Another complication is that teen drug use is actually pretty low relative to historical norms. On the positive side this suggests that you really need to focus prevention efforts on a fairly small number of people. On the negative side it suggests that opioids and fentanyl are so harmful that they only need to capture a small slice of the population to cause extraordinary suffering and death.
In Mexico they have this drug treatment program where if its the right match: parent to child, even between spouses I think, they can go find the addict and literally force kidnap him for a full year. First few months is to break the addiction. Next few months is usually some faith based foundation. And the last bit of the year to fully recover. Its expensive, but it seems promising. I think the only way to get ahead of this is something super aggressive like that. I've known my fair share of addicts and only the ones that became super religious made it out alive.
It's not remotely politically realistic, but I've always thought that the ideal policy would be direct government provision of drugs. You go to a clinic, show them a letter from a doctor certifying you as an addict, and are proscribed a few days worth of opiates. Maybe you first have to sit through a health checkup and a lecture about quitting.
I'm all for harm reduction personally, but, as you point out, actually existing harm reduction policies only address the direct harm to the users, but most of the bad stuff associated with drugs is a product of the fact that they’re only available via the black market and are therefore very expensive. Back when you could buy heroin at the drug store it cost about a tenth of what it does now on the street.
And it's not as if heroin causes people to commit crimes as a side effect. Drug addicts steal stuff because drugs are expensive, and drug dealers kill each other because the drug trade is profitable. If you made heroin available to addicts for free you’d put every dealer in the country out of business overnight and prevent a massive amount of other crime.
It would also be much, much safer for individual users. The drugs would always be pure and could be formulated in whatever fashion was found to be safest. It probably wouldn’t actually be heroin but something in pill form, provided in child-safe packaging complete with dosage information and alongside overdose reversing drugs. I think you could virtually eliminate unintentional overdoses with a bit of experimentation.
The biggest risks I can think of would be diversion and induced demand. There would be massive profits to be made if you could find a way to sell your free drugs in a jurisdiction where they’re still illegal… but it’s not like drug smuggling would be a new problem, and there’s things you could do to make it less likely; only give people small amounts of drugs at a time, make them use the drugs onsite at the clinic, etc.
Induced demand is a more serious concern. If heroin is free and less dangerous there is going to be some number of people who will begin using it who would not have otherwise. You could fight this by trying to restrict the program to people who can convince a doctor that they’re already addicted, and you could just make the whole process kind of a hassle, but still much less of a hassle than buying drugs on the black market.
Good points, but in brainstorming and assessing various approaches, why was there almost no discussion of re-reforming prescribing guidelines to make it a (last resort but ultimately feasible) legal possibility for desperate sufferers of chronic pain to choose to accept some addiction risk (and even some overdose risk)? The policy lever would be to make it more acceptable for doctors to allow severe chronic pain patients to choose this with updated knowledge of the risks and to favor opiates, like methadone, that effectively mitigate pain without getting people high. This would mitigate externalities like "leakage".
Methadone is highly effective at mitigating chronic pain without the complications of getting people high, including for those who've never taken heroin or fentanyl. It's not very valuable on the black market for buyers seeking mainly to get high or for prescription opiate-seekers mainly interested in getting high.
We currently give sufferers of immiserating chronic pain who are not able to control their pain without opioids the following choices:
- Seek legal routes for obtaining opiates that are physically addictive but don't get them high and are reliably dosed. Fail. Be told to take ibuprofen and do deep breathing exercises. Try it and find it overwhelmingly inadequate. Get labeled drug-seeking after looking for a doctor who's less afraid of prescribing opiates to pain patients. Fail to be presented by the same medical community with effective alternatives. Try to muddle through the misery. If it becomes untenable, consider suicide.
- Seek legal routes for obtaining opiates that are physically addictive but don't get people high and are reliably dosed. Fail. Fail again. Get labeled drug-seeking without being presented with effective pain-controlling alternatives. If the misery is otherwise untenable with no relief in sight, consider looking in to black market pain control alternatives for lack of safer (albeit not completely safe, but...trade-offs) options. Wrack your brain for someone you were friendly with in high school who vaguely fit the profile of someone who might know someone who knows someone. Hide the next steps from those closest to you.
How does meth compare? That’s also very easy to make in a small lab too, right? Did putting all the cough syrup behind the pharmacy counter help?
While I did read and enjoy “Dreamland,” it did succumb to the myths criticized at the top of the piece. There was a rather smug intro denouncing Americans for buying houses too big for them, for overeating, and for not being tough minded enough to tolerate pain. And IIRC, “Dreamland” was the name of a swimming pool that was closed in a dying industrial town. So that myth got some purchase as well.
Still a riveting read for the industriousness of the heroin dealers and the difficulty in even figuring out that opioid deaths had become a problem, given how medical examiners report their data.
I’m sure the tv series Dopesick is heavily dramatized, but it does give you a sense of just how evil the Sackler family is.
People will probably tell me I'm crazy for this, but I think the permanent solution here is free government provision of all recreational drugs to anyone already addicted to that substance.
You would instantly destroy every drug cartel overnight - the vast majority of their customer base would leave, because who can compete with free. There is still the small customer base of "haven't tried fentanyl yet, sounds fun", but since they could switch over from the black market to get free drugs at any time, that's not a stable or sustainable source of income.
But of course I don't think the most popular politician in America could sell this policy, it seems totally politically toxic.
No, in Portugal addicts can get permission from the government to use drugs w/o fear of arrest, but they're still getting their drugs from illegal criminal organizations.
Unlike the Portuguese model (which is the closest to what I'm proposing), government provision would remove the street crime aspect of drug decriminalization, and probably reduce the amount of future addicts as well.
If anyone is interested, a top anesthesiology journal had a deep dive on this a couple months back. Former Surgeon General Jerome Adams is a co-author (this is well within in his zone of professional expertise and personal passion. He has a professional career independent of the Trump administration). I'm sure they'll forgive me for breaking the paywall here for educational reasons (or I'll ignore them if they complain). It's quite informative.
I wish to another source of our endemic opiate addiction: hospitals.
At some point part way through my many decades of medical practice, hospital nurses added pain assessment scoring to the vital signs. I saw patients trying to decline narcotics only to be beaten down by nurses repeatedly badgering them to accept narcotics they tried to decline. From this I was called to manage the acute complications of respiratory depression and psychosis. As a post op patient several times, I was myself subject to this pressure, needing to politely decline well intended offers when my pain level did not warrant narcotics. A lay person is likely to be less aware than a seasoned clinician.
This is the best MY column I've read. It's not often you see a pundit grapple with a really difficult problem with no simple solutions and conclude, "a really difficult problem with no simple solutions."
I've read here and there about anti-addition programs that appear to be effective (my sources were cheerleading for the programs, so who knows?), but in most cases they were part of the local correctional system and they served cons and ex cons. Some programs seem to be really effective.
The libertarian in me doesn't even want to see drug use remain illegal; but the pragmatist suggests that since we have already gone down the road of criminalizing drug use, maybe it should be the correctional establishment rather than the medical establishment that works on this, given the disincentives you mention above. But before that can occur correctional programs have to shift away from being punitive and retributive to instead being remedial and, well, correctional. I'm not sure that can ever happen in a big way in the USA.
I was recently re-reading/listening to some of Michael Pollan's stuff on psyechedelics, which seem like a potential backdoor out of the no-solutions zone. (See his seminal New Yorker article: https://www.newyorker.com/magazine/2015/02/09/trip-treatment) Psilocybin-assisted therapy has shown extremely promising progress against cigarette addiction, and apparently the founder of AA originally wanted to use LSD to cure alcolohism before he was overruled by his more generally prohibitionist board. There's naturally been a lot of interest in using psychedelics to combat opiate addiction as well.
There's a lot of unsettled but really interesting neuroscience here (psychedelics seem to lower the brain's certainty of things it is usually pretty sure of, so just as you might get less sure of "I cannot fly" while on psychedelics, you might also get less sure of "I need heroine" or even "This back pain is so bad that I need medication"), and there's the perennial question of whether the initial trials will scale. But the bottom line is that this sort of treatment (with the right precautions) could really help people.
What’s the truth of the oft repeated story about how US soldiers used a lot of heroin in Vietnam but a remarkably large number of them just stopped when they got back to the US?
I wonder if dosing education would offer one approach. Is "the doctor says take one every four hours so that's what I am going to do" part of the problem?
I have noticed over the years that the dosages for certain medications are far higher than I can tolerate. The prescription may say "1 tablet as needed" but if I take a whole tablet I am a wreck. A quarter or just a crumb of a tablet does what needs to be done.
For those who strictly follow doctors' orders, perhaps there is a way to educate these patients to pay attention to their reactions to the drug and so titrate doses accordingly.
It's nice to see the acknowledgement here that not every problem can be solved via technocratic means.
On this though:
"Michael Shellenberger and other Bay Area critics of Chesa Boudin argue that bad progressive policy is responsible for drug addiction, and drug addiction is responsible for San Francisco’s homelessness problem. I think this is pretty clearly mistaken. "
I don't know about progressive policy in the Bay Area, but it definitely is true that the homeless population has a much, much higher rate of drug and alcohol addiction and that is a driver of a significant portion of homelessness.
I have an example from my own family where my brother-in-law went from a successful upper-middle class business owner to living in the streets because of his alcoholism, which eventually killed him. No government program and not even his own robust and supportive network of family and friends prevented it, despite many attempts at intervention.
I have a close friend who does social work in San Francisco, helping transition people out of prison who struggle with mental illness and addiction. He is very much left of center but hates Chesa Boudin with a passion. He says that addicts will never voluntarily agree to enter rehab without the threat of incarceration. So Chesa’s decision not to prosecute low-level offenses basically makes his job impossible. Meanwhile, overdose deaths in San Francisco have tripled since 2018. The arrival of fentanyl deserves the vast majority of the blame for this, but Chesa isn’t helping.
I have spent many mornings volunteering at my local shelter calling every impatient detox place in King County to see if they have an open bed so that I can try to get maybe three of the two dozen folks who show up in the morning wanting to get into detox. The rest have to wait and try the next day when many don't show up because their window of having hope or recognizing their worth has closed. Our drop in clinic for medically assisted addiction treatment is open four days a week and we have never had an unclaimed appointment. I have had folks on the street, often freshly freaked out by a recent near OD ask me to help them find any kind of bridge to treatment. There are lots folks out there who don't want to get clean, think that they are unable to get clean, or don't think they are worth the effort. But there are also a lot of folks who desperately want to get clean and don't have sufficient access to treatment when they are ready for it. Even those who do almost never get a gold standard of care with sufficient impatient supports. It can feel perverse to chase folks to threaten them with jail when they aren't looking to get clean while we aren't offering services to those who want them.
This aligns with one of Shellenberger's ideas (and what Darawk gets at below) which is to send addicts to a treatment center far removed from the streets where they can spend time receiving wrap-around services to (hopefully) be able to re-enter society. But that would require cities to recognize and treat them as addicts, not victims of abstract, structural economic forces.
If you happen to check out the Lancet /Stanford commission study that Matt cites it seems to have this problem. Reading it I get the impression that addiction strikes people randomly like cancer or strokes. It's all about how doctors need to treat addiction as a disease, which is fine as far as it goes. But it's not the sole way society needs to look at the issue.
Former oxycontin/heroin addict here. The right way to think about addiction treatment is as a lottery. Each time you send an addict to treatment they have an x% probability of recovering. That x% is mostly correlated with *length* of stay in a treatment facility. And when I say "stay" I mean inpatient, because all outpatient addiction treatment is bullshit, at least for the acute phase. Effectively zero people have ever quit using opioids from outpatient treatment alone.
The most important thing you can do is physically separate the person from the drugs - by force. This means we need to retain the threat of prison on the books for these crimes, but we shouldn't be using it. We should be giving people a stark choice "go to prison or go to treatment" and in that treatment center, they will be held, by force if necessary. Each time you do this to someone, you get an x% probability of them not going back to using. 'x' is probably not super high, but it is correlated primarily with *length* of stay, and almost nothing else. Different treatment modalities probably help at the margin, but we don't really know what's best and that barely matters anyway.
What works is physical separation by force. Force someone to stop using, and you get some chance that they won't go back. The best we can really do is keep cycling addicts through this system each time they're caught. But the key piece here that I really want to emphasize is "force". The state just paying for their treatment is not enough. They need to be put there and held there at the point of a gun if necessary. Actually exercising the state's power to compel people who've broken the law is what's necessary here.
Ironically the solution here is a middle path between conservatism and liberalism. You need force and coercion, but it needs to be used in a compassionate, not punitive way. I suspect this is why we've made less progress than we otherwise might. Conservatives just want to punish. Liberals just want to tolerate. Those willing to use coercion aren't using it in a useful way.
I tried to stay away from "should" statements. Whether or not the government *should* do this is a moral and ethical question. However, I think it's undeniable that it is the only way to address the problem that's likely to have success.
Whether or not that means we *should* do it is still an open question.
I’ve been thinking lately that maybe the solution is drug jails. Segregate users from gen pop, make it very akin to a rehab facility with comfortable accommodations, but make it mandatory and enforce participation in treatment. People will say it is draconian, but you are completely right that physical separation and time are the two ways people quit.
This was what I learned in policy school. RAND had done a huge study and found that each time you put someone in rehab you get them to stop using for that period, and likely for some amount of time after they get out and even if they relapse, you are reducing their overall consumption and thereby lowering the harm that they cause to themselves and the community. And that there is no difference in the likelihood of rehab succeeding connected to it being voluntary or involuntary. People who go to rehab to avoid incarceration have as much remission as those who check themselves in.
I don‘t think I ever expected to see a Dandy Warhols reference in a policy article and it makes me incredibly happy. It‘s mostly that Matt and I seem to have a vaguely similar taste in pop culture but while I really like the substance of SB I continue to be surprised by how much I like the style.
Another complication is that teen drug use is actually pretty low relative to historical norms. On the positive side this suggests that you really need to focus prevention efforts on a fairly small number of people. On the negative side it suggests that opioids and fentanyl are so harmful that they only need to capture a small slice of the population to cause extraordinary suffering and death.
In Mexico they have this drug treatment program where if its the right match: parent to child, even between spouses I think, they can go find the addict and literally force kidnap him for a full year. First few months is to break the addiction. Next few months is usually some faith based foundation. And the last bit of the year to fully recover. Its expensive, but it seems promising. I think the only way to get ahead of this is something super aggressive like that. I've known my fair share of addicts and only the ones that became super religious made it out alive.
It's not remotely politically realistic, but I've always thought that the ideal policy would be direct government provision of drugs. You go to a clinic, show them a letter from a doctor certifying you as an addict, and are proscribed a few days worth of opiates. Maybe you first have to sit through a health checkup and a lecture about quitting.
I'm all for harm reduction personally, but, as you point out, actually existing harm reduction policies only address the direct harm to the users, but most of the bad stuff associated with drugs is a product of the fact that they’re only available via the black market and are therefore very expensive. Back when you could buy heroin at the drug store it cost about a tenth of what it does now on the street.
And it's not as if heroin causes people to commit crimes as a side effect. Drug addicts steal stuff because drugs are expensive, and drug dealers kill each other because the drug trade is profitable. If you made heroin available to addicts for free you’d put every dealer in the country out of business overnight and prevent a massive amount of other crime.
It would also be much, much safer for individual users. The drugs would always be pure and could be formulated in whatever fashion was found to be safest. It probably wouldn’t actually be heroin but something in pill form, provided in child-safe packaging complete with dosage information and alongside overdose reversing drugs. I think you could virtually eliminate unintentional overdoses with a bit of experimentation.
The biggest risks I can think of would be diversion and induced demand. There would be massive profits to be made if you could find a way to sell your free drugs in a jurisdiction where they’re still illegal… but it’s not like drug smuggling would be a new problem, and there’s things you could do to make it less likely; only give people small amounts of drugs at a time, make them use the drugs onsite at the clinic, etc.
Induced demand is a more serious concern. If heroin is free and less dangerous there is going to be some number of people who will begin using it who would not have otherwise. You could fight this by trying to restrict the program to people who can convince a doctor that they’re already addicted, and you could just make the whole process kind of a hassle, but still much less of a hassle than buying drugs on the black market.
Good points, but in brainstorming and assessing various approaches, why was there almost no discussion of re-reforming prescribing guidelines to make it a (last resort but ultimately feasible) legal possibility for desperate sufferers of chronic pain to choose to accept some addiction risk (and even some overdose risk)? The policy lever would be to make it more acceptable for doctors to allow severe chronic pain patients to choose this with updated knowledge of the risks and to favor opiates, like methadone, that effectively mitigate pain without getting people high. This would mitigate externalities like "leakage".
Methadone is highly effective at mitigating chronic pain without the complications of getting people high, including for those who've never taken heroin or fentanyl. It's not very valuable on the black market for buyers seeking mainly to get high or for prescription opiate-seekers mainly interested in getting high.
We currently give sufferers of immiserating chronic pain who are not able to control their pain without opioids the following choices:
- Seek legal routes for obtaining opiates that are physically addictive but don't get them high and are reliably dosed. Fail. Be told to take ibuprofen and do deep breathing exercises. Try it and find it overwhelmingly inadequate. Get labeled drug-seeking after looking for a doctor who's less afraid of prescribing opiates to pain patients. Fail to be presented by the same medical community with effective alternatives. Try to muddle through the misery. If it becomes untenable, consider suicide.
- Seek legal routes for obtaining opiates that are physically addictive but don't get people high and are reliably dosed. Fail. Fail again. Get labeled drug-seeking without being presented with effective pain-controlling alternatives. If the misery is otherwise untenable with no relief in sight, consider looking in to black market pain control alternatives for lack of safer (albeit not completely safe, but...trade-offs) options. Wrack your brain for someone you were friendly with in high school who vaguely fit the profile of someone who might know someone who knows someone. Hide the next steps from those closest to you.
How does meth compare? That’s also very easy to make in a small lab too, right? Did putting all the cough syrup behind the pharmacy counter help?
While I did read and enjoy “Dreamland,” it did succumb to the myths criticized at the top of the piece. There was a rather smug intro denouncing Americans for buying houses too big for them, for overeating, and for not being tough minded enough to tolerate pain. And IIRC, “Dreamland” was the name of a swimming pool that was closed in a dying industrial town. So that myth got some purchase as well.
Still a riveting read for the industriousness of the heroin dealers and the difficulty in even figuring out that opioid deaths had become a problem, given how medical examiners report their data.
I’m sure the tv series Dopesick is heavily dramatized, but it does give you a sense of just how evil the Sackler family is.
People will probably tell me I'm crazy for this, but I think the permanent solution here is free government provision of all recreational drugs to anyone already addicted to that substance.
You would instantly destroy every drug cartel overnight - the vast majority of their customer base would leave, because who can compete with free. There is still the small customer base of "haven't tried fentanyl yet, sounds fun", but since they could switch over from the black market to get free drugs at any time, that's not a stable or sustainable source of income.
But of course I don't think the most popular politician in America could sell this policy, it seems totally politically toxic.
I think you’re describing Portugal, which is both very successful, and, as Matt mentioned, politically impossible.
No, in Portugal addicts can get permission from the government to use drugs w/o fear of arrest, but they're still getting their drugs from illegal criminal organizations.
Unlike the Portuguese model (which is the closest to what I'm proposing), government provision would remove the street crime aspect of drug decriminalization, and probably reduce the amount of future addicts as well.
If anyone is interested, a top anesthesiology journal had a deep dive on this a couple months back. Former Surgeon General Jerome Adams is a co-author (this is well within in his zone of professional expertise and personal passion. He has a professional career independent of the Trump administration). I'm sure they'll forgive me for breaking the paywall here for educational reasons (or I'll ignore them if they complain). It's quite informative.
https://drive.google.com/file/d/162MPldZWowNtz1mqmdI2E77ZO63xffuW/view?usp=drivesdk
Matthew, an excellent column.
I wish to another source of our endemic opiate addiction: hospitals.
At some point part way through my many decades of medical practice, hospital nurses added pain assessment scoring to the vital signs. I saw patients trying to decline narcotics only to be beaten down by nurses repeatedly badgering them to accept narcotics they tried to decline. From this I was called to manage the acute complications of respiratory depression and psychosis. As a post op patient several times, I was myself subject to this pressure, needing to politely decline well intended offers when my pain level did not warrant narcotics. A lay person is likely to be less aware than a seasoned clinician.
Habituation can begin on the hospital ward.
“Pain is the fifth vital sign” was all over in the early 2000s. Nurses certainly didn’t come up with that themselves.
This is the best MY column I've read. It's not often you see a pundit grapple with a really difficult problem with no simple solutions and conclude, "a really difficult problem with no simple solutions."
I've read here and there about anti-addition programs that appear to be effective (my sources were cheerleading for the programs, so who knows?), but in most cases they were part of the local correctional system and they served cons and ex cons. Some programs seem to be really effective.
The libertarian in me doesn't even want to see drug use remain illegal; but the pragmatist suggests that since we have already gone down the road of criminalizing drug use, maybe it should be the correctional establishment rather than the medical establishment that works on this, given the disincentives you mention above. But before that can occur correctional programs have to shift away from being punitive and retributive to instead being remedial and, well, correctional. I'm not sure that can ever happen in a big way in the USA.
I was recently re-reading/listening to some of Michael Pollan's stuff on psyechedelics, which seem like a potential backdoor out of the no-solutions zone. (See his seminal New Yorker article: https://www.newyorker.com/magazine/2015/02/09/trip-treatment) Psilocybin-assisted therapy has shown extremely promising progress against cigarette addiction, and apparently the founder of AA originally wanted to use LSD to cure alcolohism before he was overruled by his more generally prohibitionist board. There's naturally been a lot of interest in using psychedelics to combat opiate addiction as well.
There's a lot of unsettled but really interesting neuroscience here (psychedelics seem to lower the brain's certainty of things it is usually pretty sure of, so just as you might get less sure of "I cannot fly" while on psychedelics, you might also get less sure of "I need heroine" or even "This back pain is so bad that I need medication"), and there's the perennial question of whether the initial trials will scale. But the bottom line is that this sort of treatment (with the right precautions) could really help people.
What’s the truth of the oft repeated story about how US soldiers used a lot of heroin in Vietnam but a remarkably large number of them just stopped when they got back to the US?
I wonder if dosing education would offer one approach. Is "the doctor says take one every four hours so that's what I am going to do" part of the problem?
I have noticed over the years that the dosages for certain medications are far higher than I can tolerate. The prescription may say "1 tablet as needed" but if I take a whole tablet I am a wreck. A quarter or just a crumb of a tablet does what needs to be done.
For those who strictly follow doctors' orders, perhaps there is a way to educate these patients to pay attention to their reactions to the drug and so titrate doses accordingly.
It's nice to see the acknowledgement here that not every problem can be solved via technocratic means.
On this though:
"Michael Shellenberger and other Bay Area critics of Chesa Boudin argue that bad progressive policy is responsible for drug addiction, and drug addiction is responsible for San Francisco’s homelessness problem. I think this is pretty clearly mistaken. "
I don't know about progressive policy in the Bay Area, but it definitely is true that the homeless population has a much, much higher rate of drug and alcohol addiction and that is a driver of a significant portion of homelessness.
I have an example from my own family where my brother-in-law went from a successful upper-middle class business owner to living in the streets because of his alcoholism, which eventually killed him. No government program and not even his own robust and supportive network of family and friends prevented it, despite many attempts at intervention.
I have a close friend who does social work in San Francisco, helping transition people out of prison who struggle with mental illness and addiction. He is very much left of center but hates Chesa Boudin with a passion. He says that addicts will never voluntarily agree to enter rehab without the threat of incarceration. So Chesa’s decision not to prosecute low-level offenses basically makes his job impossible. Meanwhile, overdose deaths in San Francisco have tripled since 2018. The arrival of fentanyl deserves the vast majority of the blame for this, but Chesa isn’t helping.
I have spent many mornings volunteering at my local shelter calling every impatient detox place in King County to see if they have an open bed so that I can try to get maybe three of the two dozen folks who show up in the morning wanting to get into detox. The rest have to wait and try the next day when many don't show up because their window of having hope or recognizing their worth has closed. Our drop in clinic for medically assisted addiction treatment is open four days a week and we have never had an unclaimed appointment. I have had folks on the street, often freshly freaked out by a recent near OD ask me to help them find any kind of bridge to treatment. There are lots folks out there who don't want to get clean, think that they are unable to get clean, or don't think they are worth the effort. But there are also a lot of folks who desperately want to get clean and don't have sufficient access to treatment when they are ready for it. Even those who do almost never get a gold standard of care with sufficient impatient supports. It can feel perverse to chase folks to threaten them with jail when they aren't looking to get clean while we aren't offering services to those who want them.
This aligns with one of Shellenberger's ideas (and what Darawk gets at below) which is to send addicts to a treatment center far removed from the streets where they can spend time receiving wrap-around services to (hopefully) be able to re-enter society. But that would require cities to recognize and treat them as addicts, not victims of abstract, structural economic forces.
If you happen to check out the Lancet /Stanford commission study that Matt cites it seems to have this problem. Reading it I get the impression that addiction strikes people randomly like cancer or strokes. It's all about how doctors need to treat addiction as a disease, which is fine as far as it goes. But it's not the sole way society needs to look at the issue.
This squares completely with darawk's point below (or above, whichever way it appears to you)
Former oxycontin/heroin addict here. The right way to think about addiction treatment is as a lottery. Each time you send an addict to treatment they have an x% probability of recovering. That x% is mostly correlated with *length* of stay in a treatment facility. And when I say "stay" I mean inpatient, because all outpatient addiction treatment is bullshit, at least for the acute phase. Effectively zero people have ever quit using opioids from outpatient treatment alone.
The most important thing you can do is physically separate the person from the drugs - by force. This means we need to retain the threat of prison on the books for these crimes, but we shouldn't be using it. We should be giving people a stark choice "go to prison or go to treatment" and in that treatment center, they will be held, by force if necessary. Each time you do this to someone, you get an x% probability of them not going back to using. 'x' is probably not super high, but it is correlated primarily with *length* of stay, and almost nothing else. Different treatment modalities probably help at the margin, but we don't really know what's best and that barely matters anyway.
What works is physical separation by force. Force someone to stop using, and you get some chance that they won't go back. The best we can really do is keep cycling addicts through this system each time they're caught. But the key piece here that I really want to emphasize is "force". The state just paying for their treatment is not enough. They need to be put there and held there at the point of a gun if necessary. Actually exercising the state's power to compel people who've broken the law is what's necessary here.
Ironically the solution here is a middle path between conservatism and liberalism. You need force and coercion, but it needs to be used in a compassionate, not punitive way. I suspect this is why we've made less progress than we otherwise might. Conservatives just want to punish. Liberals just want to tolerate. Those willing to use coercion aren't using it in a useful way.
Disagree. I don't think it's any of governments business what I put in my body
And people have to want to get clean.
I did everything under the sun. I even did 10 months in jail.
I stopped partying as I grew up got married etc
I tried to stay away from "should" statements. Whether or not the government *should* do this is a moral and ethical question. However, I think it's undeniable that it is the only way to address the problem that's likely to have success.
Whether or not that means we *should* do it is still an open question.
I’ve been thinking lately that maybe the solution is drug jails. Segregate users from gen pop, make it very akin to a rehab facility with comfortable accommodations, but make it mandatory and enforce participation in treatment. People will say it is draconian, but you are completely right that physical separation and time are the two ways people quit.
Ya, agree. Something like this is necessary if we actually want to solve the problem.
This was what I learned in policy school. RAND had done a huge study and found that each time you put someone in rehab you get them to stop using for that period, and likely for some amount of time after they get out and even if they relapse, you are reducing their overall consumption and thereby lowering the harm that they cause to themselves and the community. And that there is no difference in the likelihood of rehab succeeding connected to it being voluntary or involuntary. People who go to rehab to avoid incarceration have as much remission as those who check themselves in.
This is the best thing I've read on the subject all day.
I don‘t think I ever expected to see a Dandy Warhols reference in a policy article and it makes me incredibly happy. It‘s mostly that Matt and I seem to have a vaguely similar taste in pop culture but while I really like the substance of SB I continue to be surprised by how much I like the style.