An oft quoted observation by Desmond Tutu: “there comes a point where we need to stop just pulling people out of the river. We need to go upstream and find out why they’re falling in.” We seem to be stumbling on even the first measure, pulling people out of the river. We simply toss in flotation devices in an attempt to stop immediate death. We need to help people keep their heads above the water, pull them out, and work on upstream causation. We have difficulty with complex, coordinated responses, ones that extend beyond first aid. Drug policy, mired in negative perceptions about helping people with SUDs, made even more so by an increasingly lethal drug supply. Challenging issues exacerbated by repeated ODs, concurrent medical and mental health needs of those trapped in addiction.
This was in my mind in April, as I attended the Smart Approaches to Marijuana conference. A theme of the day, “let’s meet people where they are at, but let’s not leave them there” is what this blog, Recovery Review stands for. Multiple speakers, including Patrick Kennedy repeated this phrase from the podium as drug policy in America was discussed. The highlight of the event for me was a speech by Patrick who raised important points about what we should consider in respect to addiction prevention, harm reduction, treatment, and recovery policy in the US.
There are ethical matters here. If our parents, children, or siblings were on the street, we would want them to get a clean needle as first aid and to prevent the spread of disease, a ham sandwich to fill their belly and we would want someone to actively engage them in efforts to get well before they die in the gutter. I recently heard Thomas Wolf speak from first-hand experience people dying on the streets in San Francisco’s tenderloin district, and not being allowed to be engaged in conversations about help unless the suffering person specifically ask about it first. Any of us would want more for our loved ones in this scenario. We should want as much for every other family in every other community.
Also consider that for an increasing subpopulation, the capacity to make reasoned decisions has been impacted by multiple overdose reversals. A recent study, Neurocognitive impairments and brain abnormalities resulting from opioid-related overdoses notes it is an understudied issue. That we have not studied this more fully is itself disturbing. The paper suggests a high probability that as related neurocognitive impairments climb, the risk of poor treatment outcomes also go up. It warns us the fourth wave of the opioid epidemic may further increase the incidence of overdose related brain injuries due to the known neurotoxicity of methamphetamine. It does not mention xylazine, probably as the study occurred before its use was prevalent.
We must face the fact that waiting until cognitively impaired community members ask for help is in essence a death sentence. I anticipate that a number of readers will point out that compulsory treatment is fraught with risks. They are right. The risks of not doing so is even greater. If we don’t, we can anticipate more death and a backlash of regressive policy. Crafting policy that gets people help when they cannot help themselves must be a priority. It should include the very people who are most concerned about how it may be potentially misused in order to reduce negative outcomes.
Harm reductions strategies must be adopted. Getting clean needles into the drug using communities is vital, but it is not the equivalent of recovery for a person with a severe substance use disorder. Efforts to assist and support people to flourish is the ethical outcome. Let’s not forget this. We used to educate society that we did not have to wait until someone hits rock bottom to help them. Now it is far too often the approach used. I keep hearing stories of people I know who have found their way back into recovery recounting offers of clean needles and ham sandwiches, but not one word about getting into treatment. We must do better.
In the eyes of the public, things are clearly getting worse. Some may vehemently disagree with how the stories below portray the issues. Yet they do reflect a pervasive view that we are not doing enough to get people off the street. Public opinion matters. It will demand the streets to be cleared one way or another. We should preference a recovery, but it is also quite possible we risk a shift to a primary law enforcement focus. A sample of headlines:
- Want to ‘Reduce Harm’? Try Abstinence – The American Conservative – 08/11/23
- Scenes From a City That Only Hands Out Tickets for Using Fentanyl – The New York Times – 07/31/23
- Pills, petty crime, despair: A ‘perfect storm’ batters heart of downtown Portland – Oregon Live – 04/17/23
- Downtown San Francisco Whole Foods Closing a Year After Opening – The San Francisco Standard – 04/10/23
- A Sandwich Shop, a Tent City and an American Crisis– The New York Times – 03/19/23
- LA Riders bail on Metro trains Amid Horror of deadly drug overdoses, crime – LA Times – 03/14/23
We need law enforcement. Consider that the illicit drug supply chain is changing. Like any business, the cartels constantly adapt strategies to maximize profits. This increasingly means controlling distribution from production all the way down to the street. As noted in this US DOJ Press release against the Sinaloa Cartel’s Global Operation, fentanyl production to street distribution is complex and operates as a lucrative illicit international business. Law enforcement is key to push back against these murderous cartels that destabilize governments across the globe, including ours.
If the drug market changes, the cartels work to stay a step ahead of the competition. We need to think about this as we hear increasing dialogue about drug legalization. The early dialogue on Cannabis legalization in Colorado was that it would eliminate illegal drug trade. Yet, as this NPR story notes, Colorado’s marijuana legalization strengthened the drug’s black market. Whoever has the best and cheapest product wins the customer. We see this dynamic as drugs ike Xylazine are added into the drug supply to potentiate euphoria. Legalizing drugs will not change these dynamics, it will become a race to the bottom on cost and increasing potency, which has other, significant public policy implications.
Nor am I arguing for only a law enforcement focus. It alone will fail. History reflects that it is far too often used in ways that further marginalize marginalized community. Recovery for all communities is the other option here, yet increasingly we seem to be shortchanging recovery efforts, focusing only on first aid. Stopping an overdose is not a long-term solution, particularly as nearly all users use more than just opioids. We are not solving anything.
Jason Schwartz recently touched on several related themes in recent pieces. One here on the simple yet deceptive concept of safe supply, one exploring drug policy beyond legal or illegal, and the notions of direct and indirect harms, and one focused on unpacking the elements of drug policy which is as he writes, complex. As one of my mentors often says, if it was simple, we would have fixed it already. In broad brush strokes, our national drug control policy since its inception has vacillated between interdiction / incarceration methods and prevention / treatment priorities. Get rid of the drugs before people use them or get people to stop using drugs by force or choice. It is likely that no single focused goal here is fully achievable. While it may not be possible to “win” through to a society without drug use and addiction problems, if we do not address these issues drugs destroy our families, erode our communities, and weaken our society. China knows that drugs weaken America, which is why they dump Fentanyl here and launder money for the drug cartels, it strengthens them and harms us.
We need to support harm reduction, prevention, treatment, and the use of law enforcement for more effective drug policy solutions. All of these areas of focus have vital roles, If we do not help people get into recovery, they keep using drugs, we focus on keeping their heads above the water while they are robbed of their potential if they could get out of the river or even be kept from falling in. Everyone deserves a fair chance at recovery. This requires more than a life preserver thrown into the water. We must pull people out of the water, while also stopping what is occurring upstream.
Sources
Felbab-Brown, V. (2023, March 31). China’s role in the fentanyl crisis. Brookings. https://www.brookings.edu/testimonies/chinas-role-in-the-fentanyl-crisis/
Former drug addict Tom Wolf on widespread fentanyl use in California: “The crisis of our generation” | Fox News Video. (2022, December 28). Fox News. https://www.foxnews.com/video/6317909033112
How Colorado’s marijuana legalization strengthened the drug’s black market. (2019, July 15). PBS NewsHour. https://www.pbs.org/newshour/show/how-colorados-marijuana-legalization-strengthened-the-drugs-black-market
Justice Department Announces Charges Against Sinaloa Cartel’s Global Operation. (2023, April 14). Www.justice.gov. https://www.justice.gov/opa/pr/justice-department-announces-charges-against-sinaloa-cartel-s-global-operation
Strain, E. C. (2021). Meaning and purpose in the context of opioid overdose deaths. Drug and Alcohol Dependence, 219, 108528. https://doi.org/10.1016/j.drugalcdep.2021.108528
Schwartz, J. (2023, March 21). Unpacking “drug policy.” https://recoveryreview.blog/2023/03/21/unpacking-drug-policy/
Schwartz, J. (2023, April 14). There’s more to drug policy than legal or illegal. https://recoveryreview.blog/2023/04/14/theres-more-to-drug-policy-and-legal-or-illegal/
Schwartz, J. (2023, April 21). Promotional Practices in Drug Policy Advocacy. https://recoveryreview.blog/2023/04/21/promotional-practices-in-drug-policy-advocacy/
Winstanley, E. L., Mahoney, J. J., 3rd, Castillo, F., & Comer, S. D. (2021). Neurocognitive impairments and brain abnormalities resulting from opioid-related overdoses: A systematic review. Drug and alcohol dependence, 226, 108838. https://doi.org/10.1016/j.drugalcdep.2021.108838
Article link – HERE
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