While the federal government continues to pursue a punitive “War on Drugs,” some states have adopted evidence-based, human-focused approaches to reducing drug-related harm. This article discusses recent legal changes in three states that can serve as models for others interested in reducing, rather than increasing, individual and community harm.

Drug benefits policy-making for seniors in British Columbia has been increasingly influenced by research since 1993. The "evidence-based medicine" paradigm, which emphasizes the primacy of direct evidence from randomized control trials, inspired key policy-makers and influenced policy concerning coverage of new and existing drugs. New drugs, if more expensive than existing similar drugs, are not covered unless published randomized control trials show superior effectiveness. Indirect evidence of effectiveness, based on surrogates, is given less weight, and non-randomized studies are rarely considered. Evidence of cost-effectiveness of new drugs is reviewed separately. For existing drugs, a new reimbursement policy, Reference Based Pricing (RBP), was introduced, based on both direct and indirect evidence of comparative effectiveness of drugs. Implementation of RBP was complex and necessarily rapid, which meant that independent systematic review of evidence relevant to implementation issues was infeasible, particularly in regard to rapid prior authorization of exemptions to RBP. Contrasts between the processes for new and existing drugs provide insights into the difficulties of applying the idea of direct evidence-based policy-making in practice.

Escalating medication prices are forcing drug benefit programs worldwide to change their payment policies. Physicians object that this intrudes on their long established authority to prescribe medications they judge best for their patients. This paper reports data from focus groups and a large random sample of seniors in British Columbia who were asked for their views towards Pharmacare's reference based pricing (RBP) policy. Seniors expressed the desire for physicians to be more knowledgeable and more involved in all aspects of medical care including policy changes. They have confidence in physicians as a credible source of information, but they also have as much confidence in pharmacists and almost as much in the Ministry of Health. Seniors overwhelmingly accept, and the majority support government's efforts with their cost-saving Pharmacare policies. Furthermore, those who know more about the policy are more likely to support it. The paper closes with a discussion of the feedback process with decision-makers.

Antiretroviral pre-exposure prophylaxis (PrEP) is protective against HIV. Low utilization rates amongst HIV vulnerable populations are due in part to the high cost of PrEP. Generic PrEP offers the potential to improve health at significantly reduced costs. In this study, we examine early utilization patterns and prices for generic PrEP. We discuss the opportunities and challenges for generic PrEP to improve health among HIV vulnerable populations.

Involuntary commitment links the healthcare, public health, and legislative systems to act as a “carceral health-service.” While masquerading as more humane and medicalized, such coercive modalities nevertheless further reinforce the systems, structures, practices, and policies of structural oppression and white supremacy. We argue that due to involuntary commitment’s inextricable connection to the carceral system, and a longer history of violent social control, this legal framework cannot and must not be held out as a viable alternative to the criminal legal system responses to behavioral and mental health challenges. Instead, this article proposes true alternatives to incarceration that are centered on liberation that seeks to shrink the carceral system’s grasp on individuals’ and communities’ lives. In this, we draw inspiration from street-level praxis and action theory emanating from grassroots organizations and community organizers across the country under a Public Health Abolition framework.

International pressure to suppress cocaine trafficking sustained decades of harsh drug laws in Bolivia against cocaleros (coca producers), thus affecting coca production for traditional consumption and for manufacturing illicit cocaine. These harsh drug laws caused social unrest in cocalero communities outside traditional coca zones. President Evo Morales, leader of the Movimiento al Socialismo (Movement toward Socialism, MAS) party, implemented ‘Coca Yes, Cocaine No’ (CYCN), a harm-reduction strategy that authorised ‘non-traditional’ farmers to cultivate legal coca and self-police production. This article compares CYCN outcomes in Bolivia's traditional and non-traditional coca regions and finds that strong cocalero organisations were vital to CYCN success in non-traditional areas. In contrast, organised resistance in traditional zones restricted CYCN success and added to regime instability in the lead-up to Morales’ forced resignation in 2019. Hence, while Morales harnessed state power to change drug policy, he was constrained by the rural grassroots organisations that brought him to power.

There are few topics that divide public opinion as sharply as the use of psychoactive substances and it is easy to see why. Substance use is complex and can be examined from numerous perspectives, including legal, health, economic, cultural and ethical. These varying approaches can lead to a range of different conclusions. Here we explore some of the common approaches adopted towards drug policy and suggest a number of principles, which may inform a psychiatrist's own view.

Popular attitudes towards crime in Latin America induce local legislators to support harsh sentencing frameworks. What, therefore, explains the adoption of non-prison sentences across the region? Using Brazil as a case study, this article claims that sentencing reform is a consequence of the growing autonomy of bureaucrats who manage the criminal justice system. Insulated from patronage networks and granted broad mandates to pursue solutions to pressing penal crises, these policy elites use their position in the state to develop new rules and facilitate their approval despite popular opposition to measures that limit the state's punitive capacity. The findings point to the importance of bureaucratic autonomy for the enactment of policies that can benefit the underprivileged but do not enjoy widespread support from voters.

Increasingly, governments and police agencies require evidence of effectiveness and efficiency with respect to law enforcement policies. The existing “what works” literature, specifically on drug law enforcement, focuses mainly on the effectiveness question when making complex choices between drug policy alternatives, but fails when it comes to incorporating empirical evidence and the experience of key experts in the decision-making process. In addition, little attempt has been made to employ sophisticated techniques to assist in complex policy decision making with respect to funding competing policing policy alternatives. We use the methamphetamine problem in Australia to illustrate a way of evaluating, using multi-criteria analysis, alternative policy options for developing better drug policy.

Objectives: To identify core issues that contribute to the gap between pre-marketing clinical research and practice as seen from the perspective of medical practice, as well as possible changes and potential barriers for closing this gap.

Methods: Interviews with 47 physicians and pharmacists who were liaised to drug regulation through their role in the pre- and post-marketing shaping of new cardiovascular drugs. Data were analyzed using methods of grounded theory and analytical evaluations.

Results: Six core issues were identified that referred to the standards in drug regulation, the organization of the regulatory system, and conflicting interests. Pre-marketing trials should focus more on populations and research questions relevant to medical practice. In particular, variability in drug responses between subgroups of patients and demonstration of effectiveness should become major principles in drug regulation. An interactive post-marketing process in which public interests are represented was considered necessary to further guide research and development according to the needs in daily practice. Strategies for change could be applied within the present system of drug regulation, or affect its basic principles. Regulatory authorities were primarily identified to initiate changes, but many other parties should be involved. Barriers for change were identified regarding differences in interests between parties, organizational matters, and with respect to broader healthcare policies.

Conclusions: Based on the respondents' opinions, there is a need to focus regulatory standards more on the needs in medical practice. Therefore, regulatory authorities should further develop their influence in the pre- and post-marketing drug development process, together with other parties involved, in order to bridge the gap between clinical research and medical practice.