Feb. 22, 2023 – For a forgotten moment, at the very start of the United States’ half-century long war on drugs, public health was the weapon of choice. In the 1970s, when soldiers returning from Vietnam were grappling with heroin addiction, the nation’s first drug czar — appointed by President Richard Nixon — developed a national system of clinics that offered not only methadone but also counseling, 12-step programs and social services. Roughly 70 percent of the nation’s drug control budget was devoted to this initiative; only the remaining 30 percent went to law enforcement.
The moment was short-lived, of course. Mired in controversy and wanting to appear tough on crime, Nixon tacked right just months before resigning from office, and nearly every president after him — from Reagan to Clinton to Bush — followed the course he set. Before long, the funding ratio between public health and criminal justice measures flipped. Police and prison budgets soared, and anything related to health, medicine or social services was left to dangle by its own shoestring.
The results of that shift are clear: Drug use is soaring. More Americans are dying of overdoses than at any point in modern history. It’s time to reverse course.
Drug use and addiction are as old as humanity itself, and historians and policymakers likely will debate whether the war on drugs was ever winnable, or what its true aims even were. In the meantime, it’s clear that to exit the current morass, Americans will have to restore public health to the center of its approach.
The Biden administration has taken some welcome steps in the right direction. In 2021, the Office of National Drug Control Policybegan spending slightly more money on treatment and prevention than on law enforcement and interdiction, for the first time in a generation. The Department of Health and Human Services is granting waivers to states that want to activate Medicaid for inmates before they are released from prison. The Labor Department is finally enforcing laws that require health insurance providers to cover addiction treatment at the same level that they cover other types of care.
Laws are changing, too. Doctors who want to treat opioid addiction with medications like buprenorphine no longer have to secure a waiver from the Drug Enforcement Administration. Lawmakersare also pushing for naloxone, the overdose reversal medication, to be sold over the counter — an important measure that could help save thousands of lives.
But there’s still much work for the nation’s leaders to do.
Amend outdated policies. Criminal justice still has a role to play in tackling addiction and overdose. The harm done by drugs extends far beyond the people who use them, and addictive substances — including legal ones like alcohol — have always contributed to crime. There is a better balance to strike, nonetheless, between public health and law enforcement.
One example is the so-called “crack house statute.” This federal lawsubjects anyone to steep penalties, including decades in prison, if they maintain a building for the purpose of using illicit drugs. It was enacted at the height of the crack epidemic but is currently being used to stymie supervised consumption sites, which are fundamentally different from crack houses.
At supervised consumption programs, people bring their own drugs, including heroin, and use them under the supervision of staff who have been trained to reverse overdoses, promote safer drug use and in some cases help people access treatment. With several states now considering, planning or starting supervised consumption programs, federal officials should make it clear that the people operating them will not face prosecution.
The federal sentencing disparity between crack and powder cocaine should finally be eliminated. The “Len Bias Law,” which enables courts to send anyone involved in an overdose death to prison, should also be amended, so that family members or fellow drug users aren’t criminalized for calling 911 in a crisis.
Invest in treatment. There are not enough programs or trained medical professionals to treat substance-use disorders.
As a result, it is too often left to the criminal justice system to decide who gets care. When wait lists for programs run long, people whose treatment is court-ordered jump to the front of the line. The outcomes have not been great. Judges and probation officers tend to have a paltry understanding of addiction medicine, producing treatment that tends to be punitive instead of therapeutic. For example, people placed on parole or probation for drug-related crimes are often incarcerated when they relapse, instead of getting additional care. (Relapses are a common feature of substance-use disorder and a normal part of the recovery process.)
One way to shift this calculus is to create incentives for more doctors and medical professionals to treat addiction. Lifting the special waiver that doctors need to prescribe buprenorphine — as federal lawmakers recently did — will help.
Other policy tweaks are needed as well: Parity laws, which require health insurers to cover addiction and mental health services as extensively as they cover treatments for other medical conditions, should be expanded to include Medicare. There are a lot of people aging into that program with substance-use disorders. Elected officials should also make basic training in addiction treatment a requirement for medical schools that receive state and federal funding.
Address root causes. People cannot heal from, or live stably with, substance-use disorders if they lack proper housing or suffer from untreated trauma or mental illness. For harm reduction — or any honest attempt to address the nation’s drug use and overdose epidemic — to succeed, communities will need to create more housing options. They will also need to provide clear pathways for people struggling with addiction to achieve food security and to have access to basic medical care. Policies that make it easier for people convicted of drug felonies to get benefits from social safety-net programs — including food stamps and supportive housing programs — would help. So would the Medicaid Re-entry Act, a bill that would reactivate Medicaid for inmates before their release.
Build an actual system. In other advanced nations, harm reduction and treatment for addiction are core public health services funded and protected by the national government. In the United States, syringe service programs and would-be supervised consumption sites have largely been left on their own, forced to design vital public health programs from scratch, then operate them in a legal morass, with little guidance or support.
The Office of National Drug Control Policy could help if it worked to stitch organizations together into a national network, bound to a set of standards and guided by the same policies and procedures. Again, policy changes would help. Among other things, lawmakers should lift the ban on federal funding for syringes used in needle exchange programs.
Study the solutions. Leading public health agencies, including the Food and Drug Administration and the Centers for Disease Control and Prevention, failed to prevent or even adequately respond to the opioid epidemic that has engulfed the nation. But health officials can still step up. As opioid settlement funds are deployed (along with federal dollars) and harm reduction programs are begun, the C.D.C. especially should impartially study what is working and what is not. The response to this crisis should finally be based on evidence.
The nation’s leaders are not the only ones with work to do. To fully replace the war on drugs with something more humane or more effective, the public will have to come to terms with the prejudices that war helped instill. That means accepting that people who use drugs are still members of our communities and are still worthy of compassion and care. It also means acknowledging the needs and wishes of people who don’t use drugs, including streets free of syringe litter and neighborhoods free of drug-related crime. These goals are not mutually exclusive. In fact, they go hand in hand. But to make them a reality, lawmakers and other officials will have to lead the way.