barbic","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1ElEQVRIiWNgGAWjYDACHiBmbGBgMGBmYHwAYpCkhdmARC0MDGwSRGmR7zlj+IBxh12+OTvzs2reHXYM/O0H8GsxONtjbMB4JtlyZzOb2W3eM8kMEmcSCGjh5zGTYGxjNjA4zMN2m7ftANCFBLTI9/OY/2BsqwdrKQZr4X9AwDNne8wYGNsOg7Uwg7VIEHLYmWPFEolnjhtYNrMZS849k8wjcYOALfI9yRs/fNxRbWDOf/jhh7c77OT4+wnYwsDAgepfHkLqgYCdgDtGwSgYBaNgFAAAt588vZ7mRwYAAAAASUVORK5CYII=","orcid":"","institution":"University of British Columbia","correspondingAuthor":true,"prefix":"","firstName":"Skye","middleName":"Pamela","lastName":"Barbic","suffix":""}],"badges":[],"createdAt":"2025-04-04 20:08:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6378624/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6378624/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12954-025-01320-x","type":"published","date":"2025-10-21T16:17:13+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":82058180,"identity":"4e06f9af-1178-46fa-9976-d699e7074f0c","added_by":"auto","created_at":"2025-05-06 10:55:17","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":179963,"visible":true,"origin":"","legend":"\u003cp\u003eThis figure describes the three main themes that were identified. Participants said that BC needs: (1) A safe, regulated supply that better addresses the toxic drug supply, (2) Service providers and PWUD, especially youth, having a seat at the table, and (3) Upstream interventions that address cycles of oppression and substance use.\u003c/p\u003e","description":"","filename":"ProblemTree.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6378624/v1/7d3c0d92c7926dc5b1c82ac7.jpeg"},{"id":94490288,"identity":"f71f2a2b-42a7-40ac-abc4-4db9c0ccb52b","added_by":"auto","created_at":"2025-10-27 17:08:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":929241,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6378624/v1/7783f3ca-6301-4c3a-bca5-1dfc85cfc65a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eDrug Decriminalization: A Co-Designed Study Outlining the Implications for Providers of Youth Services\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCanada is the world\u0026rsquo;s second highest opioid prescribing nation, behind only the United States [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. While the toxic drug crisis affects all of Canada, one of the most affected provinces is British Columbia (BC) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. With increasing deaths due to drug toxicity, BC declared a public health emergency in 2016 [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. However, the death rate from the unregulated drug supply has increased, despite expansion of harm reduction and treatment services across BC [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Since 2016, more than 13,300 individuals have died from the unregulated drug supply [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. As this public health emergency continues to kill people who use drugs (PWUD), it becomes clearer that simple solutions do not address high death rates [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. One group of particular concern is youth. Death by drug toxicity is now the leading cause of death among youth in BC; for instance, children and youth accounted for 1.3% of deaths due to unregulated drug toxicity between 2016 and 2023[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Canadian youth ages 15\u0026ndash;24 are the fastest growing population requiring hospital care from opioid overdoses [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWith these factors considered, the Government of BC requested an exemption from the federal government regarding the Controlled Drugs and Substances Act to decriminalize the possession of small amounts of illicit drugs for people over 18 years old [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. According to the initial exemption, from January 31, 2023\u0026ndash;2026, individuals in possession of less than 2.5 cumulative grams of cocaine, ecstasy, heroin, fentanyl, or morphine cannot be arrested, charged or have their drugs confiscated by law enforcement [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Decriminalization has been proposed as a matter of public health and justice and equity [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], along with destigmatizing drug use and possession and connecting people to care where and when they needed it [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan additionalcitationids=\"CR10 CR11\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTraditionally, reaching youth early in their mental health and substance use trajectory has been challenging [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] and youth in BC have consistently been found to face barriers to accessing and sustaining opioid treatment services [\u003cspan additionalcitationids=\"CR15 CR16 CR17\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In BC, an integrated youth services (IYS) initiative, the BC-IYS, has been established to improve youth\u0026rsquo;s access to mental health and substance use services [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. IYS initiatives provide multiple services at a single access point, thereby facilitating collaboration among various team members [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. With the decriminalization of simple possession in BC, it was uncertain what youth who use drugs (YWUD) and their service providers understood about the exemption and how it would impact service delivery, outcomes, and experiences among youth accessing the BC-IYS. Therefore, this study aimed to better understand 1) What are the attitudes and beliefs of service providers at the BC-IYS around drug decriminalization? and 2) What knowledge and tools would service providers like to be equipped with to discuss the topic of decriminalization with youth? The researchers defined service providers as healthcare professionals and front desk staff that support the delivery of IYS at an urban centre where toxic drug deaths have been consistently high.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eThe methodology of this qualitative study was rooted in reflexive thematic analysis and the outlines of Thorne and colleagues [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] for interpretative description. The researchers chose interpretative description due to its accessibility, theoretical flexibility, and prevalence in healthcare research [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Interpretive description was merged with reflexive thematic analysis because these methodologies synergistically highlight the variety of participant experiences and translate these experiences into a story arch of various realities and meanings [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Given the fact that reflexivity is a vital component of interpretative description and reflexive thematic analysis, the researchers JS, NM, and JL tracked decision making and met regularly to discuss how potential research biases, impressions, and assumptions might impact their interpretation of the data.\u003c/p\u003e \u003cp\u003eCommunity-based participatory research (CBPR) was woven into all stages of this research. CBPR is a collaborative research approach that aims to improve the health and social equity of communities by striving for equitable knowledge generation among multiple parties and building on the existing strengths of communities (Wallerstein \u0026amp; Duran, 2006). This study was also rooted in co-design, a human-centred way of conducting research that is increasingly adopted within healthcare research due to its focus on improving healthcare experiences and outcomes [\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Taken together, CBPR and co-design prioritize \u0026ldquo;end users\u0026rdquo; (i.e., service providers) and iterative co-creation [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] The researchers prioritized service providers by incorporating their feedback into their thematic analyses. The researchers engaged in co-design by using iterative collaboration with BC-IYS leadership and other members of the research team to create the interview guide and analyze themes. Ethics approval was obtained from the University of British Columbia (#H23-02800).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSetting\u003c/h3\u003e\n\u003cp\u003eThe BC-IYS initiative where this study took place has a provincial central office to support backbone operations, virtual services, and 17 physical centres located across BC (with 18 more in development). The initiative\u0026rsquo;s core services include care for physical and sexual health, mental health, substance use health, peer support, and social services, which are youth- and family-driven to meet the needs of youth [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. After consultation with BC-IYS leadership, participants were recruited from one BC-IYS centre that provides substance use services to a high number of youth in downtown Vancouver, a metropolitan city (2021 population: 2,642,825) with a high rate of illicit drug toxicity deaths [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eRecruitment and sampling\u003c/h3\u003e\n\u003cp\u003eThe researchers engaged in purposive sampling to recruit participants. Participants were recruited during fall 2023 through posters displayed at the BC-IYS centre and through word of mouth from other staff members. Service providers met the study inclusion criteria if they worked at the office for at least one month, spoke English, and could verbally consent to participation. The inclusion criteria were kept broad to account for the widest representation of service providers working at the centre. Various roles were encouraged to participate in the study, such as occupational therapists, social workers, registered nurses, clinic support assistants, nurse practitioners, peer support workers, physicians, and case managers. These professionals were encouraged to partake given that they are all involved in service provision. To maintain confidentiality, each participant chose or was assigned a pseudonym.\u003c/p\u003e\n\u003ch3\u003eProcedures\u003c/h3\u003e\n\u003cp\u003e Following CBPR and co-design, the initial interview questions were proposed by three BC-IYS staff members in positions of leadership; then, four different staff in leadership positions provided feedback on the initial questions during virtual interviews. The researchers (NM, JS, JL) utilized this feedback to develop the next iteration of the interview guide, which was then refined based on the content of the first three interviews with participants. Each interview question was developed to explore three topics: 1) experience providing substance use services, 2) personal knowledge of recent decriminalization policy, and 3) impact of decriminalization policy on service provision to youth. Some of the interview questions included: \u0026ldquo;How, if at all, did drug decriminalization affect the substance use care you provide to youth?\u0026rdquo;, \u0026ldquo;What lessons regarding decriminalization would you share with service providers who work in this field?\u0026rdquo;, and \u0026ldquo;How, if at all, has the topic of decriminalization come up in your day-to-day work?\u0026rdquo;.\u003c/p\u003e \u003cp\u003eThe interviews took place between September-November 2023; thus, data were gathered seven months after decriminalization. Interested participants were informed about the aim of the study, the procedures, data privacy and the professional background of the research team. After giving verbal consent, each participant completed a semi-structured interview. With the implementation of the aforementioned research approaches, researchers NM, JL, and JS conducted 15 semi-structured interviews in a manner that centred participants\u0026rsquo; expertise. Participants were each interviewed once. NM, JS, and JL are Occupational Therapy graduate students with experience conducting qualitative interviews and using qualitative research. They are not employees of the BC-IYS initiative and had no prior connection to participants before interviewing them.\u003c/p\u003e \u003cp\u003eInterviews were conducted either by Zoom (n\u0026thinsp;=\u0026thinsp;6) or in-person in a private office (n\u0026thinsp;=\u0026thinsp;9), depending on participant preferences. For in-person and video interviews, the researchers monitored participants\u0026rsquo; tone of voice, facial expressions, and body language. Interviews ranged from 15\u0026ndash;45 minutes and averaged a total of 26.85 minutes. Interviews were audio-recorded and transcribed verbatim on Zoom. Transcripts were de-identified, and data was stored on a password-protected file in a secure research environment, in accordance with applicable regulations. Researchers SA and SB supervised data generation and provided feedback during data analyses.\u003c/p\u003e\n\u003ch3\u003e2.5 Data analysis\u003c/h3\u003e\n\u003cp\u003eThe de-identified transcripts were analyzed in accordance with Braun and Clarke\u0026rsquo;s (2019) reflexive thematic analysis. Before coding, researchers JS and NM familiarized themselves with the data by re-listening to audio-recordings and re-reading transcripts. They used NVivo 14 [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] to organize and code the semantic content of their transcribed data, using inductive thematic analyses. They independently coded two of the richest de-identified transcript data and met three times over a period of three weeks to review quotes that were challenging to code. They coded remaining transcripts independently. This research involved two coders because the researchers completed this qualitative data analysis as part of their studies. Following the initial round of coding, researchers JS and NM brainstormed preliminary themes by determining common patterns across the data. They shared a file of combined codes with researcher JL, and all three engaged in theme generalization. To ensure their themes represented the data, they reviewed emerging themes at the level of coded data extracts. These researchers met weekly to organize their codes into preliminary themes, distilling and amalgamating the strongest supporting quotes for each theme.\u003c/p\u003e \u003cp\u003eTo maintain their commitment to co-design, the researchers NM, JS, and JL presented preliminary themes to their BC-IYS leadership partners and integrated their feedback accordingly. Next, they engaged in triangulation by sharing their thematic analyses with three participants and revising their analyses. Preliminary results were presented to the rehabilitation team at BC-IYS and the research team at the BC-IYS central office.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eDemographic Characteristics\u003c/h2\u003e \u003cp\u003eFifteen interviews were conducted with occupational therapists (n\u0026thinsp;=\u0026thinsp;2), social workers (n\u0026thinsp;=\u0026thinsp;3), registered nurses (n\u0026thinsp;=\u0026thinsp;3), rehabilitation assistants (n\u0026thinsp;=\u0026thinsp;2), clinic support assistants (n\u0026thinsp;=\u0026thinsp;2), a nurse practitioner (n\u0026thinsp;=\u0026thinsp;1), a physician (n\u0026thinsp;=\u0026thinsp;1), and a case manager (n\u0026thinsp;=\u0026thinsp;1). Participants had worked at the BC-IYS initiative for a minimum of two months and maximum of 9.5 years; however, many participants had prior experience in substance use and harm reduction prior to working at the BC-IYS. Participants spoke to their experiences of working with PWUD and the impact of decriminalization on their work with this population; however, it is important to note that participants work with youth, therefore these findings are applicable to YWUD.\u003c/p\u003e \u003cp\u003eOur thematic analysis revealed a significant disjunction between the decriminalization policy framework and the actual needs of youth in BC. Service providers expressed a robust understanding of the requirements of this demographic; however, they reported a lack of involvement in the policy development process and inadequate guidance on its practical implementation. During discussions, participants swiftly transitioned to proposing solutions aimed at enhancing support for youth and integrating forthcoming policies into practices that address the needs of young individuals who use drugs.\u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e describes the three main themes that were identified. Participants said that BC needs: (1) A safe, regulated supply that better addresses the toxic drug supply, (2) Service providers and PWUD, especially youth, having a seat at the table, and (3) Upstream interventions that address cycles of oppression and substance use. The overarching take-away from the findings was that drug decriminalization is a step in the right direction but not enough. Participants consistently used this language to refer to the ways that the decriminalization policy was the right direction by aiming to support PWUD but that the policy lacked the potential to positively impact the lives of YWUD.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eTheme 1: A safe, regulated supply that better addresses the toxic drug supply\u003c/h3\u003e\n\u003cp\u003eThis theme refers to calls from service providers for increased access to a safe and regulated drug supply to prevent youth death by drug toxicity. As \u0026ldquo;Taylor\u0026rdquo; (Registered Nurse) noted, \u0026ldquo;I definitely think that the government needs to come in and create the safe, regulated drug supply and start saving lives because what we're doing now just ain't it.\u0026rdquo; The BC Centre on Substance Use (2023) defines safe supply as \u0026ldquo;a legal and regulated supply of psychoactive substances that traditionally have been accessible only through the illicit drug market\u0026rdquo;.\u003c/p\u003e \u003cp\u003eWhile some participants were hopeful that decriminalization would reduce the number of individuals in the justice system, participants consistently noted that youth and adults who use drugs are still dying from the toxic drug supply. Participants questioned the importance of decriminalization within the context of BC\u0026rsquo;s toxic drug crisis. In reference to the youth they work with, \u0026ldquo;Bruce\u0026rdquo; (Social Worker) said, \u0026ldquo;The big concern is, is the person I'm seeing going to die tomorrow based on the drugs that are in their pocket right now, whether or not those drugs are criminalized or not is kind of irrelevant.\u0026rdquo; Participants emphasized the critical importance of early intervention in the provision of youth substance use care. However, there was a prevailing sense of hopelessness among participants who shared that the absence of a safe drug supply significantly undermined their possibility of achieving positive outcomes. For example, \u0026ldquo;Jane\u0026rdquo; (Nurse Practitioner), noted:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI think what we do is, a lot of what we see is very sad and the reality is just, you know, is decriminalization really gonna change how people are overdosing and dying? I don't \u0026ndash; I'd like to see the stats. I don't think it's going to\u0026hellip;\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eTheme 2: Service providers and PWUD, especially youth, having a seat at the table\u003c/h2\u003e \u003cp\u003eThis theme addresses the implications of not incorporating the perspectives of people who provide and access substance use services in the decriminalization policy. \u0026ldquo;At the table\u0026rdquo; refers to the discussions that contributed to the establishment and implementation of drug decriminalization. The findings of this study suggest that service providers who care for youth wanted to take part in policy creation and wanted PWUD to be included in these discussions. Participants argued that these parties needed to be involved in the policy creation because their relevant knowledge, education, professional experience working with youth, and personal experience may have impacted the outcomes of drug decriminalization. For instance, \u0026ldquo;Chester\u0026rdquo; (Addictions Medicine Physician) said, \u0026ldquo;I feel like, I feel like \u003cem\u003e\u0026ndash;\u003c/em\u003e I wish I knew the different options that were being discussed at the table because I, you know, I learned all about decriminalization pretty much like as it was being rolled out and all the decisions had been made.\u0026rdquo;\u003c/p\u003e \u003cp\u003e Participants consistently noted that drug decriminalization had minimal impact on their substance use services. \u0026ldquo;Chester\u0026rdquo; noted, \u0026ldquo;I don\u0026rsquo;t think it\u0026rsquo;s really changed how I practice. I think I\u0026rsquo;ve practiced more or less the same way before and after.\u0026rdquo; Similarly, \u0026ldquo;Karmel\u0026rdquo; (Registered Nurse) said, \u0026ldquo;There hasn\u0026rsquo;t really been a huge shift in the way we\u0026rsquo;ve provided care because that\u0026rsquo;s always the lens we\u0026rsquo;ve looked at it through.\u0026rdquo; Participants also noted that drug decriminalization was not coming up in their conversations with youth and families; as a result, they felt that they did not require additional training or tools to navigate conversations around decriminalization. For instance, \u0026ldquo;Taylor\u0026rdquo; (Registered Nurse) said:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eIt hasn\u0026rsquo;t at all \u0026ndash; changed anything that I do. Because I think again, I will say, like the people that are in it, like working for a line in it like my colleagues that are in the Downtown Eastside [an area of Vancouver with a high number of street-entrenched individuals who experience barriers to participation in the community, such as substance use] and my colleagues here, I think we all very much understand that just decriminalizing doesn't do anything for supporting the youth out of addiction.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipants also discussed how the details in the policy were not aligned with what was actually happening on the ground with diverse youth. This was particularly discussed in relation to the 2.5-gram requirement of possession. Each participant shared that they worked with youth who commonly use more than 2.5 grams in one sitting. Participants consistently agreed that 2.5 grams was not large enough to reflect the purchasing or use patterns of all YWUD. For instance, \u0026ldquo;Taylor\u0026rdquo; (Registered Nurse) said, \u0026ldquo;2.5 is a joke. I've got clients that do that in a single shot in a day. How, how is this helpful?\u0026rdquo; They also said:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThen really, like, the goal should be ending overdose death, right? Like it should be \u003cem\u003e\u0026ndash;\u003c/em\u003e and 2.5 grams, like limiting like an amount, it doesn't stop the poison drug supply, right? Like \u0026lsquo;cause that's the problem is the poison drug supply, not how much drugs.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAdditionally, \u0026ldquo;Jimmy\u0026rdquo; (Social Worker) shared:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e[The 2.5 gram limit] really, I don't know if \u0026ndash; like for lack of a better term [context] like imprisons, the people who are using with these guidelines that are not conducive to supporting them in their lifestyle, not conducive to making sure they're getting what they need in a safe way.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipants underscored the necessity for equitable partnership among policymakers, YWUD, families, service providers, and other stakeholders in the decision-making processes that affect youth in BC. While some PWUD were engaged in the formulation of BC decriminalization policies, participants felt that their recommendations were not adequately incorporated. For instance, \"Taylor\" (Registered Nurse) remarked that PWUD advocated for a decriminalization exemption limit of five grams, based on their insights into substance use patterns, yet the perspectives of other stakeholders, such as law enforcement and government, were prioritized by policymakers.\u003c/p\u003e \u003cp\u003eSeveral participants expressed the view that the decriminalization policy should have centered the voices of PWUD and individuals who access substance use services. They noted that youth and those who work closely with them are frequently excluded from critical discussions and planning activities. Participants highlighted their commitment to providing care within a system that is increasingly focused on upstream and tailored interventions for youth. In alignment with these principles, they asserted that youth voices must be included at all levels of policy development and intervention.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eTheme 3: Upstream interventions that address cycles of oppression and substance use\u003c/h2\u003e \u003cp\u003eThe third theme speaks to the need for prevention-based interventions, such as early interventions for mental health and substance use, reworking the foster care system, and other interventions that meet the basic needs of children, youth, and families. \u0026ldquo;Cycles of oppression\u0026rdquo; refers to the cycle of poverty, incarceration, and unemployment that can occur among intersectional, equity-deserving populations, such as people who are unhoused, street-entrenched, and/or using drugs. Participants in each interview emphasized that decriminalization does not address social determinants of health. Several participants noted the need for additional policies that address the social determinants of health that can contribute to poor health outcomes among youth and adults who use drugs, such as social inclusion and non-discrimination, early childhood experiences, and access to housing, education, employment, and income. For example, \u0026ldquo;Marigold\u0026rdquo; (Occupational Therapist) shared:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eBut I feel like in general, like the intervention needs to happen like way upstream from that. Because typically people who wind up using a ton of substances, and that being like the primary thing in their lives or one of the primary things in their lives, it's because the system has failed them multiple times before that, especially in this work. And so, you know, like they had a family that probably failed them. They had a health system that failed them. They had probably an education system that failed them. They probably had \u0026ndash; they probably had maybe a justice system that failed them, they probably had a foster care system that failed them. And, many of the people that I've worked with through my career have had all those systems fail them. And some, it doesn't even take that you know, like sometimes it just takes one like you know, you're abused by your family and maybe everything else is hunky dory and eventually you know the trauma of that winds up leading to substance use. You so I just think that, you know, if we're going to really focus resources any place it just needs to be way, way upstream from, from that.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipants consistently shared that additional policies are needed to address the complex intersectional social determinants of health that contribute to substance use and addiction. For instance, Marigold (Occupational Therapist) said:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eIt's just like the system is not really set up to succeed, right? So I just feel like if you want to really make big changes in terms of substance use patterns, you need to look at the causes of those patterns and then like, and then spend money appropriately there and it's actually not that radical.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSimilarly, Taylor (Nurse) said:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eLike housing is a great way to support people that use substances into not using substances, right? Like safe, dignified housing or you know education, right? The social determinants of health really are what actually supports people out of addiction and out of substance use and away from death, right? And really this policy doesn't address any of that.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eFinally, participants noted that decriminalization does not address the stigma of drug use. They acknowledged that the intention behind decriminalization was to reduce the stigma around drug use (BC Centre for Disease Control, 2024). However, none of the participants reported that decriminalization destigmatized drug use. Glen, an occupational therapist, shared, \u0026ldquo;If anyone has stigma or had that stigma, it\u0026rsquo;s not going to go away just because it was decriminalized.\u0026rdquo; Similarly, another participant noted that more time is needed to destigmatize drug use and PWUD. \u0026ldquo;Bruce\u0026rdquo; (Social worker) shared: \u0026ldquo;[\u0026hellip;] I think that if we wanted to see significant change in stigma that it\u0026rsquo;s years and years away. Like that's, I'll be lucky to see it in my lifetime\u0026rdquo;.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eGovernment policies are instrumental in shaping the healthcare landscape, directly influencing the provision and accessibility of clinical care for patients, including youth. In light of recent decriminalization, this study aimed to explore its impact on service providers delivering care to youth in BC. The findings revealed a significant disconnect between the actions of service providers and the actual implementation of the policy. Specifically, service providers engaged in substance use care for youth expressed feelings of exclusion from both the decision-making process and the implementation of the policy. While they acknowledged the policy as a positive step forward, they regarded it as insufficient in its current form. It is noteworthy that the decriminalization policy has undergone revisions since the commencement of this research, trending toward a re-criminalization approach. Despite these developments, the findings of this study retain their relevance for future policymakers and service providers involved in substance use care for youth and families in BC and beyond.\u003c/p\u003e \u003cp\u003eThese themes align with Duong\u0026rsquo;s perspective [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] that, while many British Columbians support decriminalization, the potential success of the current decriminalization policy is compromised by several missing components. They note that the success of decriminalization depends on whether service providers are able to provide PWUD with alternatives and divert them to other services [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Duong, as well as Bonn and colleagues [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], argue that decriminalization must be implemented alongside access to social supports and safe, regulated drugs. In addition, in a report to the Chief Coroner of BC, it is noted that unregulated toxic drugs are driving the current drug toxicity emergency and that increased access to safe, regulated drug supply is needed to save lives [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The finding that service providers and PWUD need a seat at the table is supported by other researchers\u0026rsquo; work that the policy\u0026rsquo;s 2.5-gram exemption is seen as too low and not conducive to the buying practices of many PWUD [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough service providers and advocates called for a higher exempted amount [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], the amount was set at 2.5 grams. Research in BC has shown that low thresholds have not been impactful [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Consequently, participants felt that decriminalization did not protect PWUD who are most at risk of poor health outcomes related to substance use, such as youth; for instance, street-entrenched individuals who buy drugs in bulk do not often carry small amounts for personal use [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Insights from Portugal\u0026rsquo;s decriminalization underscore the importance of establishing objective, substance-specific limits that align with people\u0026rsquo;s needs [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Service providers can play a pivotal role in collaborating with youth to clarify these established limits, offer psychoeducation regarding consumption levels, and deliver pertinent harm reduction support and treatment.\u003c/p\u003e \u003cp\u003eThe importance of upstream interventions that address cycles of oppression is consistent with the findings of existing research that the social determinants of health, such as income, unemployment, and housing, are highly associated with the health outcomes of people who use opioids [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. This research, in the youth context, articulates that health policies need to address the social determinants of health to effectively support the needs of YWUD [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Participants highlighted that these health policies are missing from BC\u0026rsquo;s response to the toxic drug crisis.\u003c/p\u003e \u003cp\u003eCanadian youth aged 15\u0026ndash;24 are the fastest-growing demographic requiring hospitalization for opioid use [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e], yet BC\u0026rsquo;s decriminalization policy excludes YWUD under 18. Participants noted that this exclusion contradicts literature indicating that, without access to a safe, regulated drug supply, youth face increased risks of death and non-fatal drug toxicity, particularly given their existing barriers to opioid treatment [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Therefore, policies must include and protect youth in BC, with upstream interventions having significant impacts on YWUD. Participants also stressed that current policies often overlook youth\u0026rsquo;s needs by excluding them from co-design processes and failing to create developmentally and culturally relevant implementation strategies. The findings suggest that service providers who work with youth are uniquely positioned to advocate for their needs and ensure their representation in policy decision making. Professionals with clinical experience in substance use, especially with youth, have the capacity to influence policy and advocate for the inclusion of individuals with lived experiences in the policy-making process. As the re/decriminalization policy in BC evolves [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], meaningful, evidence-based, and co-designed policies are crucial to prevent mortality and empower individuals to lead fulfilling lives. This research highlights the importance of maximizing collaboration in policy development to improve health outcomes for all community members.\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis study has several limitations. First, the sample size may not fully represent the diverse perspectives of all service providers working with youth, potentially limiting the findings\u0026rsquo; generalizability. Second, the study relies on self-reported data, which may bias the findings. Third, the evolving nature of BC\u0026rsquo;s decriminalization policy may also impact the relevance of the findings over time. Finally, the exclusion of youth under 18 from the decriminalization policy presents a significant gap in understanding the needs of this vulnerable population.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eTo the researchers\u0026rsquo; knowledge, this is one of the first known studies to strategically combine the complementary features of interpretive description, CBPR, and co-design to understand the impact of drug decriminalization on service provision at an IYS centre. The qualitative findings revealed that while drug decriminalization is a step in the right direction, it is not enough to support the needs of YWUD. Service providers highlighted that additional policies and social services are needed to support this population effectively. Although drug decriminalization aims to reduce the stigma of drug use and encourage access to life-saving services, the findings suggest that stigma persists, contributing to ongoing fatalities and incidents of drug toxicity. The service providers indicated that, in addition to decriminalization, BC requires a safe, regulated drug supply, active involvement of service providers and PWUD in policy decision-making, and upstream interventions that address systemic cycles of oppression and substance use. Addressing the limitations of drug decriminalization and proposing viable integrated solutions is crucial for the health and well-being of YWUD.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData Availability.\u0026nbsp;\u003c/strong\u003eThe dataset generated during and/or analyzed during the study are not publicly available due to pseudo anonymity of research participants, but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval.\u0026nbsp;\u003c/strong\u003eThis research was subject to institutional behavioural research ethics through the harmonized research ethics review and approval process at the University of British Columbia (Study ID:\u0026nbsp;#H23-02800). Participants provided informed consent before all data generation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding sources.\u0026nbsp;\u003c/strong\u003eThis research was not funded by any specific grants from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of Competing Interest.\u0026nbsp;\u003c/strong\u003eThe researchers declare no known competing financial interests or personal relationships that appeared to have influenced the research reported in this paper.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCrediT authorship contribution statement.\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eNicole Morgan:\u003c/strong\u003e Writing \u0026ndash; review \u0026amp; editing, Writing \u0026ndash; original draft, Formal analysis, Data curation, Conceptualization, Project Administration.\u0026nbsp;\u003cstrong\u003eJennifer Suen:\u003c/strong\u003e Writing- original draft, Formal analysis, Data curation, Conceptualization, Project Administration.\u0026nbsp;\u003cstrong\u003eJoyce Liao:\u003c/strong\u003e Writing\u0026nbsp;\u0026ndash;\u0026nbsp;original draft, Formal analysis, Data curation, Conceptualization, Project Administration. \u003cstrong\u003eSarah Adair:\u003c/strong\u003e Writing \u0026ndash; review \u0026amp; editing, Formal analysis, Data curation, Conceptualization, Project Administration.\u0026nbsp;\u003cstrong\u003eLyn Heinemann:\u003c/strong\u003e Conceptualization, Project Administration.\u0026nbsp;\u003cstrong\u003eSylvia Lai:\u003c/strong\u003e Conceptualization. \u003cstrong\u003eKirsten Marchand:\u003c/strong\u003e Writing \u0026ndash; review \u0026amp; editing, Formal analysis. \u003cstrong\u003eSkye Barbic:\u003c/strong\u003e Writing \u0026ndash; review \u0026amp; editing, Writing \u0026ndash; original draft, Formal analysis, Conceptualization, Project administration, Methodology\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements.\u0026nbsp;\u003c/strong\u003eThe researchers are grateful to the service providers who were willing to co-create this research project as well as the stewards of the unceded, ancestral, and traditional lands upon which this research was conducted: the xʷmə\u0026theta;kʷəy̓əm (Musqueam), səlilwətaɬ (Tsleil-Waututh), and Sḵwx̱w\u0026uacute;7mesh (Squamish) Peoples.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBelzak, L. and J. Halverson, \u003cem\u003eThe opioid crisis in Canada: a national perspective.\u003c/em\u003e Health Promot Chronic Dis Prev Can, 2018. \u003cstrong\u003e38\u003c/strong\u003e(6): p. 224-233.\u003c/li\u003e\n\u003cli\u003eBC Ministry of Health, \u003cem\u003eProvincial health officer declares public health emergency\u003c/em\u003e. 2016.\u003c/li\u003e\n\u003cli\u003eAckermann, E., et al., \u003cem\u003eAwareness and knowledge of the Good Samaritan Drug Overdose Act among people at risk of witnessing an overdose in British Columbia, Canada: a multi-methods cross sectional study.\u003c/em\u003e Subst Abuse Treat Prev Policy, 2022. \u003cstrong\u003e17\u003c/strong\u003e(1): p. 42.\u003c/li\u003e\n\u003cli\u003eBC Coroners Service Death Review Panel, \u003cem\u003eAn urgent response to a continuing crisis\u003c/em\u003e. 2023.\u003c/li\u003e\n\u003cli\u003eSlaunwhite, A., et al., \u003cem\u003eEffect of Risk Mitigation Guidance opioid and stimulant dispensations on mortality and acute care visits during dual public health emergencies: retrospective cohort study.\u003c/em\u003e Bmj, 2024. \u003cstrong\u003e384\u003c/strong\u003e: p. e076336.\u003c/li\u003e\n\u003cli\u003eCanadian Institutes for Health Information. \u003cem\u003eChild and Youth Mental Health in Canada\u003c/em\u003e. 2018 [cited 2018 November 20th, 2018]; Available from: https://www.cihi.ca/en/child-and-youth-mental-health-in-canada-infographic.\u003c/li\u003e\n\u003cli\u003eGovernment of BC., \u003cem\u003eDecriminalizing people who use drugs in B.C.\u003c/em\u003e 2024.\u003c/li\u003e\n\u003cli\u003eVirani, H.N. and R.J. Haines-Saah, \u003cem\u003eDrug Decriminalization: A Matter of Justice and Equity, Not Just Health.\u003c/em\u003e Am J Prev Med, 2020. \u003cstrong\u003e58\u003c/strong\u003e(1): p. 161-164.\u003c/li\u003e\n\u003cli\u003eBratberg, J.P., et al., \u003cem\u003eSupport, don\u0026apos;t punish: Drug decriminalization is harm reduction.\u003c/em\u003e J Am Pharm Assoc (2003), 2023. \u003cstrong\u003e63\u003c/strong\u003e(1): p. 224-229.\u003c/li\u003e\n\u003cli\u003eVicknasingam, B., et al., \u003cem\u003eDecriminalization of drug use.\u003c/em\u003e Curr Opin Psychiatry, 2018. \u003cstrong\u003e31\u003c/strong\u003e(4): p. 300-305.\u003c/li\u003e\n\u003cli\u003evan Boekel, L.C., et al., \u003cem\u003eStigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: systematic review.\u003c/em\u003e Drug Alcohol Depend, 2013. \u003cstrong\u003e131\u003c/strong\u003e(1-2): p. 23-35.\u003c/li\u003e\n\u003cli\u003eKolla, G., et al., \u003cem\u003eCanada\u0026apos;s overdose crisis: authorities are not acting fast enough.\u003c/em\u003e Lancet Public Health, 2019. \u003cstrong\u003e4\u003c/strong\u003e(4): p. e180.\u003c/li\u003e\n\u003cli\u003eKidd, S.A., K.J. McKenzie, and G. Virdee, \u003cem\u003eMental health reform at a systems level: widening the lens on recovery-oriented care.\u003c/em\u003e Can J Psychiatry, 2014. \u003cstrong\u003e59\u003c/strong\u003e(5): p. 243-9.\u003c/li\u003e\n\u003cli\u003eBarbic, S., et al., \u003cem\u003eImplementing Foundry: A cohort study describing the regional and virtual expansion of a youth integrated service in British Columbia, Canada.\u003c/em\u003e Early Interv Psychiatry, 2024. \u003cstrong\u003e18\u003c/strong\u003e(10): p. 877-887.\u003c/li\u003e\n\u003cli\u003eGiang, V., et al., \u003cem\u003eOpioid agonist therapy trajectories among street entrenched youth in the context of a public health crisis.\u003c/em\u003e SSM Popul Health, 2020. \u003cstrong\u003e11\u003c/strong\u003e: p. 100609.\u003c/li\u003e\n\u003cli\u003eHadland, S.E., T.W. Park, and S.M. Bagley, \u003cem\u003eStigma associated with medication treatment for young adults with opioid use disorder: a case series.\u003c/em\u003e Addict Sci Clin Pract, 2018. \u003cstrong\u003e13\u003c/strong\u003e(1): p. 15.\u003c/li\u003e\n\u003cli\u003eMarchand, K., K.M. Pellatt, and S. Barbic, \u003cem\u003eCentering Young People\u0026apos;s Perspectives, Needs, and Preferences in Researching Barriers to Medications for Opioid Use Disorder.\u003c/em\u003e JAMA Pediatr, 2022.\u003c/li\u003e\n\u003cli\u003eTuruba, R., et al., \u003cem\u003eA qualitative study exploring how young people perceive and experience substance use services in British Columbia, Canada.\u003c/em\u003e Subst Abuse Treat Prev Policy, 2022. \u003cstrong\u003e17\u003c/strong\u003e(1): p. 43.\u003c/li\u003e\n\u003cli\u003eMathias, S., et al., \u003cem\u003eFoundry: Early learnings from the implementation of an integrated youth service network.\u003c/em\u003e Early Interv Psychiatry, 2022. \u003cstrong\u003e16\u003c/strong\u003e(4): p. 410-418.\u003c/li\u003e\n\u003cli\u003eHetrick, S.E., et al., \u003cem\u003eIntegrated (one-stop shop) youth health care: best available evidence and future directions.\u003c/em\u003e Med J Aust, 2017. \u003cstrong\u003e207\u003c/strong\u003e(10): p. S5-s18.\u003c/li\u003e\n\u003cli\u003eThorne, S., S.R. Kirkham, and K.O. Flynn-Magee, \u003cem\u003eThe analytic challenge in interpretive description.\u003c/em\u003e International Journal of Qualitative Methods, 2004. \u003cstrong\u003e3\u003c/strong\u003e(1): p. 1-11.\u003c/li\u003e\n\u003cli\u003eBurdine, J.T., S. Thorne, and G.b. Sandhu, \u003cem\u003eInterpretive description: A flexible qualitative methodology for medical education research.\u003c/em\u003e Medical Education, 2020. \u003cstrong\u003e55\u003c/strong\u003e(3): p. 336-343.\u003c/li\u003e\n\u003cli\u003eBraun, V. and V. Clarke, \u003cem\u003eReflecting on reflexive thematic analysis.\u003c/em\u003e Qualitative Research in Sport, Exercise, and Health, 2019. \u003cstrong\u003e11\u003c/strong\u003e(4): p. 589-597.\u003c/li\u003e\n\u003cli\u003eBate, P. and G. Robert, \u003cem\u003eExperience-based design: from redesigning the system around the patient to co-designing services with the patient.\u003c/em\u003e Qual Saf Health Care, 2006. \u003cstrong\u003e15\u003c/strong\u003e(5): p. 307-10.\u003c/li\u003e\n\u003cli\u003eChen, E., et al., \u003cem\u003eEnhancing Community-Based Participatory Research Through Human-Centered Design Strategies.\u003c/em\u003e Health Promot Pract, 2020. \u003cstrong\u003e21\u003c/strong\u003e(1): p. 37-48.\u003c/li\u003e\n\u003cli\u003eMarchand, K., et al., \u003cem\u003eImproving Treatment Together: a protocol for a multi-phase, community-based participatory, and co-design project to improve youth opioid treatment service experiences in British Columbia.\u003c/em\u003e Addict Sci Clin Pract, 2021. \u003cstrong\u003e16\u003c/strong\u003e(1): p. 53.\u003c/li\u003e\n\u003cli\u003eGreenhalgh, T., et al., \u003cem\u003eAchieving Research Impact Through Co-creation in Community-Based Health Services: Literature Review and Case Study.\u003c/em\u003e Milbank Q, 2016. \u003cstrong\u003e94\u003c/strong\u003e(2): p. 392-429.\u003c/li\u003e\n\u003cli\u003eBC Centre for Disease Control, \u003cem\u003eDistribution of illicit drug toxicity deaths (2015-2024).\u003c/em\u003e 2025.\u003c/li\u003e\n\u003cli\u003eStatistics Canada, \u003cem\u003eFocus on geography series, 2021 census of population: Vancouver, census metropolitan area.\u003c/em\u003e 2021.\u003c/li\u003e\n\u003cli\u003eLumivero, \u003cem\u003eNVivo\u003c/em\u003e. 2023.\u003c/li\u003e\n\u003cli\u003eDuong, D., \u003cem\u003eBritish Columbia trials drug decriminalization.\u003c/em\u003e Cmaj, 2023. \u003cstrong\u003e195\u003c/strong\u003e(7): p. E281.\u003c/li\u003e\n\u003cli\u003eBonn, M., et al., \u003cem\u003e\u0026quot;The Times They Are a-Changin\u0026apos;\u0026quot;: Addressing Common Misconceptions About the Role of Safe Supply in North America\u0026apos;s Overdose Crisis.\u003c/em\u003e J Stud Alcohol Drugs, 2021. \u003cstrong\u003e82\u003c/strong\u003e(1): p. 158-160.\u003c/li\u003e\n\u003cli\u003eAli, F., et al., \u003cem\u003e\u0026quot;2.5 g, I could do that before noon\u0026quot;: a qualitative study on people who use drugs\u0026apos; perspectives on the impacts of British Columbia\u0026apos;s decriminalization of illegal drugs threshold limit.\u003c/em\u003e Subst Abuse Treat Prev Policy, 2023. \u003cstrong\u003e18\u003c/strong\u003e(1): p. 32.\u003c/li\u003e\n\u003cli\u003eHenry, B., \u003cem\u003eStopping the harm decriminalization of people who use drugs in B.C. \u003c/em\u003e. 2019.\u003c/li\u003e\n\u003cli\u003eAlsabbagh, M.W., et al., \u003cem\u003eStepping up to the Canadian opioid crisis: a longitudinal analysis of the correlation between socioeconomic status and population rates of opioid-related mortality, hospitalization and emergency department visits (2000-2017).\u003c/em\u003e Health Promot Chronic Dis Prev Can, 2022. \u003cstrong\u003e42\u003c/strong\u003e(6): p. 229-237.\u003c/li\u003e\n\u003cli\u003eCanadian Institute for Health Information, \u003cem\u003eOpioid-related harms in Canada\u003c/em\u003e. 2017.\u003c/li\u003e\n\u003cli\u003eXavier, J., et al., \u003cem\u003e\u0026quot;There are solutions and I think we\u0026apos;re still working in the problem\u0026quot;: The limitations of decriminalization under the good Samaritan drug overdose act and lessons from an evaluation in British Columbia, Canada.\u003c/em\u003e Int J Drug Policy, 2022. \u003cstrong\u003e105\u003c/strong\u003e: p. 103714.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"harm-reduction-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"harj","sideBox":"Learn more about [Harm Reduction Journal](http://harmreductionjournal.biomedcentral.com/)","snPcode":"12954","submissionUrl":"https://submission.nature.com/new-submission/12954/3","title":"Harm Reduction Journal","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"adolescents, young adults, youth, toxic drug crisis, drug decriminalization, integrated youth services","lastPublishedDoi":"10.21203/rs.3.rs-6378624/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6378624/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eDeath by drug toxicity is now the leading cause of death among youth in British Columbia (BC). In January 2023, BC implemented decriminalization for personal possession (2.5 grams) of certain substances for individuals 18 and over. The purpose of this study was to gain a deeper understanding of service providers who work with youth (ages 15\u0026ndash;24). Specifically, the study aimed to explore: 1) their attitudes and beliefs regarding drug decriminalization, and 2) the knowledge and resources they need to effectively discuss drug decriminalization with their clients.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eCommunity-based participatory research and interpretive description were used to co-design an interview guide and recruitment strategy with leaders at a BC integrated youth services initiative. Fifteen semi-structured interviews were conducted with service providers and data were coded using reflexive, inductive semantic thematic analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe thematic analysis revealed that while decriminalization was perceived as a \u0026ldquo;step in the right direction,\u0026rdquo; it remains insufficient to address the needs of youth in BC. Service providers expressed a significant disconnect between the policy and practical support required for youth clients. Despite their strong understanding of youth\u0026rsquo;s needs, providers reported a lack of involvement in the policy development process.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eService providers said that decriminalization is \u0026ldquo;a step in the right direction, but not enough.\u0026rdquo; Additional youth-centred policies and services are needed to address the drug toxicity crisis in BC, and service providers and people who use drugs need a seat at the table to inform, design, and implement policies that will impact youth who use drugs.\u003c/p\u003e","manuscriptTitle":"Drug Decriminalization: A Co-Designed Study Outlining the Implications for Providers of Youth Services","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-06 10:55:12","doi":"10.21203/rs.3.rs-6378624/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-08-08T22:01:13+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-08T20:41:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"296761552342132339280332673546129990797","date":"2025-07-16T14:50:34+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-15T16:36:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"112829315644479673341044943317958665875","date":"2025-06-27T15:32:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"155357888178787563467942976506809441887","date":"2025-05-01T04:24:50+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-30T21:45:47+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-07T11:59:50+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-07T11:56:19+00:00","index":"","fulltext":""},{"type":"submitted","content":"Harm Reduction Journal","date":"2025-04-04T20:06:19+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"harm-reduction-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"harj","sideBox":"Learn more about [Harm Reduction Journal](http://harmreductionjournal.biomedcentral.com/)","snPcode":"12954","submissionUrl":"https://submission.nature.com/new-submission/12954/3","title":"Harm Reduction Journal","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"de215f7b-7463-44fb-aad6-bfef48d28720","owner":[],"postedDate":"May 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-10-27T16:24:13+00:00","versionOfRecord":{"articleIdentity":"rs-6378624","link":"https://doi.org/10.1186/s12954-025-01320-x","journal":{"identity":"harm-reduction-journal","isVorOnly":false,"title":"Harm Reduction Journal"},"publishedOn":"2025-10-21 16:17:13","publishedOnDateReadable":"October 21st, 2025"},"versionCreatedAt":"2025-05-06 10:55:12","video":"","vorDoi":"10.1186/s12954-025-01320-x","vorDoiUrl":"https://doi.org/10.1186/s12954-025-01320-x","workflowStages":[]},"version":"v1","identity":"rs-6378624","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6378624","identity":"rs-6378624","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}