San Francisco — The problem with pendulum metaphors in the drug policy world is that they constrain thinking to a singular line of ideas and actions in which all movement is only forward or back along a two-dimensional plane. It would appear that in the face of increasing overdose deaths around the country there seems to be a growing consideration to return to more punitive responses to illicit drug use, and away from evidenced-based practices. According to the metaphor, the pendulum is swinging backwards. And San Francisco, long considered a bastion of liberal thinking and progressive policies, is ground zero for this dangerous reemerging perspective.
Look at any major media news outlet over the past year and you are bound to find articles about the spiking rates of overdose deaths across the country related to the use of illicit Fentanyl or Fentanyl analogs. Behind the headlines of COVID-19 deaths lurked an alarming increase in the number of people having died from drug overdoses—93,000 nationwide in 2020, an increase of nearly 30% from 2019. The San Francisco Bay Area in particular, where I live and work, has been the focus of a great deal of national attention – in part as a result of the startling fact that between March of 2020 and March of 2021, the 12-month period starting at the beginning of our COVID-19 shelter in place order, more people died of a drug overdose in San Francisco than from COVID-19.
There have been increasing calls for more of the same failed authoritarian approaches to public drug use than harm reduction and evidence-based treatment. Supply-reduction policies that focus on reducing illicit drug use via criminalization and strict enforcement have been the nation’s go-to response since President Nixon declared the “War on Drugs” in 1971. The endless “War on Drugs” has done little to demonstrably prevent addiction and overdose deaths. Rather, our “tough on drugs” policies have swelled the numbers of people in prisons and jails across the country for over five decades, with devasting results for Black and Brown people.
Consider, instead, the possibility that our current framework for responding to illicit drug use has actually made people and communities sicker. We know that criminalizing drug use drives individuals who use drugs further into the margins of our society. People who have been convicted of drug possession, disproportionately Black and Brown people, face greater challenges securing housing, employment, federally backed student loans, and even, in many states, the right to vote. Drug-free workplace laws drive individuals who use drugs into the shadows. The current response to drug-use breeds secrecy, deception, shame, and stigma. Driven to purchase drugs from illegal and unregulated sources, our current policies continue to fuel overdose deaths as individuals face the risk of a fatality from adulterated drugs of unknown potency or provenance. Let’s consider some alternatives that have been proven effective: Decriminalizing drugs, supervised consumption services, and safer supply.
What might decriminalizing drugs look like? It can look like Portugal, where possessing small amounts of drugs, including heroin and cocaine, is not illegal. Portugal has used a public health approach to drug use since 2001 that deploys outreach workers and social workers to guide individuals with problematic drug use into treatment. Portugal’s approach has since resulted in a decrease in overdose deaths and an increase in treatment participation. Most notably, it has not resulted in increased drug use per capita over the policy’s 20-year history.
Supervised consumption services (SCS) found throughout much of Europe and Canada, are programs where people who use drugs can bring pre-obtained drugs to consume in a safe environment, using sterile equipment, and under the supervision of service staff who can intervene in the event of a drug overdose. SCS programs have a 30+ year history of preventing overdoses, preventing the spread of HIV and Hep C, and connecting marginalized individuals to care. Despite the efforts of advocates across the country, and the strong body of evidence demonstrating the efficacy of SCS, not a single sanctioned SCS program has gained approval and commenced operations in the US to date, due to opposition and ignorance.
In the face of the rising death toll from illicit opioid overdoses, decriminalization can also include a safer supply. Safer supply programs provide individuals who have an opioid use disorder with prescribed opioids in a safe and regulated manner. Health Canada operates a safer supply program that distributes pharmaceutically pure opioids to people with Opioid Use Disorder. In this way, individuals for whom methadone and buprenorphine do not provide relief may be prescribed pharmaceutical-grade opioids that are more chemically like heroin, but with predictable quality, availability, and potency. Research from safer supply programs in Canada and Switzerland has shown promise in preventing opioid overdoses.
As we begin to recover from the shock of the COIVD-19 pandemic, as we grapple with legacy of racism in law enforcement resulting in the death of Black and Brown people at the hands of police, as we comfort the surviving friends and family members lost to an ever-increasing rise in overdose deaths, let us take from those experiences a commitment to do things differently. Let us be willing to solve this crisis in new ways that may challenge everything we have thought or tried before. Instead of the tired pendulum metaphor, let us be a starburst of innovation.
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