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Decriminalizing Opioids Will Save Countless Lives

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Ideas
Grinspoon, M.D., is an instructor at Harvard Medical School and the author of Seeing Through the Smoke: A Cannabis Expert Untangles the Truth About Marijuana

Even the most fervent drug warrior would have to concede that cannabis legalization has been a success. In thirty-eight states patients can now freely access high-quality cannabis for medical conditions that are often notoriously resistant to other treatments. In the twenty-three states in which cannabis is legal for both medical and recreational purposes, citizens enjoy the right to partake in a substance that is far safer than other recreational drugs—including and especially alcohol—without fear of prosecution. Driving fatalities have not increased and rates of psychosis (which cannabis can contribute to) have been broadly stable. Teen usage rates and rates of addiction haven’t spiked. Drug War-fueled prosecutions that were particularly devastating to Black and brown communities are down.

At the same time as cannabis legalization sweeps across the country, the opioid epidemic continues tragically apace. If we are serious about ending the latter it’s time to apply the lessons of the former. That may seem counter-intuitive. After all, cannabis is a comparatively safe substance and opioids are often deadly. That doesn’t make criminalization the cure. Criminalization is a formidable barrier to treatment and enhances risk on a number of fronts. I know this because of my work as a physician and because of my own hellish struggle with opioid addiction, which nearly destroyed my life. I’m one of many. We have lost more than one hundred thousand people per year to opioid overdoses for the last several years. Millions of others continue to limp through their miserable addicted lives. The police and the courts have become the de facto first responders to a public health scourge, when it should be doctors, addiction specialists, and other healthcare professionals on the front lines.

I’m fifteen years into recovery. I have helped hundreds of other doctors who were addicted, and I have treated thousands with addiction over the decades. I’ve come to realize that it is the criminalization of drugs more than the drugs themselves, that causes most our problems.

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Specifically with opioids, it is the illegal nature of street opioids that is killing people. Currently, people with untreated addiction or undertreated chronic pain—increasingly common problems— are forced to buy their opioids on the street to obtain relief from their pain or their soul-crushing withdrawal symptoms. The street supply of most drugs is now contaminated with fentanyl, as well as xylazine, and many other deadly adulterants. Only a small fraction of the overdoses stem from the use of legally prescribed opioids, with the vast majority arising from illegally bought contaminated drugs.

Read More: We Can Prevent Opioid Overdoses If We Change How We Think About Them

We’ve known that legal or decriminalized drugs are safer than those bought in the underground market since the early 20th century when we launched our disastrous experiment with alcohol prohibition. Those years—from 1920 to 1933—saw a proliferation of poisonings from a tainted supply. In much the same way, the illegality of opioids has fatally tainted the street supply. By contrast, cannabis that is bought from dispensaries is screened for molds, heavy metals and pesticides, and is labeled; it is safer. When one buys any drug from a street dealer there are no controls, checks, regulations or recalls. For the buyer this was once a roll of the dice. Now, with the risk of fentanyl laced drugs, it is more a game of Russian roulette. It is my conviction that if opioids were decriminalized and accessible, very few would be dying from fentanyl.

A recent study in The American Journal of Public Health lends evidence to the idea that law enforcement is contributing to the carnage from opioids. The authors were able to prove the following hypothesis,

We tested the hypothesis that law enforcement efforts to disrupt local drug markets through routine supply-side interdictions—as measured by police seizures of opioid- and stimulant-related substances—are associated with increased spatiotemporal clustering of fatal and nonfatal overdoses, as well as increases in EMS naloxone administration, in the area surrounding the seizure.

The over-involvement of law enforcement in the drug realm harms in indirect ways as well, with billions of dollars being wasted on militarized police units that could be far better spent on addiction treatment. With this money, we also could be offering patients a pathway out of their addicted lives by providing healthcare, jobs training and housing, such as they have been doing in Portugal since they decriminalized drugs, with overall success.

This can’t be done in the ‘free for all’ manner of cannabis dispensaries as opioids have much more potential for harm and need to be more strictly regulated. The dispensing of opioids should be part of a treatment regimen. The access could take the form of government-controlled stores. Potentially, people could present a card from their doctors. The access would have to be very low threshold for patients, in order to circumvent the illicit market.

According to a study by the Rand Corporation, there is good evidence for heroin assisted treatment (HAT) from Europe and Canada,

Evidence from randomized controlled trials of HAT in Canada and Europe indicates that supervised injectable HAT—with optional oral methadone—can offer benefits over oral methadone alone for treating OUD among individuals who have tried traditional treatment modalities, including methadone, multiple times but are still injecting heroin.

An often-overlooked benefit of the legalization of cannabis is that it has allowed for more open and truthful communication between doctors and patients. Patients can now freely discuss their use with doctors. The result is greater safety and open discussion about potential misuse. Opioid users would stand a better chance of getting potentially life-saving help if they could candidly discuss their concerns with doctors and healthcare providers.

We now have good tools, such as medications that can help people addicted to opioids, known as Medications for Opioid Use Disorder (MOUD), including methadone and buprenorphine (Suboxone), that can affect a fifty percent reduction in deaths from overdoses. Yet, we don’t have the medical infrastructure or social safety nets to provide this care to more than 10-20% of patients who need it. We are nibbling at the edges, first with clean needles, now with ‘safe injection facilities’—where people suffering from opioid addiction can use opioids in a medically monitored setting, and recently, with over-the-counter Narcan, which can transiently reverse an opioid overdose. These measures are not enough. It is time to legalize opioids and reroute resources from prosecution to treatment and support services.

The War on Drugs, which we’ve been suffering from for more than a half century, was never truly about drugs. Rather, it was a fabricated moral panic to help control and subjugate certain sectors of our population, mostly people with brown and black skin. It has been quite effective for this nefarious purpose, but it also has resulted, among other harms, in our current opioid crisis.

We do not need to continue fighting this war that we have already lost. Law enforcement are exactly the wrong people to be involved with the drug issue, except in cases of impaired driving or violent behavior. We would be a lot better off if we extrapolated our soaring success with legal cannabis into the opioid realm, and focused our attention, on resources, on treatment not punishment. Let’s legalize, or at least decriminalize, opioids, and let’s start saving lives.

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