Albert Einstein defined insanity as “doing the same thing over and over again and expecting different results.”
Over several decades, attempts to control opiate drug abuse through stricter enforcement and stiffer penalties (think Rockefeller drug laws or presidential wars on drugs) have failed miserably, yet we can’t bring ourselves to abandon them. Police and politicians puff up with pride and self-righteousness as they announce the latest controls on trafficking and prescribing, but are less interested in weighing the costs of these programs against the actual reduction in harm.
What has worked is less palatable: decriminalization and restricted legalization. Vancouver, Canada, began a clinical trial in 2014 in which hard-core heroin addicts were given heroin and clean needles to use under supervision. A physician familiar with the program told me this reduced drug-dealing in the streets. Many addicts sell drugs to support their habits, which becomes no longer necessary, and these addicts buy drugs from higher-level dealers, who become superfluous. And imagine if someone didn’t have to kill four people in a drugstore because he could obtain what he needed at a facility.
Drug substitution therapy with Suboxone or methadone is often effective, and is preferable, but the Vancouver addicts had failed these treatments and will be maintained on government-supplied heroin indefinitely. On Long Island, it isn’t terribly easy for an addict to even get enrolled in a methadone or Suboxone program, particularly without insurance coverage or with Medicaid.
According to Harper’s Magazine, the United States spends more money on enforcement than treatment, even though it believes each dollar spent on treatment saves seven, and enforcement bloats the prison population at an immense expense. Portugal appreciated this in 2001 when it decriminalized all illicit drugs. Its prisons dramatically lightened their loads without worsening societal ills.
Switzerland and the Netherlands have programs similar to Vancouver’s, and are happy with them. Upstate Ithaca has proposed to begin one.
While replacing one opiate with another — be it methadone, Suboxone or as a last resort heroin itself — may grate on our puritanical mores, it’s more successful than demonization and pillory. Supply does not create much demand. Despite the heavily promoted pain-relief campaigns of the pharmaceutical industry, doctors’ careless prescribing accounts for a minuscule percentage of opiate addicts (note that pot, cocaine and alcohol flourish on their own). Demand, on the other hand, makes supply inevitable. Certain intractable types of anxiety and depression are alleviated better by opiates than by prescription psychiatric drugs, and many addicts, similar to alcoholics, are self-medicators. But the U.S. government — the same government that thinks stanching supply will stop the bleeding — funds precious little psychiatric research in this arena.
People will kill for opiates and will risk their lives to get high. They will not kill for antipsychotics, tranquilizers or lifesaving antibiotics. Opiates are unique. We need to take a hard, painful look at solutions that work to prevent loved ones from dying of overdoses, to lessen drug-related crime, and to reduce costly and useless incarcerations. To keep pouring resources into enforcement (like Nassau County police’s heroin task force to arrest drug dealers) and controls (like New York State’s recently instituted e-prescribing law) while ignoring their lack of efficacy is just . . . insane.
Robert S. Bobrow, M.D., is a clinical associate professor of Family, Population and Preventive Medicine at Stony Brook University. He administers a state-sponsored opioid overdose prevention program.