Promotional Practices in Drug Policy Advocacy

[“Megaphon” by floeschie is licensed under CC BY 2.0.]

“Safe supply” is a promotional term, when what is needed is careful evaluation of the risk of such initiatives to increase addiction, toxicity, and overdose.

Roberts, E., Humpreys, K. (2023) Safe Supply” initiatives: Are they a recipe for harm through reduced healthcare input and supply induced toxicity and overdose? Journal of Studies on Alcohol and Drugs. https://doi.org/10.15288/jsad.23-00054

I’ve recently published a couple of posts on drug policy (here and here), trying to shine a light on how broad and complex the topic can be.

This is good news and bad news.

The bad news is that “simple” solutions are never as simple as they sound and that the devil will be in the details. Simple concepts get very complicated very quickly.

The good news is that we have a lot more levers than we typically associate with drug policy and that some of them ought to be fairly easy to implement — for example, things like marketing restrictions and zoning of outlets. These policy decisions typically won’t solve “the drug problem”, but they have the potential to influence it.

One of the questions raised was, if we legalize and regulate drugs, and one of the goals of that decision is to improve the safety of the drug supply, how do we manage and prevent innovation in the drug supply?

The NY Times has a story on the xylazine’s veterinary use and the search for policy responses to its emergence in the drug supply.

Stories about the emergence of fentanyl and xylazine often frame them as examples of poisoning of the drug supply. However, their emergence could just as easily and maybe more accurately be framed as innovations that serve a purpose — to ensure higher potency, lower price, and extend the duration of the effects of the drug.

We demonstrated that preference for fentanyl was increasing between 2017 and 2018 among our cohorts of PWUD who used opioids. In a multivariable analysis, younger age and daily crystal methamphetamine injection remained independently associated with preference for fentanyl. Most commonly reported reasons for preferring fentanyl included more euphoria, longer effects, and development of high opioid tolerance.

Ickowicz, S., Kerr, T., Grant, C., Milloy, M. J., Wood, E., & Hayashi, K. (2022). Increasing preference for fentanyl among a cohort of people who use opioids in Vancouver, Canada, 2017-2018Substance abuse43(1), 458–464. https://doi.org/10.1080/08897077.2021.1946892

Calls for “safe supply” often frame it as a simple process of ending prohibition (legalizing), getting law enforcement out of the picture, and regulating supply. However, what does that regulation look like? Does it allow innovations like fentanyl and xylazine? How are those regulations enforced and by who?

These calls also often elide the reality of the enormous public and private burdens associated with our regulated supplies of alcohol and tobacco.

All of this brings me back to the belief that we are very poorly served (harmed, actually) by sloganeering in drug policy discussions, whether those slogans are designed to promote a “war on drugs” or a “safe supply.” (It’s worth noting that harm reduction advocates used to avoid “safe” and preferred “safer” as an acknowledgment that PWUD who engage in harm reduction practices continue to face significant risks associated with their drug use.)

Mark Kleiman challenged us to confront drug problems and drug policy by facing the limitations of policy “solutions”, acknowledging the difficult decisions, and not being paralyzed by those limits and difficult choices.

Any set of policies will therefore leave us with some level of substance abuse—with attendant costs to the abusers themselves, their families, their neighbors, their co-workers and the public—and some level of damage from illicit markets and law enforcement efforts. Thus the “drug problem” cannot be abolished either by “winning the war on drugs” or by “ending prohibition.” In practice the choice among policies is a choice of which set of problems we want to have.

But the absence of a silver bullet to slay the drug werewolf does not mean we are helpless. Though perfection is beyond reach, improvement is not. Policies that pursued sensible ends with cost-effective means could vastly shrink the extent of drug abuse, the damage of that abuse, and the fiscal and human costs of enforcement efforts. More prudent policies would leave us with much less drug abuse, much less crime, and many fewer people in prison than we have today.

Dopey, Boozy, Smoky—and Stupid by Mark Kleiman