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America will always be hooked on drugs Opioid crisis is a rank simplification

In Oregon drugs have been decriminalised. Patrick T. Fallon/AFP via Getty Images

In Oregon drugs have been decriminalised. Patrick T. Fallon/AFP via Getty Images


November 21, 2024   6 mins

America is the greatest democracy in the world: a place where an incoherent system of contradictory beliefs has produced an equally incoherent politics. In the irrational ferment of what it may be best to call simply the thing that happened — the confluence of Trump and QAnon, the pandemic, Defund the Police, moral panics about gender and migrant caravans, and so on — Americans became inured, in a way rarely before seen, to the spectre of the counterintuitive miracle. One could choose any number of examples from across the ideological spectrum: the belief that a gaudy real estate mogul was a champion of the working man, or that reduction of law enforcement would bring down crime. My own favourite example, though, is the suite of measures broadly known as harm reduction that were adopted in many forms across the United States, and are now being rolled back, to the relief of some and the outrage of others.

In the best of cases, harm reduction is hard to define. It has, like most radicalisms, a front-facing and a covert side, and any given spokesperson upbraided for its defects can always resort to the no true Scotsman strategy, blaming its excesses on a fringe that is less fringey than one might be led to believe. The least objectionable of the harm reductionists cling to the addiction-as-disease model that has become commonplace despite the absence of any testable etiology, any efficacious cures, or even a good definition of what addiction is. They advocate for needle exchanges, Naloxone distribution, and the provision of basic services for the drug addicted. This is now the norm across America: all but a few states have these programmes in place, and even states with stringent drug laws are locking up far fewer people for possession than they used to.

The most extreme harm reductionists (I draw on here the unintentionally hilarious document “Harm Reduction Calls to Action from Young People who Use Drugs on the Streets of Vancouver and Lisbon”) claim that “drugs themselves can be forms of harm reduction and treatment”, and envision a novel social model in which drug abusing youth are provided with free housing, safe consumption sites, and “peer-led compassion clubs that sell pharmaceutical grade cannabis, heroin, cocaine”, free from “paternalistic and judgmental attitudes in encounters with caregivers and providers”. Attitudes of this kind are particularly prevalent among activists and academics, whose phobia of judgement has created a paradoxical, shifting model of the addict or, in their jargon, the PWUD (person who uses drugs): they must not be subject to censure, because theirs is a medical condition; at the same time, they ought not be pathologised, because they are free subjects engaged in self-care; if their behaviour is problematic, which not everyone can agree on, then the solution is to offer them more and better services and resources until they decide to quit on their own.

If harm reduction has a gospel, a foundational myth, it is surely Glenn Greenwald’s 2009 white paper for the Cato Foundation, “Drug Decriminalization in Portugal: Lessons for Creating Fair and Successful Drug Policies”. Greenwald’s work was intended to examine the effects of a 2000 law decriminalising acquisition, possession, and use of personal quantities of all psychoactive drugs. The author’s partiality was evident from the very first page — his claim that “there is no real debate about whether drugs should once again be criminalised” is rather disconfirmed by the fact that criminal penalties for possession had been reinstituted a year before his findings were published — and he systematically attributes causation to correlation to suggest a number of benefits, from reduced HIV transmission to a decrease in drug use and drug-related deaths.

Greenwald’s conclusions were parroted more or less uncritically by The Economist, Time, and Scientific American, and became a model for a shift away from a punitive approach to addiction and toward a public health one in numerous states and municipalities. The most famous adopter was Oregon, where Measure 110 decriminalised possession of most psychoactive drugs until it was amended earlier this year following a rise in violent crime, the largest spike in overdose deaths in the nation, and a proliferation of open-air drug markets. Though its problems were more severe or more evident than elsewhere in the country, Oregon was less of an outlier than its critics may admit: over the past decade, imprisonment and drug enforcement have declined across America, at the same time, overdose deaths have risen steadily, from just over 20,000 in 2002 to 107,000 in 2022. Bad as they are, the numbers hardly exhaust the associated social ills. In Philadelphia, where I live, the drug-ravaged area of Kensington has 10 times as many shootings per square mile as the rest of the city; Kensington Avenue, its former main street, is a virtual dead zone.

There are lessons here. One, of course, is to look close at the data or the absence thereof. Greenwald’s report examined a narrow range of years: 2001 to 2007. Since Portugal didn’t track the prevalence of drug use prior to decriminalisation, Greenwald had little idea where usage stood in the period prior to 2001, and many of the positive tendencies he saw in that brief interval have reversed in the intervening years. Another is to seek context: HIV rates, for example, fell across the developed world irrespective of drug policy.

But most importantly, and most obviously, one should ask whether there is any reason to believe outcomes in one country can be extrapolated elsewhere. Portugal and the United States are a particularly odd comparison to anyone who knows the two countries at all. The first is tiny and peaceful, relatively poor and relatively old, well-behaved, orderly, cohesive. The second is the land of the vaping congressman, the Gathering of the Juggalos, Diddy’s Freak-Offs, Jeffrey Epstein, the Doritos Crunchy Crust Pizza, young earth creationists, and the emotional support peacock.

If I overdo myself a bit with these examples — though they don’t scratch the surface of America’s weirdness — it’s to say that restraint isn’t exactly my people’s jam. And yet it remains a virtual heresy to suggest that our gargantuan hunger for intoxicants might point to an ethical failing on our part, or even a problem with drugs themselves. As to the latter, with great certainty, and with no proof at all, Maia Szalavitz of The New York Times tells us that “most addiction results from attempts to self-medicate isolation, social disconnection, psychiatric disorders, trauma and severe economic distress”. The greatest predictor for addiction is, of course, the easy availability of drugs. I would broadly assume that some of the problems Szalavitz cites are more pressing in Chad or Iraq than in the United States; but in these countries, and many like them, drugs are scarce, few can afford them, and the penalties are severe. Studies of rats, which seem to display similar addiction dynamics to humans, show a significant minority of them are vulnerable to addiction (around 15-20% in the case of cocaine) — perhaps Szalavitz and the rest of the trauma inflation crowd think scientists are just really good at finding rats plagued with anomie?

“If I overdo myself a bit with these examples, it’s to say that restraint isn’t exactly my people’s jam.”

If we shouldn’t generalise among countries, we should be wary of doing so among drugs, too. Users, police, counsellors, and drug dealers will all tell you fentanyl has been destructive on an unprecedented scale. Two milligrams — less than a pinch of salt — can be deadly, and because it’s cheap, hard to detect, and easy to transport, it’s now found in everything: fake prescription pills, cocaine, ecstasy. Fentanyl is shorter-acting than heroin, which it has nearly pushed out of the market, so users who might once have held a job or cared for their families now spend half their days chasing the next high. The xylazine and benzodiazepines people take with fentanyl, either unwittingly or to stretch out its effects, knock them out so fast that more and more are using methamphetamine and crack to stay awake, making the term “opioid crisis” a rank simplification.

A recent spate of articles has celebrated a drop in the rate of overdose deaths in America for the first time since 2018 (that year was an anomaly, and apart from it, rates have risen steadily since the Nineties). Many speculated on which political interventions have finally bent the curve. None that I’ve seen has stated the obvious: that the supply of hard drug users is not infinitely elastic, and that in the past decade, 700,000 of them have died. Moreover, this is an underestimate: the Center for Disease Control tracks overdose mortality, but not deaths from drug-related sepsis, cirrhosis, suicide, or violence. Drugs follow the pattern of epidemics: they strike at vulnerable populations, some of whom die and some of whom recover, and they confer a measure of immunity in their wake. In the Eighties, crack devastated many black communities, to the point that “crackhead” became one of the worst terms of abuse; now young whites are nine times as likely to try crack as young blacks (this is perhaps the place to say a word in praise of the efficacy of stigma, which despite its bad reputation among harm reductionists is the primary enforcer of behavioural norms). The same pattern has already begun to play out with fentanyl and meth, and cocaine will probably follow in short order.

When the numbers go down, the dead will be forgotten. Whoever happens to be in power will claim victory over problems they did nothing to solve, and we will attribute to the policy in vogue at the time the abatement of an affliction many have pontificated about, and few have bothered to try to understand. Then eventually, a new drug will appear, or an old one will come back into fashion, and we will start the cycle again.


Adrian Nathan West is an essayist, author of the novel My Father’s Diet, and a literary translator.
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Alex Lekas
Alex Lekas
15 days ago

America is the greatest democracy in the world
Uh, no. America is a republic. A pure democracy would not have an Electoral College. A pure democracy would provide the states with very few and quite limited powers.
The issue with drugs is twofold: first, the refusal to accept that bans do not work. Prohibition should have made that a concrete lesson, and if not that, then the decades of the failed ‘war on drugs’ should have confirmed what was already known. Second, the refusal to understand that life never offers solutions, just tradeoffs. Whether legal or not, there will be spill-over effects from drug use. Perhaps the nation’s mistake is to treat drug use as a criminal problem rather than a public health issue, but given the quality of person in public service, the outcome would likely be just as bad either way.

AJ Mac
AJ Mac
15 days ago
Reply to  Alex Lekas

Has anybody claimed it’s a pure democracy? Great Britain, though a parliamentary commonwealth with a symbolic monarch, is still a democracy by the normal definition.

Your remarks on drug policy seem sensible to me. Until you pivot from trade offs to a damn-it-all conclusion where the different trade-offs are “likely” to be equally bad. What is the point of understanding when it is joined to a refusal of hope or unwillingness to help anyone beyond ourselves?

Andrew Fisher
Andrew Fisher
13 days ago
Reply to  Alex Lekas

Drug use in the US today, IS largely treated as a public health problem, albeit very unsuccessfully and often without any robust evidence, as the excellent article made clear

Thomas Wagner
Thomas Wagner
15 days ago

I recommend reading the actual article “Harm Reduction Calls to Action from Young People who Use Drugs on the Streets of Vancouver and Lisbon”. The ten points listed at the end might be called The Drug User’s Bill of Rights. Basically we’re to give them food, shelter and their drugs of choice and then not interfere in their activities in any way.
No.

Brett H
Brett H
15 days ago

The “War on drugs” began in the eighties. That’s 44 years to have developed effective programs and show results. Despite all the talk and programs things have got worse. From what I can see certain drugs come very cheaply. Those drugs obviously appeal to the poor. Fentanyl obviously isn’t a dance drug, it’s the drug of misery. What’s behind all that misery? Harm reduction is a bit of a joke when these people are already seriously harmed. By what? What is it about these societies that destroy people first and then watch them fall into drug dependency and then offer ideological band-aids?

Paul Airey
Paul Airey
15 days ago
Reply to  Brett H

Offer users non-voluntary assisted dying.

Thomas Wagner
Thomas Wagner
15 days ago
Reply to  Paul Airey

Easier, if no better morally, to just stand back when they self-administer that cure.

Brett H
Brett H
14 days ago
Reply to  Paul Airey

Do you mean they’re all guilty for their own misery and don’t deserve any concern?

UnHerd Reader
UnHerd Reader
10 days ago
Reply to  Paul Airey

Well, is it really involuntary?

Robert
Robert
15 days ago
Reply to  Brett H

Harmed by what? What is it about our societies? I don’t know for certain. But, I’ve come to believe that the person who comes closest to answering those questions is Ian McGilchrist.

Dave Canuck
Dave Canuck
15 days ago
Reply to  Brett H

The war on drugs became official in 1971 under Nixon, it was a war on Nixon ‘s enemies, marijuana smoking white hippies who opposed the Vietnam War, and blacks living in ghettos and using mostly heroin. It accelerated under Reagan and led to mass incarceration of mostly blacks for simple possession and became a source of cheap labor in prisons. The war cost over a trillion dollars, and amounted to nothing in terms of dealing with the drug problems, except alot of people profited from that war. Let’s face it , it was a race war. Like all drug bans, opium laws were aimed at Chinese immigrants, the 1st marijuana laws were aimed at Mexicans and migrants. Even prohibition was racial, aimed mostly at Irish and Italian catholics.

AJ Mac
AJ Mac
15 days ago
Reply to  Dave Canuck

Your claims seem sensible in the main, Canuck, if overgeneralized. You do seem to make Nixon stand in for the whole 1971 establishment: military, church, school, police, distraught parents, etc.—and fair enough to a point. But you’re using race as a proxy for both ethnicity and class, which makes “race” into a catch-all umbrella term that isn’t very useful.

Also note that penalties for marijuana possession in particular were vastly reduced in most states and in Canada between about 1968-1971. Drug use or alleged sale was indeed used as a pretext during the height of mass imprisonment. They locked up “undesirables”—both non-whites and poor, uneducated white (especially when you had two or more “demographic strikes”)—for a range of crimes that included gun possession, theft, and petty parole violations. Drugs or drinking were of course at least somewhat involved in many other crimes like theft and assault, as a rule—and they can’t lock you up very long just for using the drug of alcohol.

I think the author of this article is correct to stress drug availability and non-enforcement as major drivers of overdose death and severity addiction, but wrong to deny the singular severity of fentanyl.

A comprehensive social approach that involves de-criminalization, along with outreach, treatment, and measured supply is one thing. In the States, most harm-reductionist approaches (with which I’m in sympathy, especially in principle) have used a hands-off approach that is supposedly compassionate but usually leads to more public disorder as well as more misery and death among addicts themselves.

I’ve read Gabor Mate on Vancouver’s de-criminalized Eastside; truly horrific, epidemic misery there. What approach(es) do you favor or suggest?

Andrew Fisher
Andrew Fisher
13 days ago
Reply to  AJ Mac

Thank you for your considered points, which however seems to me to depart rather a lot from those rather extreme ones of Dave Canuck above!. I just can’t see however how it could be possible for any state to reduce and control the often terrible effects of drugs, without strong intervention involving at least the possibility of a degree of coercion of the users. But modern liberal and progressive opinions simply isn’t willing to countenance this. Much as I want to live in a free society, it is just obvious that the drug problem in the US is very much worse than in China, or even Japan.

Andrew Fisher
Andrew Fisher
13 days ago
Reply to  Dave Canuck

Oh my goodness – an actual sincere woke analysis on UnHerd! No, it is ludicrous to suggest it was a “race war”! (I imagine that Nixon, like Trump might be pleased that some black people have rather conservative views and might consider voting for them!). Was it a good thing for blacks that so many used heroin?! So, is the implication here that because we can always find some difference between the rates of use of harmful drugs between different ethnic groups, that essentially the state should have a completely laissez faire attitude towards the widespread use of addictive and extremely destructive drugs in society?

The scenes of people totally raddled and destroyed by crystal meth in the centres of cities like San Francisco are appalling. It isn’t nice for everyone else, is economically damaging, but most importantly is a disaster for the drug addicts themselves. No doubt liberals and progressives feel like thet have adopted a humanitarian policy – they have not!

Clare Knight
Clare Knight
15 days ago
Reply to  Brett H

A thoughtful comment.

Andrew Fisher
Andrew Fisher
13 days ago
Reply to  Brett H

There is “no war on drugs”! As the article makes clear! Americans are still pretty well off on average, drugs are cheap and widely available, and people like the effects of them! You are exceedingly unlikely to be punished for using. Then a significant fraction get physically or psychologically addicted – as indeed do rats. What is difficult to understand about this?

It seems that some people broadly on the post liberal right now echo exactly the same points as progressives on drugs – that people use them mainly because they are somehow are traumatized or suffering from all sorts of social ills. But many of these social ills, such as poverty and poor housing and physical violence are much worse in other countries where drug uses much lower – drugs being expensive and the penalties very severe!

Sophy T
Sophy T
15 days ago

What is it about these societies that destroy people first and then watch them fall into drug dependency and then offer ideological band-aids?
Korea and Japan both have some social problems but the vast majority of their citizens haven’t fallen into drug dependency.

AJ Mac
AJ Mac
15 days ago
Reply to  Sophy T

There is far more social cohesion and pressure to conform there than anywhere in Western Europe or the Anglosphere.

Michael Mcelwee
Michael Mcelwee
15 days ago

As Sherlock Holmes taught us: The only way to survive modernity is drugs and music.

Santiago Saefjord
Santiago Saefjord
15 days ago

perhaps we could one day ambitiously espouse: “drugs or music’… I’ve never done a hard drug in my life, but as a musician I mostly get my high when I need it. But I do imagine drugs as more efficient for the musically lame person.
Actually one question I want to have an answer to is did Classical geniuses like Shakespeare, Mozart, Bach and the like take drugs like 70s rock and rollers, intentionally or not? (e.g. they likely ate or drank things that made them drunk all the time, like beer, but perhaps they were harder drug users too?!), Does anyone have a solid answer to this, or read anything of the like?
Perhaps Christianity thrived on drug use back in the day… I certainly see it helped the new agers in their mission so why not general Christianity or religion.

Michael Mcelwee
Michael Mcelwee
14 days ago

The word I would emphasize is “modernity.” A modern person is one who aspires to comfortable self-preservation and fears death. He can have such a life, however, only if there are men like SH, for whom such light stuff is insufferable. SH must have danger. And modern men must have their SHs. It was not this way in pre-modern times. The noble have no place in modernity and thus take refuge in drugs and music. It is an escape for them.

Andrew Fisher
Andrew Fisher
13 days ago

That is mostly complete rubbish! People from all backgrounds can be offered drugs, which are cheap, and, hey, they like the effects and some start to habitually use!. The bad effects are not as obvious, at first. There isn’t anything “noble” about drug use – and I am not being “judgemental” here.

Michael Mcelwee
Michael Mcelwee
12 days ago
Reply to  Andrew Fisher

Please, be judgmental.

Andrew Fisher
Andrew Fisher
13 days ago

This sounds like a pretty flippant and silly point. It is sometimes possible to use drugs in moderation, but all too often it isn’t. Being addicted to crystal meth (I have some experience).or presumably fentenyl and others doesn’t seem to me to do anything except make whatever defects “modernity” might have very much worse. Losing your job and home, for starters. And by the way, what about the other people in your life who are close to you?

Michael Mcelwee
Michael Mcelwee
12 days ago
Reply to  Andrew Fisher

SH had no squeamishness about using narcotics to excess. The more the better actually. As for your suggestion that modernity is no worse than other times in history, all I can say is that I so hope you are right.

Bruce Bishkin
Bruce Bishkin
15 days ago

Very incisive

S Adams
S Adams
12 days ago

I used to do drugs in my youth, but since I started going to mass every Sunday I no longer have that hole in me, where I’m searching for that point of peaceful oblivion – just over the horizon.

The urge to turn everything from drug abuse and depression to racism and gender into medical conditions is a materialist fallacy. We as a species made some metaphysical assumptions with the likes of Ockham and Bacon 700 years ago which have slowly disintegrated reality such that our default perspective cannot even perceive meaning, beauty, purpose etc in their transcendent sense – leaving everything as pure surface onto which we impose a banal meaning..

The only solution to our problems are spiritual, no government policies can fix them, but how long will we go on thinking “if only government X really did Y properly, everything would be great now.

Martin M
Martin M
10 days ago
Reply to  S Adams

You gave up drugs for the Catholic Church? That sounds like a poor bargain to me! I mean, give up drugs if you must, but the Catholic Church?

Connecticut Yankee
Connecticut Yankee
8 days ago
Reply to  Martin M

Catholic Church is more good than bad for the most part.

Roddy Campbell
Roddy Campbell
9 days ago

Singapore. For dealers.

Next question?