My sister-in-law, Molly, would have turned 50 this month were it not for the fact that she died of an accidental drug overdose 20 years ago. Long before people were talking about the “opioid epidemic,” Molly got addicted to pain medication and ultimately the drugs that she took to kill her pain killed her. Last month, our Global Mental Health Program hosted a meeting in Lima focused on mental health and substance use disorders where scientists, policymakers, WHO and PAHO officials shared research and debated strategies for addressing the global web of drug use and abuse that ensnares millions of people and billions of dollars. And before I finished unpacking from our time in Peru, I had an email from Johns Hopkins University that four students had overdosed on opioids. I don’t generally believe in angels, but these students were minutes from losing their lives when they were serendipitously found by police carrying Narcan who were called by neighbors complaining of excessive noise coming from the fraternity house where they lay unconscious.
The War on Drugs isn’t working. Those “this is your brain on drugs” public service announcements with the frying pan and the egg? Nope. School-based education programs like D.A.R.E.? No impact. It has taken a while, but around the world, countries and communities are daring to try new strategies, some quite radical. These pioneering efforts are abandoning the War on Drugs in favor of public health policies that promote community based solutions. No longer a moral scourge, caused by lack of will power or the act of a villainous character, drug addictions are understood as disorders of the brain that can wreak havoc.
The U.S. alone has spent more than $16 billion on the “war on drugs” this year. But prohibition didn’t work with alcohol, why would we think it would work with other drugs? Here are some forward thinking strategies and alternatives. Kudos to those who dare to innovate – with a big caution that many questions remain about what is really going to work long-term.
Decriminalization. The “war on drugs” creates criminals. This war has not decreased rates of drug use but it has catalyzed a skyrocketing of incarcerations. Australia, Portugal, the Czech Republic and the Netherlands are among the 30 countries worldwide pioneering public health strategies that decriminalize drug use. The decriminalization laws among the 30 countries vary widely, and the long-term effects need to be evaluated from multiple angles – individual rates of drug use and addiction, community impact, legal burden, etc – but the data so far indicate that decriminalization does not encourage or promote drug use while the public cost and the harms associated with drug use (like unemployment and crime) are dramatically reduced.
Legalization. Legalizing drugs is a bold move. In the US we have seven states and the District of Columbia that have legalized marijuana for recreational use. Around the world, Uruguay stands out. It decriminalized possession of all drugs, not just marijuana, in 1974. And in 2013, Uruguay went one step further and legalized marijuana, the first country to do so as a national policy. The results? Too soon to tell. Drug seizures are down since legalization, but there’s been a bump in crime. If the crime increase is related to drug use (which is not clear), it might be because Uruguay is taking a while to set up legal ways to purchase marijuana. Time shall tell.
Moving further upstream. Iceland’s public health strategy takes us further upstream. Applying the burgeoning data on brain science, they understand that it’s useless to try to get kids to stop using drugs without providing them with suitable substitutions for all of the endorphins and other brain-altering sensations they’re desperately seeking as teenagers. Iceland has made a major investment in after school activities and public health programs that facilitate parental engagement in their children’s lives across all kinds of social and athletic programs that create what some call a “natural high.” They’ve seen incredible success. In 2016, the percentage of 15- and 16-year-olds who had been drunk in the previous month plummeted to 5% as compared to 42% in 1998, and reported cannabis use dropped to an all-time low of 7% compared to 17% in 1998.
Care rather than incarceration. Jails and prisons have become default (and ill-equipped) mental health facilities in many parts of the world, including the US. But innovative programs like Miami-Dade County’s Criminal Mental Health Project are receiving accolades from the U.S. Supreme Court and the New England Journal of Medicine. Law-enforcement officers are trained in recognizing signs of mental illness and deescalating potentially violent situations, and judges facilitate transfer to units that provide treatment. This is especially important because we know that most psychiatric and substance use disorders emerge in adolescence and early adulthood. Because adolescence is a time of high brain plasticity when neural connections are eliminated and strengthened, identifying teens who have drug use problems and getting them treatment early is key to mitigating the negative effects on the developing brain.
Kudos to Hopkins for speaking out. I am a Hopkins parent and alumna so there is no way that I was happy to receive the opioid overdose email, but I was proud. Many universities turn a blind eye, gag the press, and pull an opaque curtain around their campuses when it comes to mental health and substance use disorders. But silence perpetuates the shame and the stigma that has plagued mental health and substance use research and interventions for too long. I applaud Hopkins’ willingness to put the issue out there to make sure that as a community we act in partnership to address this urgent and life threatening public health priority. It is the only way that the future will be different from the past.
Of course the problem of drug use is complex, and each country or locality brings its unique set of challenges and circumstances. The experiments to date make it eminently clear that health-centered drug policies are more effective than criminal justice approaches. It’s time to hang up the cops and robbers paradigm. It’s time to abandon the idea that drug treatment is a moral affliction, and it’s essential that funding for research be prioritized to ensure that our best intentions and novel strategies actually lead to the outcomes we wish for our children and grandchildren.
Molly, I wish you were here to see how your tragic ending has contributed to the growing public outcry for a change of course in how we understand and treat substance use.