The Most Important Question About Addiction

Despite rising overdose deaths, there’s some important good news regarding opioid misuse. Rates of nonmedical use by high school seniors have fallen by nearly 83 percent since 2002, when 14 percent reported having ever tried using prescription pain pills to get high. By 2021, that proportion was down to just 2 percent. Heroin use also shows a precipitous drop, with only 0.4 percent of 12th graders reporting trying it as of 2021.

This is especially welcome news because teen use is an excellent predictor of the course of drug epidemics: The vast majority of addictions start in late adolescence or early adulthood. Since the deadliest opioids like fentanyl are most often sold in the guise of prescription pain pills or heroin, this bodes well for reductions in overdose deaths.

But to translate this positive change into lasting reductions in addiction and overdoses, it’s important to understand how drug use patterns change over time and not view them solely as isolated crises related to specific substances.

The story of crack cocaine shows what can happen when the underlying causes of a drug crisis are ignored. (...)

Today, with youth opioid use falling, America may be at another inflection point. “Quite often, drug epidemics follow a classic curve,” said Samuel K. Roberts, an associate professor of history and of sociomedical sciences at Columbia University, describing how they seem to start slowly, spike and then fall.

One reason for this pattern may be the rising visibility of harm associated with use, both in the media and, probably more important, among family and friends. “What makes it subside is usually a number of things,” said Dr. Roberts, “but one of them is often that the negative perception of a particular drug will take off.”

That seems to be happening with opioids now, given the extraordinarily high death rate. There is no fentanyl chic; the drug is publicly associated with sudden death, homelessness and skin infections, not fun. (...)

Just like youths in the crack era, however, this doesn’t mean young people aren’t doing other drugs. There’s a phenomenon known as generational forgetting, originally identified by Lloyd Johnston, who led the largest national survey on drug use among youths for the past 43 years. The idea is that young people often avoid the drug that is currently the most feared. But since they have little experience with those that were popular earlier, they are less aware of their potential dangers.

This results in a broadly defined cycle in which, roughly every 10 to 15 years, a different drug epidemic appears. Heroin, for example, was the demon drug of the 1970s, crack in the 1980s, heroin again in the 1990s, methamphetamine in the 2000s, prescription opioids in the 2010s and now fentanyl and other opioids that are being sold as heroin. By seeing and covering each crisis as being caused by a particular substance — without understanding why addiction persists — we miss the opportunity to use policy to reduce related harm.

by Maia Szalavitz, NY Times | Read more:
Image: Teun Voeten/Panos Pictures, via Red​ux

[ed. See also: Principles of Harm Reduction (Nat. Harm Reduction Coalition), and these articles about Ms Szalavit's efforts to change current drug policy: “Undoing Drugs”—Maia Szalavitz’s Profound History of Harm Reduction (Filter); and, "On Drugs and Harm Reduction with Maia Szalavitz" (JSTOR Daily).]