Tim sends along some other bits he thinks might be useful. I will keep my ideas off here and put them in the comments as we go along
A few other things you might find interesting/helpful...
The world of think tanks and policy experts is in a completely different realm than political leadership.
The Manhattan Institute is optimistic on harm reduction and "overdose prevention centers."
The DOJ under the Biden Administration still hasn't decided whether or
not they plan on shutting NYC's centers down and allowing other states
to follow. This is all because of legislation Biden championed and
passed.
An interesting tidbit I ran across
recently in a book about a Catholic priest who worked with Heroin users
in NY in the 1950s and 60s. At the time, he noted that heavy users were
spending $40-$100 a day on heroin in unadjusted dollars. I spoke with an
outreach worker here in Manchester and he said he doesn't know anyone
who is spending $100 a day in today's dollars.
Prohibition
hasn't raised the price of opioids at all... it has dramatically
decreased them by incentivizing the creation of more potent synthetic
alternatives... The exact opposite of the intended policy outcome.
The
best model out there, I believe, is what they did in Switzerland. I
wasn't completely convinced when my book deadline was approaching so I
didn't include it. But, I'm now sold.
They had
a large open air drug scene right in front of the equivalent of their
White House. They went in and allowed the people there to register for
"heroin assisted treatment." All registered users could go to a clinic
2-3 times a day to receive an injection of prescription-grade heroin.
The program, unsurprisingly, was quite popular.
The
illicit market collapsed and public drug use mostly disappeared. Anyone
who was a "user dealer" stopped dealing and those who were just dealing
lost their market. Property and violent crime dropped as anyone who had
been stealing to get money for drugs no longer needed to.
What
is particularly interesting, is that with free heroin available many
people decreased their usage. The unpredictability of supply tends to
encourage people to binge when the drug is available. Stability
decreased that drive.
And, while I haven't
seen good recent numbers on this, is how many people left the program
voluntarily. If memory serves correctly it was roughly 80% of a cohort
over a ten-year period.
Some people "age out,"
others end up seeking treatment over time and 2-5% a year have a
"spontaneous" recovery. The numbers aren't great in any given year but
over the course of ten years... it adds up.
And,
heroin use actually declined in the population overall with time. It
turns out that one of the most powerful forces spreading heroin use is
heroin users trying to make enough money to cover their own heroin use.
I
disagree with an approach that would end up with opioids available over
the counter in a similar way to alcohol. I already think alcohol and
cannabis advertising is problematic and that the government does have a
legitimate right to limit access to potentially harmful and addictive
substances.
But, there are a host of policy options in between complete prohibition and overt-the-counter
There
is good reason to believe that the people most motivated to divert
these kinds of drugs to young people are the folks desperate to make
money to buy the drugs they are addicted to. While some drugs would
still get diverted to young people, it isn't clear the problem would be
worse than it is now. And, the drugs that would get diverted would at
least be of consistent dosing and not poisoned.
I
haven't written publicly about all of this yet but plan on doing so
soon. So, if you see any flaws in my logic or see compelling
counterarguments, please send them my way.
Right
now the best counterargument I've encountered is... sounds good on
paper... but just wait for DC to muck it up! Which, unfortunately, is a
pretty good argument.
The problem in education programs is that they seem to fall apart when they get scaled up, and I would worry that this is what would happen with the Switzerland Plan. The US isn't Switzerland, not in terms of size and not in terms of permeable borders and diversity.
ReplyDeleteOn the other hand. If fentanyl really is the problem now, then doing a Swiss-style program for heroin is unlikely to be worse, and might be significantly better. It might even undercut the needs for fentanyl
There is no real need for fentanyl; most addicts, I hear, think they are buying something else that proves to have been cut with fentanyl. They would probably prefer pure heroin (or cocaine, I guess).
ReplyDeleteI can't imagine this kind of suggestion getting past Congress, though. No matter how good the science looks on paper, no Republican Congress is going to pass a law handing out free heroin to addicts because the party has a huge policing-punishing bent; and while left Democrats would be happy to propose it, the centrist ones would be terrified of the reaction from the voting public to them being the party of Free Drugs for Everyone. Apart from DC screwing it up, which I agree is a very good argument (look at the VA), I don't see how it falls within the 'art of the possible.'
I agree it would be the Republicans who are the bigger obstacle here. Yet I think among the rank-and-file the polling might be closer to the middle. The Democrats who opposed harm reduction would probably be quieter and less obnoxious, but they are there. I've met plenty who say they want to help lots of the unfortunate but can't abide any help for addicts. OTOH, there are those on the right, especially libertarians, vets, and evangelicals and Catholics who do downtown ministries who would be in favor of harm reduction policies.
ReplyDeleteSo it would probably take a Republican who took the risk of being hated because he felt it was the right thing. I'm not seeing who on the national scene that would be.
I live not far from a community that may have had the largest population of maintenance junkies in BC. I knew some of them, and they were kind of the leaders of this lose community. They were also one of the best wreckers around, and I needed parts back in those days.
ReplyDeleteJunk, heroin, is not a dangerous drug. It is very close to natural substances your body produces and used gently is quite benign. So people can live out their lives without having to quit junk, which is hard. And many have.
Now I have picked a burning cigarette from the naked chest of a sleeping junkie, so its not like I don't know how bad it can be. Experienced junkies roll their own, no saltpetre, so they go out.
Lots of interesting ideas here. The questions probably could only be answered by trial and error, which in the USA means federalism and competing experiments at the local level, which is difficult as long as there are federal drug laws. Where to start?
ReplyDeleteI disagree with an approach that would end up with opioids available over the counter in a similar way to alcohol. I already think alcohol and cannabis advertising is problematic and that the government does have a legitimate right to limit access to potentially harmful and addictive substances.
ReplyDeleteI like this and it makes me much more receptive to his other ideas. The 'legalize it all' libertarians who refuse to recognize that we already have serious second and third order effects from addictive substances that are already over-the-counter legal drive me nuts, and do nothing more than signal that they are affluent enough to be able to avoid them.
I have thoughts on scalability and political feasibility but that will take a little longer to write out. So, a few other points to respond to.
ReplyDelete@Grim... spot on. The switch to fentanyl was not a market demand but a result of the "iron law of prohibition." Alcohol prohibition meant that beer and wine drinkers switched to liquor because liquor made more money and was easier to smuggle for illicit suppliers. It's simpler and more profitable to set up an illicit fentanyl trade than one for heroin.
@PenGun... it is really hard to talk accurately about the risks of opioids without people thinking you are dismissing all risk or corrupting the youth. But, you are right. Pharmaceutical grade opioids aren't toxic. Tylenol is going to do a number on your liver before heroin does. And, it doesn't carry as high of a behavioral risk as alcohol or stimulants like cocaine or meth. And, some people are able to use in a relatively stable manner over the course of decades with few adverse physical or behavioral effects.
@Christopher B. Yes, alcohol is an easy example that drug use is not always relegated to the realm of "personal liberty." And, you hit another really important point. The harms of drug use are amplified or limited by financial resources and stability. A partner at a law firm can disappear for 40 days to a spa like treatment center and not have their life ruined. Someone living on the edge misses a shift or two and the dominoes start to fall. I do think it is a good thing to structure public policy with an eye towards protecting vulnerable populations.