Some numbers put the problem in perspective. After Covid-19, drugs are now the leading driver of America's steadily declining life expectancy. A reported 111,219 Americans died from a drug overdose in 2021. That figure has risen more or less unabated, and at an increasing pace, since the early 1990s. Back in 2011, 43,544 Americans died from a drug overdose — less than half the 2021 figure. Ten years earlier, in 2001, it was 21,705 — less than half as many again. And the problem keeps getting worse: The 2021 figure is nearly 50% higher than it was in 2019.
Of course, President Biden is not uniquely to blame. Overdose deaths rose through the Obama and Trump administrations; the seeds of the crisis were planted as far back as Bill Clinton's first term. The failure has been ongoing and systematic. It is in part a failure of know-how: Over a century into drug control, we still have only limited ideas about how to abate the harms of drugs. It is also a failure of knowledge. One can easily find out how many people died of Covid-19 last week, but we still have only estimates of how many people died of drug overdoses last year. And of course, it is in part a failure of political will.
But in crucial respects what we face is a failure of understanding. What many people — policymakers and the general public alike — fail to grasp is that today's crisis is not like crises past. Historically, drug crises were characterized by the (re)emergence of a drug, followed by the spread of addiction and its attendant ills. The problems they caused affected individual and social health — physical illness, social dysfunction, frayed relationships, public disorder, etc. While these still play a role, today's crisis is predominantly characterized by an unprecedented increase in the drug supply's lethality. Historical crises inflicted many more or less equally weighty harms — to users' health, to families, to communities. In this crisis, one problem dwarfs all others: death.
Drugs have changed, probably for good. They now kill their users. Until policymakers internalize this fact, they will not make any progress. A haphazard approach was tolerable when the harms of drug use took time to accumulate. But with tens of thousands being poisoned to death every year, bolder action is required.
THE NEW DRUGS
Humans have long used drugs, to the benefit of some and the detriment of others. But drug crises — society-scale problems caused by drugs — are a relatively recent phenomenon. (...)
In the mid-1990s, something changed. Death rates began rising, slowly but exponentially. Between 1990 and 2000, the overdose death rate doubled, from 2.6 per 100,000 to 5.3 per 100,000. The decade between 2000 and 2010 saw another doubling. From 2010 to 2020, the rate tripled, to 29.2 per 100,000 — 10 times the rate in the 1980s, and 30 times the lows of the postwar period.
Drug overdose is now the leading cause of non-medical death in the United States. As of 2021, it was only slightly less deadly than all homicides, suicides, and motor-vehicle fatalities combined. Drugs still cause addiction, of course, and addiction still hurts addicts and society. But, likely for the first time ever, the primary harm of today's drug crisis is death.
DRUG INNOVATION AND DEATH
At the most abstract level, two changes explain this increase. The first is that the number of people using drugs has risen somewhat. The second is that the death risk of drug use has increased exponentially.
The story of the first change is relatively well known. As the American Enterprise Institute's Sally Satel has documented in these pages, in the early 1990s, physicians began prescribing more opioid painkillers at much higher doses. Many people became addicted, either to something they were prescribed or to pills diverted from the expanded legal supply. The growth of the drug-using population — and therefore the overdose risk — surely explains some of the increase in overdose deaths.
But a growing number of users cannot fully explain that increase. Estimates from the RAND Corporation indicate that between 2006 and 2016, the number of chronic heroin and methamphetamine users rose about 40%, while the number of chronic cocaine users fell 40%. In the same period, cocaine-involved deaths rose 30%, meth-involved deaths rose 380%, and heroin-involved deaths rose a staggering 617%. There are not just more people using drugs; drugs are killing more people. (...)
DEATH IS DIFFERENT
The emergence of synthetics has altered the balance of the harms associated with drug use. While addiction is still an issue, death now constitutes a far larger share of the problem. This has significant implications for the mitigation strategies the situation demands. (...)
Death is different. The risk of overdose death is not uncorrelated from history of use; both tolerance and probability of more aggressive use rise with time. But that risk exists in any use session. Death is an all-or-nothing proposition: Either this dose kills you, or it doesn't. Whereas historically, most of addiction's harms were concentrated among the population of the most serious users, a more deadly drug supply means that the risk that any given use session results in death is much higher.
In decades past, educators illustrating the harms of drug use usually described a life course: Someone tries a drug and gets hooked; he uses compulsively, burning through money and friends; and eventually he hits "rock bottom" or, in some cases, dies. Today, these events can all still happen. But the risk of death is also much, much higher, and can occur at any point along the life course of drug use. (...)
In decades past, educators illustrating the harms of drug use usually described a life course: Someone tries a drug and gets hooked; he uses compulsively, burning through money and friends; and eventually he hits "rock bottom" or, in some cases, dies. Today, these events can all still happen. But the risk of death is also much, much higher, and can occur at any point along the life course of drug use. (...)
DEALING WITH DEATH
Given that today's drug crisis is fundamentally different from drug crises past, different policy measures are required to address it. Some dramatic shift is needed along at least some margin. But where should policymakers concentrate their attention and resources?
One increasingly common answer is "harm reduction," the umbrella term for interventions meant to reduce the harms associated with drug use short of encouraging cessation. Harm-reduction programs — distributing naloxone, operating needle exchanges, or setting up safe consumption sites (SCSs) where people can use under supervision — are gaining increased traction as a solution to the rise in deaths. Major urban areas from New York City to San Francisco are investigating or embracing harm reduction; the Biden administration has handed out tens of millions of dollars in harm-reduction grants.
Proponents argue that harm-reduction strategies are particularly well suited to the current crisis. The drug supply is toxic, they argue, so policymakers should prioritize reducing its toxicity over controlling its use. Opponents of harm reduction, meanwhile, often frame their objections in moral terms — we shouldn't facilitate drug use and addiction, even toward some instrumental end. But the "death is different" view provides another critique: Harm-reduction strategies are a poor fit for the current crisis because they address the safety of individual use sessions rather than trying to discourage people from using altogether. Such approaches may help to address accumulating harms, but they are not well suited to a risk that obtains across all use sessions and for which a single failure results in death. (...)
PROBLEM USERS
A rule of thumb is that for any addictive substance — legal or illegal — consumption is power-law distributed. That is, 20% (or less) of the users consume 80% (or more) of the substance. The former are also the users among whom problems are most common, including most likely deaths. For this population — those who not only use, but are seriously, actively addicted — the best tool available is treatment. A proportional policy response to these individuals' needs must focus on offering — and compelling — treatment like never before.
How many Americans need treatment? As of 2020, survey data suggest that roughly 18 million Americans had in the past year suffered from an illicit drug-use disorder, including 4.2 million whose disorder involved a drug other than marijuana. Just 2.6 million people, however, reported actually receiving treatment that year, including 800,000 who received medication-assisted treatment (MAT). The survey from which those estimates come, the National Survey on Drug Use and Health (NSDUH), likely underestimates the true prevalence of abuse: One study that attempted to account for insufficiencies in the NSDUH found that more than 7.6 million Americans suffered from an opioid-use disorder, while only about 1 million were receiving MAT.
by Charles Fain Lehman, National Affairs | Read more:
Image: uncredited/US Congress/CDC
[ed. Pretty good summary until things go off the rails near the end. Whenever someone is forced to do something 'for their own good' (as in involuntary civil commitment), is when they lose me.]
