Tactics are shifting in the war on drugs

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The writer is a contributing columnist, based in Chicago

For more than half a century, the US has been fighting a “war on drugs”. Yet overdose deaths are at record levels, even knocking back US life expectancy. Six times as many Americans died of an overdose in 2021 as in 1999, says the US Centers for Disease Control and Prevention, with 111,000 people dying in the year to April 2023, according to provisional CDC figures.  

The risk of dying from accidental opioid overdose is now greater than the chance of death from a car accident, according to the US National Safety Council.

US states and cities are frantic to tackle the crisis and are experimenting with potential solutions. Emergency overdose boxes have popped up at my local library and senior centre; vending machines stocked with Narcan — the naloxone nasal spray that can reduce opioid overdose — are being installed at some Chicago subway stations; and my local pharmacy has begun selling Narcan over the counter, right next to the Halloween candy and Covid tests.

But decades of experimentation — with everything from clean-needle sites to drug courts and decriminalising possession of small amounts of drugs — haven’t removed this blight on lives and society. In recent years, the crisis has been fuelled by synthetic opioids such as fentanyl, which are far more potent and dangerous than heroin. US state and local governments are expected to get more than $50bn over the next two decades from opioid legal settlements with drugmakers and middlemen, but addiction experts say it’s not clear how most of that money will be used. 

Alex Elswick, who became homeless because he developed opioid addiction after wisdom teeth removal, tells me his mother couldn’t get hold of Narcan for him when he was in active addiction in 2012. Elswick, who has just celebrated 10 years in recovery, says he and his mother formed the Kentucky non-profit Voices of Hope primarily to distribute Narcan. He’s glad that mothers like his can now buy it at the drugstore.

But addiction experts agree that the $44.99 list price for two doses of the drug will put it out of reach for most of those who need it, and cities such as Chicago are expanding programmes to give it away free. Even so, “making it available over the counter will continue to shift the narrative around opioid use . . . and destigmatise it,” says Sarah Richardson of Chicago city’s substance use team. Pharmacists in Illinois have been allowed to dispense Narcan without a doctor’s prescription since 2017, she tells me, and many insurance companies cover the cost. But having to ask the pharmacist is still a barrier for many.

Christopher Jones, director of the centre for substance abuse prevention at the US Substance Abuse and Mental Health Services Administration, says he carries naloxone with him everywhere, and thinks emergency overdose kits should be as common in public places as automated external defibrillators for heart attacks. 

“Naloxone is just one piece of the puzzle,” he tells me. “Opioid deaths are complex . . . the problem has to be looked at holistically, including treating underlying mental health issues.” SAMHSA said recently that 94 per cent of those with a substance abuse disorder in the US did not get treatment, but that was because most did not want it. “We have to raise awareness,” Jones says.

But Elswick is one of a growing number in the addiction treatment community who think the focus must shift away from what he calls the “boilerplate single story of recovery” based on abstinence, usually through a 12-step programme. He says the goal of the “harm reduction” movement is “to reduce harm, not to reduce drug use” — through measures such as naloxone distribution and providing clean needles. “People are getting well all sorts of different ways,” he says. 

Most people agree that wider distribution of life-saving overdose treatments is a good idea — but that’s where the agreement ends. The forces in today’s American drug war are divided between those who still want to lock up drug users; those who want them to get clean; and those who want to help them use drugs more safely.

And so the fight goes on, while the body count mounts.