More than fifty years ago, President Richard Nixon announced a new federal initiative he called the War on Drugs. With bipartisan support, the number of drug arrests nearly quadrupled while officials enhanced border interdiction efforts and ratcheted up jail and prison sentences for people who possessed or sold drugs.
A trillion dollars and several decades later, the failures of the Drug War are abundantly clear. Police efforts to disrupt local drug markets didn’t eradicate drugs or make them harder to get, but they did trigger violence. Illicit drugs are now cheaper, stronger, and easier to get than ever. Drug fatalities rose throughout the 2010s and reached record levels in 2022. Over two-thirds of these deaths—nearly 200 a day—involved synthetic opioids, mainly fentanyl. The use of jail and prison also exacerbated drug-related harm—harms disproportionately imposed on Black and brown people and their communities.
Public awareness of these failures has fueled support for harm reduction practices and other drug policy reforms. Today, though, with the retrenchment of law-and-order politics, even modest shifts away from punitive prohibition are once again controversial on both the right and the left. For example, although harm reduction services such as syringe exchange and Narcan distribution have spread even in red states, the Trump administration frequently attacks harm reduction, while funding shifts will decimate desperately needed services, treatment, and research. Meanwhile, Democratic leaders in progressive cities now also attack harm reduction measures while passing new laws that make public drug use a crime—despite abundant evidence that such tactics don’t work.
Critics of drug policy reform aren’t just recycling the bad ideas of the past, though. Today, a leading and ostensibly centrist argument goes like this: Fentanyl and other drugs wreak havoc not only on the people who use them, but also on cities and communities where visible drug use causes fear and discomfort. The fact that this problem is especially pronounced in West Coast cities that have more fully embraced harm reduction and rely less on law enforcement is proof that harm reduction has gone too far, that decriminalization has failed—and that mandatory treatment is needed to deter and rein in harmful drug use.
This line of argument has gained significant traction, in part because it recognizes and validates people’s understandable concerns about visible drug use. But it also confuses correlation with causation and obscures the real reasons for the overdose crisis. A more accurate understanding of what has happened—and why—is necessary if we are to actually reduce drug-related harm and promote deep and lasting recovery.
It is easy for critics to blame the crisis on blue cities’ embrace of harm reduction and other drug policy reforms. For example, many observers attributed Portland’s overdose crisis to the state’s 2021–24 experiment with decriminalization. But this tragedy is not unique to liberal states and cities. In fact, drug fatalities are concentrated in places such as West Virginia, Kentucky, Tennessee, Delaware, New Mexico, and Ohio—places that don’t attract much media attention and have largely escaped critical commentary.
Changes in the global supply chain—not harm reduction services or even decriminalization—are the root of the problem. More compact and cheaper to produce than heroin, fentanyl began appearing in illicit drug supply chains in the eastern United States in the 2010s and has come to dominate drug supply chains in the western United States as well. At the same time, new ways of producing methamphetamine have made today’s “super-meth” cheaper and more dangerous than ever. As top DEA officials have concluded, “The shift from plant-based drugs, like heroin and cocaine, to synthetic, chemical-based drugs, like fentanyl and methamphetamine, has resulted in the most dangerous and deadly drug crisis the United States has ever faced.”
But the U.S. news media tell a very different story about the drug crisis. Like critics of drug policy reform, outlets ranging from Fox News to the New York Times focus overwhelmingly on visible drug use in liberal West Coast cities. Images of stooped and bedraggled fentanyl smokers with open wounds, amputated limbs, and burned scraps of tin foil in cities like San Francisco, Seattle, and Portland create the false impression that other parts of the country do not also struggle with the problem of addiction.
It is undeniably true that conditions in parts of West Coast cities are shocking and that the response to the drug crisis in those cities could be improved. But the relentless focus on the severity of the problem in these and other ostensibly progressive places is both incomplete and misleading. Among U.S. cities, San Francisco’s, Seattle’s, and Portland’s overdose death rates ranked eleventh, eighteenth, and nineteenth in 2023. The five cities in which overdose deaths are most common—Baltimore, Cleveland, Philadelphia, Columbus, and Louisville (in descending order)—are concentrated on the East Coast and in the Midwest, in red and purple states. These cities are not harm reduction pioneers. Similarly, the states with the highest overdose death rates—West Virginia, Tennessee, Delaware, Louisiana, Kentucky—are hardly paragons of progressive governance.
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While misleading, the focus on the drug problem in a handful of West Coast cities and states is quite useful to those who argue that permissive drug policies make things worse. Michael Shellenberger’s 2021 book San Fransicko: Why Progressives Ruin Cities made this connection quite evident, as did the 2019 local news documentary Seattle is Dying, which features disturbing images of people using drugs and suffering florid psychosis. The film, which has been streamed over 19 million times on YouTube, attributes these problems to naïve and neglectful progressives.
There’s no doubt that open-air drug markets cause very real problems. Many residents who live and work nearby feel unsafe when confronted by the human suffering that often accompanies public drug use. The unauthorized encampments in which such use is common are associated with many biohazards and other forms of disorder. For these and other reasons, concerns about outdoor drug use should not be dismissed or minimized. In fact, progressive efforts to address the drug problem in new and better ways will founder if they don’t also address the public consumption of drugs.
Still, it’s important to distinguish between the country’s drug crisis and the specific challenge of visible drug use. Many cities with the highest rates of drug fatalities have comparatively abundant affordable housing, which means that most drug use takes place behind closed doors. In fact, the drug crisis is deadliest in cities where rents are relatively low and the carnage is less visible. What sets San Francisco, Portland, Seattle, and Los Angeles apart is not the severity of the drug problem but rather the fact that this problem coexists with exceptionally high rates of unsheltered homelessness. Boston, for example, is home to Mass. and Cass, a neighborhood where open-air drug market activity is quite visible and the source of tremendous civic anxiety. The intertwining of addiction and visible homelessness in high-rent cities and in states without right-to-shelter laws means that the problem is more likely to unfold in public.
Recently, some high-profile commentators have argued that the solution to visible drug use, and to addiction more generally, is to recriminalize public drug use and possession and to more aggressively use the law to compel people to enter treatment. This is necessary, they claim, because addiction is not like other diseases: absent the threat of criminal sanctions or legal pressure, people who use drugs will not choose treatment, making coercion a necessary part of any effective response to the drug crisis.
It’s true that all human behavior, including problematic drug use, is potentially affected by incentives, disincentives, and social pressure. But there is no reason to believe that sanctions (sticks) are more effective than positive incentives (carrots)—a point to which I will return in more detail in the next two sections. Moreover, aggressive drug law enforcement fuels violence and overdose deaths.
Meanwhile, nearly half of all people in state prisons would benefit from substance use disorder treatment, but only 10 percent receive clinical treatment while in prison. What’s more, some people who didn’t use drugs regularly before their incarceration start using while imprisoned, often shifting to more potent drugs when they do. This is dangerous: from 2001 to 2019, the drug and alcohol intoxication death rate increased by more than 600 percent in state prisons, where drugs are often readily available. The rate of overdose for people released from jail is more than 15 times higher than for the general population; among people who were recently released from prison, it is a shocking 129 times higher. And the experience of imprisonment has a host of psychological and social effects that deepen trauma and make it more, not less, difficult for people to establish the kind of stable, meaningful, and connected lives that are the antidote to addiction.
Just as policing and incarceration don’t work to reduce drug use and the harms associated with it, using the threat of incarceration to force people into treatment is ineffective.
Drug courts are often touted as an enlightened alternative to incarceration, albeit one that relies on the threat of criminal punishment to force people into drug treatment. While some people clearly benefit from drug court, research suggests that in the aggregate, drug courts do not reduce drug-related imprisonment and associated racial inequities. In fact, judges rely heavily on jail as a sanction for noncompliance, and participants who are unable to meet often burdensome program requirements often have to serve more time behind bars than if they had simply plead guilty in the first place. Drug courts simply cannot bear the weight that advocates of “enlightened coercion” place upon them.
Advocates of compulsory treatment ignore these issues while pointing to studies showing that the threat of punishment can motivate participation in treatment. While such studies do exist, recent meta-analyses of high-quality, peer-reviewed studies find otherwise. A 2016 meta-analysis, for example, found that only 9 of the 430 published peer-reviewed studies on this topic utilized reliable data and methods—and those 9 indicate that compulsory treatment is largely ineffective and sometimes harmful. Similarly, a 2023 meta-analysis of peer-reviewed studies with comparatively robust research designs concluded that “there is a lack of high-quality evidence to support or refute involuntary treatment.”
Proponents of mandatory treatment also ignore the crucial fact that many people who need and want treatment can’t access it. While people’s motivation and capacity to enter treatment varies and fluctuates over time, and some people who use drugs in harmful ways don’t seek treatment, many people in the throes of addiction do seek—but are unable to access—treatment programs that offer humane, effective, and dignified care. Advocates of legal coercion say that coerced treatment is better than no treatment. But why not use resources that are available to expand treatment capacity for people who already seek it?
Part of the challenge has been the paucity of treatment options that are logistically manageable and that actually reduce people’s suffering. For example, some older forms of buprenorphine—a medication that can reduce the craving for opioids as well as withdrawal symptoms—require consuming the medication on-site several times a day, a steep challenge for anyone, let alone those living outside. Some versions of the medicine also fail to prevent people who have been using fentanyl from experiencing withdrawal. Other barriers to treatment also exist, including cost, insurance constraints, lack of transportation, limited programs that won’t accept pregnant people and parents, and more. It makes little sense to adopt mandatory treatment when so much could be done to expand access to voluntary and efficacious treatment for people who badly need and want it.
More broadly, the argument for using the legal system to force people into treatment ignores the fact that treatment is just one component of meaningful recovery. The federal Substance Abuse and Mental Health Services Administration defines recovery as “a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.” Recovery thus involves the ability to make choices that support well-being, a stable and safe place to live, meaningful daily activities, and community. Even if the use of criminal “sticks” did reliably lead to compliance with court-mandated treatment—which they don’t—this approach does little to promote recovery in the fuller sense.
Fortunately, there are five evidence-based actions local governments and organizations can take to reduce the suffering associated with addiction and the harm associated with visible drug use and to promote recovery.
1) Expand Harm Reduction Services
Harm reduction services save lives, reduce disease transmission, and provide an opportunity to build trusting relationships with people who use drugs. Critics often juxtapose harm reduction with treatment, but people who use harm reduction services are five times more likely to enter treatment than people who do not.
Recently, some observers have criticized harm reduction approaches for their failure to condemn drug use. Of particular concern is the harm reduction edict that service providers should “meet people where they are at.” It’s true that public health educators and harm reduction advocates shouldn’t romanticize drug use and that this line has been crossed in a few (highly exploited) instances. But harm reduction’s commitment to reducing the stigma people who use drugs experience is warranted: stigma creates substantial barriers to treatment and services for people who use drugs.
For some, the fundamental concern is that harm reduction services don’t appear to do more than keep people who use drugs (barely) alive. There’s a grain of truth to this: while many harm reduction service providers work hard to increase opportunities for people who use drugs to fully recover with dignity, care, and support, some have limited themselves to supplying clean supplies while invoking peoples’ right to use drugs. The argument that drug use is a fundamental individual right falls flat in the face of the damage and suffering caused by synthetic drugs like fentanyl.
Harm reduction providers should support robust versions of recovery and advocate for the resources needed to support it. Initiatives such as syringe exchange and naloxone distribution programs exist in the United States but should be expanded. Other harm reduction practices, including overdose prevention centers, low-barrier housing options that allow people who use drugs to do so under medical supervision, and the use of heroin-assisted treatment have been largely rejected in the United States for political reasons. They should be adopted and supported by state and local governments.
2) Expand Access to Detox Facilities and Effective Treatments
Medication-assisted treatment (MAT), which uses medications such as buprenorphine to support recovery, is the most effective approach to opioid use disorder. Simply starting someone on buprenorphine can reduce their risk of dying from an overdose by 50 to 80 percent compared to those receiving only counseling or other non-medication-based treatments. In France overdose deaths fell by 79 percent after all doctors were allowed to prescribe buprenorphine.
In the United States, though, fewer than one in four people who could benefit from buprenorphine actually receive it. The success of new, slow-release injectable forms of the medicine offers reason for hope: users find it far less painful and more efficacious than older forms, and retention rates are comparatively high, even among vulnerable populations. Expanding access to this delivery method is essential. Researchers have also found heroin-assisted treatment to be highly effective in reducing both drug use and legal system involvement.
So far, no medication has been found to be effective for treating methamphetamine use disorder. However, a growing body of research supports the use of contingency management (CM), a behavioral therapy that uses tangible rewards—ranging from affirmations to prizes, including cash—to reinforce positive changes such as abstaining from drug use. CM has even been proven effective among individuals with serious mental illness and stimulant use disorder. The success of CM supports the idea that people who use drugs do respond to incentives—and that using carrots rather than sticks is both effective and humane. While CM offers significant benefits in terms of abstinence and overall health outcomes, broader adoption will require addressing practical barriers related to cost, training, and public perception.
3) Expand Deflection and Diversion Initiatives
While harm reduction and evidence-based treatment are necessary, they do not address the many challenges associated with visible, outdoor drug use. To be clear, there is no quick fix to this problem. But history makes clear that using law enforcement crackdowns, property seizures, banishment, demolition, and other aggressive tactics to forcibly relocate people who live outdoors, some of whom also use drugs, isn’t the answer. These tactics simply move people from one location to another while further destabilizing their lives.
Investment in affordable, low-barrier housing for people who use drugs is critical. In addition, prearrest and prebooking diversion (sometimes called deflection) initiatives like LEAD (Law Enforcement Assisted Diversion / Let Everyone Advance with Dignity) offer a humane and effective way to address the conditions that fuel outdoor drug use. LEAD trains police to divert people suspected of committing a crime related to their substance use to social workers who can provide care and support in lieu of a jail booking and criminal charges. Prebooking diversion programs such as LEAD can also authorize officers and others to make “social contact” referral even absent arrest. Community referral processes in which public defenders, social workers, business owners, and others are also allowed to make referrals are especially useful when arrests drop off, as they did during the pandemic.
These diversion initiatives are less coercive, less harmful, and more cost-effective than court-supervised diversion (such as drug court) and they are a better fit for people who lack housing and access to transportation. Evaluations show that prebooking diversion programs such as LEAD can be highly effective in reducing jail time, incarceration costs, recidivism, and other harms. The CoLEAD model—which also provides temporary housing, medical care, and intensive case management for people experiencing homelessness and mental health challenges—is especially promising. While not inexpensive, low-barrier housing alternatives with wraparound supports for people who use drugs dramatically improve the health and quality of life of people with substance use disorder who would otherwise live unsheltered.
4) Invest in Street-Based Outreach Initiatives
New forms of street-based civilian outreach focused on public safety also show promise. For example, in Seattle, a coalition of business owners, service providers, and harm reduction advocates created TAP (initially called the Third Avenue Project). In this approach, civilian outreach teams are trained in deescalation and “milieu management.” The goal is to build relationships with people on the streets in order to gain a deeper understanding of their lives and needs and ultimately to help them access housing, services, and treatment. Outreach workers also serve as first responders (including attempting to reverse overdoses with Narcan), provide a sense of security to passersby, and manage the complex and messy dynamics that accompany outdoor drug markets and drug use.
TAP’s use of civilian, unarmed public safety teams to provide safety patrols and first responder services while also serving as conduits to care, housing, and services appears to be unique in the United States. While TAP’s impacts have not yet been clearly established, preliminary results are encouraging and expanding this model to other cities is worth exploring.
5) Make the Drug Supply Safer
The unprecedented nature of the fentanyl crisis requires novel interventions that make the drug supply safer. As a first step, we should make drug-checking tools widely available to users so they can be sure the drugs they buy don’t contain deadly concentrations of fentanyl or other adulterants. Heroin-assisted treatment is another way to improve drug safety for some long-term users. Used in Europe and Canada, this approach has been shown to reduce drug deaths and crime and to enable many long-term opioid users to live healthier, more productive lives. Similarly, safe supply initiatives that provide pharmaceutical-grade fentanyl to long-term users have been found to reduce both overdoses and drug use over time.
The revival of War on Drugs tactics will certainly fail. Even with drug courts operating across the country, reliance on the criminal legal system to address harmful drug use simply will not suffice. Cuts to Medicaid and other government programs will only amplify the problem.
The intensification of the drug crisis is the result of the spread of potent, deadly synthetic drugs, especially fentanyl. The embrace of harm reduction and other drug policy reforms by West Coast progressives did not cause this crisis, and repealing those reforms will not solve it. Nor will mandating treatment through the criminal legal system end the suffering that drug addiction causes or resolve the problem of visible outdoor drug use. Fundamentally new approaches that increase access to treatment, housing, and care, while also reducing the dangers posed by synthetic drugs, are desperately needed.
Fortunately, local governments and organizations can adopt and implement these and other alternatives without waiting for a federal mandate. While these strategies can and should be refined over time, one thing is clear: throwing people who use drugs in jail will do nothing to curtail the tragic loss of health and life that is unfolding across the country. Nor are drug courts up to the task. Ultimately, investing in robust, creative, and well-designed alternatives—and ending our addiction to the fantasy that greater use of arrest and the threat of jail can solve the problem—is the only way to truly promote recovery.
Image: Simon Takatomi / Unsplash
