The Age of Drug Normalization

Sessi Blanchard, a 26-year-old harm-reduction specialist in New York, sees herself as the future of drug use in America. “I am a living example of how you can use crystal meth in moderation,” she told me last year.

Blanchard is a case manager for homeless New Yorkers with mental health or substance use issues. When I talked with her, she was a community organizer at VOCAL, a New York-based drug reform advocacy organization with seven statewide chapters and an annual budget of close to $3 million.

In addition to crystal methamphetamine, Blanchard said she also used heroin and “lots of different things under the sun.” A trans woman, she said she began using drugs while engaging in sex work after graduating from Vassar College in 2018. She added heroin to her intake when the pandemic temporarily cut off her meth supply.

After becoming dependent on heroin, Blanchard said she sought a prescription for buprenorphine, an opioid-replacement drug used to ease cravings. “I have my own battle with the city of New York to get a simple prescription for this lifesaving medication,” she said.

Like other activists at VOCAL, and throughout America’s nationwide drug policy reform movement, Blanchard’s ultimate goal is, in her words, to “decriminalize all drugs” and create a “safe supply”—guaranteed access to state-regulated, toxin-free drugs. She envisions a time when drugs, like alcohol, are legal, widely available and free from stigma.

“A century ago, people could go to their doctor and get the heroin they needed,” she said, referring to an era before the onset of federal narcotics regulation in 1914. “There’s a danger in suggesting this is a radical, progressive leap.”

It’s not as radical as it used to be.

To an extent unimaginable just a generation ago, United States drug policy is undergoing a quiet revolution. After decades of a costly war on drugs widely judged a failure, American policymakers are rethinking almost every aspect of the country’s approach to narcotics.

Last year, the Biden administration’s 2022 National Drug Control Strategy set itself the historic goal of “shifting the focus of drug policy from punishment and social exclusion to healing.” The strategy lists law enforcement as its last priority and foregrounds methods long championed by drug policy reformers. Chief among those policies is a practice called harm reduction, which seeks to ameliorate the public health dangers of drug use without punishing users or requiring them to abstain. Harm reduction is mentioned 198 times in the strategy. Neither the Trump nor Obama administrations used the term publicly at all.

Top federal researchers are studying the feasibility of decriminalizing possession of all drugs, a policy already introduced as a bill in Congress. Last year, the National Institute on Drug Abuse, which coordinates addiction research for the federal government, broadened its definition of recovery from addiction to include the possibility of continued drug use. “Recovery from substance use disorders means different things to different people,” the agency’s new strategic plan says.

The state of Oregon decriminalized personal drug possession three years ago and last year legalized production and use of hallucinogenic mushrooms. Other cities and states have achieved similar goals by deprioritizing prosecution of drug crimes and boosting funding for harm reduction. Since 2009, the number of Americans incarcerated for drug offenses declined by nearly a third. Two cities—New York and Providence, Rhode Island—have authorized so-called “safe injection sites,” where users take drugs under the supervision of volunteers. The sites operate openly and with the support of their city governments despite remaining illegal for now under state and federal law.

The flurry of new policies coincides with seismic changes in Americans’ attitudes toward drugs.

The war on drugs now ranks as one of America’s least popular public policies. Eighty-three percent of respondents to one recent poll—Republicans and Democrats alike—called the enforcement-focused strategy a failure. Just a quarter of Americans now support prosecuting drug users instead of offering treatment, according to a 2014 Pew Research Center survey. More than 90% of Americans believe marijuana should be legal for personal or medical use. The drug already is legal for personal or medical use in 38 states and Washington, D.C. Psychedelic drugs, including LSD and the club drug MDMA, are being studied as possible treatments for mental illness at prominent universities. Federal health officials approved one such drug, ketamine, as a treatment for acute depression in 2019. Recreational users of psychedelics now include what a recent NPR segment called “thousands of moms … microdosing with mushrooms to ease the stress of parenting.”

It’s a brave new world. But is it working?

The short answer is: no. Despite the rhetorical passion and best intentions of advocates—many of whom contend that their policies need more time to be judged fairly—so far, at least, harm reduction has not lived up to its many promises.

Drug policy reform means different things to different people but in essence the movement seeks to replace law enforcement with public health as the de facto response to drug use. Key goals include reducing or eliminating criminal penalties for drug use; providing users with sterile drug equipment to reduce disease spread; using drug-replacement therapies to treat addiction; distributing overdose reversal medication; expanding availability of supervised drug consumption sites; and giving drug users a greater role in setting and implementing drug policies that affect them. The ultimate goal, for harm-reduction advocates like Blanchard, is nationwide drug decriminalization, a guaranteed safe supply of drugs and an end to stigmatizing users. Their efforts are bearing fruit. New York City’s Health Department funded a harm-reduction advertising campaign last year that featured posters bearing the slogan: “Don’t be ashamed you are using, be empowered that you are using safely.”

The movement is international. This year’s biennial Harm Reduction International Conference in Melbourne, Australia, featured participants from every continent discussing topics ranging from the effect of COVID-19 on worldwide harm reduction to “Substance Use in Pregnancy: A Toolkit for All of Us.”

A lodestar for U.S reformers is the nation of Portugal, which eliminated criminal penalties for drug use and implemented a nationwide treatment system in 2001. People caught using drugs in Portugal are arrested and required to forfeit their drugs but they are not sent to jail. Instead, they appear before a civilian-led Commission for the Dissuasion of Drug Abuse, which evaluates users and refers those with a drug problem to treatment, with sanctions for those who fail to comply. The focus on treatment, combined with vigorous policing of narcotics trafficking and public drug use, has led to one of the developed world’s lowest rates of drug-induced deaths.

Reform advocates promise similar results in America once the last traces of the war on drugs are swept away. “If we want better outcomes for people with addiction … the answer isn’t to force them into our jails or prisons or our frequently fraudulent and poor-quality addiction treatment system,” wrote journalist and prominent reform advocate Maia Szalavitz recently. “Instead, spending less on coercion and more on improving quality is both more compassionate and more effective.”

For years, such claims were mostly theoretical in the United States or the subject of academic study. Today, as the pace of reform accelerates, it is becoming possible to test whether the end of the war on drugs truly does herald a bright new day for narcotics in America.

San Francisco’s Public Health Department, for example, adopted harm reduction as official policy more than two decades ago. The city of Seattle effectively decriminalized most drug use beginning in 2010, when City Attorney Pete Holmes was elected on a promise to stop prosecuting low-level drug offenses, including all marijuana possession cases. A 2014 California ballot measure downgraded drug possession to a misdemeanor and shifted funding from prisons to treatment and prevention programs. Syringe exchanges, both formal and informal, have operated in numerous U.S. cities for years, in some cases decades.

At the same time, West Virginia, Indiana, and other conservative-led states have moved to restrict or block many reform initiatives. Former Vice President Mike Pence earned a black mark on his record when, as governor of Indiana, he stymied efforts to establish a syringe exchange in a rural county hit hard by opioids, leading to an entirely preventable outbreak of needle-born HIV and hepatitis.

If advocates are right, it is reasonable to assume that cities and states with more advanced drug policy reforms would be outperforming their more traditional peers on measures of drug user health. The latest drug death estimates from the Centers for Disease Control show no discernible relationship between reform policies and reduced overdose deaths. West Virginia, despite its longstanding hostility to reform, saw an 11% decline in overdoses during the 12 months ended November 2022. Indiana experienced a similar decline. Oregon, which decriminalized drugs in 2020 and shifted funding from law enforcement to harm reduction, saw a 5% rise. Neighboring Washington performed even worse.

City-level data are similarly contradictory. San Francisco experienced a record high number of overdoses in 2020, and drug deaths remain what city officials last year called “a public health crisis.” The same is true for Seattle and surrounding King County. Eighteen months after opening the nation’s first supervised drug consumption centers, New York City continues to experience a surge in opioid deaths. By contrast, Cabell County, West Virginia, once called the “overdose capital of America,” saw a modest decline in drug deaths during the 12 months ended September 2022.

Advocates say such results are misleading because reform policies need more time, funding, and widespread adoption to become effective. One North American jurisdiction, however, has been wholeheartedly embracing reform for decades. The city of Vancouver, Canada, is known as the birthplace of North American drug user activism. The city opened North America’s first supervised drug consumption center in 2003, and for many years the local health authority has funded syringe services, medication-assisted therapy, and programs ranging from vending machines for opioids and drug paraphernalia to a managed alcohol program that taught problem drinkers how to make their own alcohol so they didn’t have to resort to consuming mouthwash or finding other non-beverage methods of intoxication. In January of this year, the province of British Columbia became the first in Canada to decriminalize personal possession of all drugs.

Last year, overdoses in Vancouver reached an all-time high, capping a five-year period during which drug deaths rose faster than in the United States. A study conducted by researchers at Simon Fraser University found that the city’s drug policies had attracted users from outside the metropolitan area, coinciding with a tripling of the local homeless population. Sixty percent of homeless people in Vancouver reported being addicted to drugs in 2020.

“It’s a big mess,” longtime Vancouver treatment counselor Tony Kennedy told me in an interview. Kennedy, who has worked with drug users at a Salvation Army shelter in the city’s Downtown Eastside neighborhood for nearly 15 years, said he now sees users forgoing treatment in favor of obtaining free prescription opioid replacement medicines, which they grind up and inject. “I don’t see anything improving,” he said. “Harm reduction has not resulted in a decrease.”

What accounts for this discrepancy between policies that have proved effective elsewhere and results so far on this side of the Atlantic? Among the many answers to that complicated question, one that stands out is suggested by the name of the civil commissions that evaluate drug cases under Portugal’s drug laws. Dissuasion Commissions are predicated on the idea that, in the words of Portugal’s National Drug Strategy, “drug addiction [is] an illness” and the government has a vested interest in “minimiz[ing] the effects of use among addicts” and reducing “the criminality associated with certain forms of drug addiction.”

Key to Portugal’s success is a robustly funded network of inpatient and outpatient drug treatment centers that use a variety of methods—drug replacement therapies, counseling, 12-step support groups—to help chronic users resolve drug problems. Users also receive help reintegrating into society and finding jobs and housing. The strategy presumes that problem drug use is not a public good, and that overcoming addiction sometimes requires help that users themselves may not be able to seek on their own. Users are encouraged to comply with Dissuasion Commission referrals by a series of mounting sanctions that include possible fines, loss of social privileges (such as a driver’s or professional’s license) and mandatory community service.

Drug policy reform in the United States is based on a different presumption. “Drug use is inherently a human right,” a prominent drug user activist named Jess Tilley told me in an interview. Tilley, a longtime heroin user now on methadone, leads a drug user activist organization in Massachusetts and last year was one of several drug users who helped Biden administration health officials set benchmarks for a $30 million federal harm-reduction grant program. “It’s the puritanical rule that says you can’t use drugs,” Tilley said. “Using drugs together and bonding is beautiful.”

Biz Berthy, of VOCAL in New York, used similar language to liken drug policy reform in America to other homegrown, right-to-choose movements, such as abortion rights and the right to gun ownership.

“When it comes to the war on drugs, it’s an issue of bodily autonomy, same as access to abortion,” she said. “In America, one of the fundamental things people are always obsessed with is autonomy: ‘Don’t tell me not to have guns.’ It’s so weird that we are obsessed with policing what people put in their bodies. I would push people to understand that … you can’t force people to do something they don’t want to do.”

Some harm-reduction advocates  go beyond this focus on personal autonomy to make a more sweeping argument that the dangers of drug use itself have been exaggerated. Columbia University neuroscientist and longtime recreational drug user Carl Hart is a leading voice for this claim that any risks associated with drug use are caused not by drugs themselves but by bad laws and ignorance. Sam Rivera, executive director of New York’s recently opened safe injection site in Harlem, told me during a tour of the center that drug users should be able to measure their quality of life not by whether they use drugs but by whether they can “participate in life while using.” He told of friends who, after years of sobriety from drug use, “realize they don’t need to be sober. They can drink or smoke pot … Treatment is one path among many. What’s your recovery? People should be able to identify their own.”

Observers seeking to understand why drug policy reform so far has not resulted in fewer overdoses or a reduction in social problems, such as homelessness, that often accompany drug use, might look first to the libertarian, pro-drug philosophy of many of the reform movement’s leading activists. The first strategic priority listed by the Drug Policy Alliance, America’s largest reform advocacy organization, is ensuring that drug users have the right “to put what they want in their own bodies” and “to live freely regardless of drug use.”

Leaders of the alliance, which authored Oregon’s historic 2020 decriminalization law and spent close to $5 million to pass it, said they modeled the Oregon initiative on Portugal’s drug strategy. But there are important differences between Measure 110 and Portuguese drug laws. There are no Dissuasion Commissions in Oregon. Instead, people caught with a controlled substance are issued a $100 ticket, which is waived if violators call a treatment referral hotline. A state audit published last year found that, 18 months after the law took effect, a total of 119 people had called the hotline, with just 27 asking for treatment. Many police departments declined to issue the tickets because they viewed them as unenforceable.

On voter ballots, Measure 110 was called the Drug Addiction Treatment and Recovery Act. But the law actually provides no funding to treatment organizations dedicated to sobriety. Instead, eligible programs are required to be “patient-centered, non-judgmental and centered on principles of harm reduction.” Providers are specifically forbidden from “mandating abstinence.”

An oversight council governing distribution of funding generated by the initiative is required to include at least three people previously arrested for drug offenses, two “recovery peers” with past drug use experience and one drug user activist. The audit found that the council’s first round of funding decisions was chaotic, with 19 canceled meetings, allegations of nepotism, “applications assessed by reviewers without specific program expertise,” and grants issued to organizations that left entire sections of their applications blank.

Earlier this year, a Measure 110-funded Behavioral Health Resource Center in Portland abruptly closed four months after opening. Described by county officials as “a first of its kind” resource center for people with drug addiction and other problems, the center “employs a workforce with lived experience” and provides harm reduction and other services in downtown Portland. Staff demanded the closure after being inundated by client overdoses, outbursts, and graffiti. A subsequent investigation found that a security contractor was using drugs onsite.

The most recent state data available show that, 12 months after Measure 110 took effect, drug deaths in Oregon reached an all-time high, rising more than twice as fast as the rest of the U.S. “It’s time for other states to follow” Oregon’s lead, Drug Policy Alliance Executive Director Kassandra Frederique said in a statement marking the law’s one-year anniversary.

Where does all of this leave American drug policy? It is hard to feel optimistic at a time when the nation appears caught between the failures of the old war on drugs and a new harm-reduction approach that, despite its public health pedigree and robust federal support, so far appears hobbled by an activist philosophy at odds with the everyday realities of drug use in America.

The most promising path forward might be an American version of Portugal’s grand compromise. Less incarceration, but enough criminal enforcement to bolster programs such as drug courts, which have been shown to be highly effective in a wide variety of settings. Proven harm-reduction services should be supported, such as syringe exchanges and drugreplacement medications, but so should sobriety-focused treatment programs, especially 12-step groups, which consistently outperform other forms of therapy. Supportive housing and other assistance for homeless residents but also less tolerance for public drug use.

To achieve this balance, Americans will have to decide whether their commitment to personal liberty extends to mind-altering substances that impair people’s ability to exercise that liberty compassionately and responsibly. In that sense, debate over drug policy is a debate over American identity itself. “When we talk about uprooting the drug war from these different systems, it’s not just from the systems. It’s from our spirits,” Kassandra Frederique of the Drug Policy Alliance said in a recent speech.

Supporters and opponents of drug policy reform can agree, at least, that she was right about that.