Three years ago, President Donald Trump bragged that “we are making progress” in reducing drug-related deaths, citing a 4 percent drop between 2017 and 2018. That progress, a dubious accomplishment even then, proved fleeting. The upward trend in drug-related deaths, which began decades ago, resumed that very year, and 2020 saw both the largest increase and the largest number ever. That record was broken last year, according to preliminary data that the Centers for Disease Control and Prevention (CDC) published this week.
The CDC projects that the total for 2021 will be nearly 108,000 when the numbers are finalized, up 15 percent from 2020, when the number of deaths jumped by 30 percent. Two-thirds of last year’s cases involved “synthetic opioids other than methadone,” the category that includes fentanyl and its analogs. Those drugs showed up in nearly three-quarters of the cases involving opioids.
Illicit fentanyl, which has become common as a heroin booster or substitute during the last decade, is now showing up in cocaine, methamphetamine, and counterfeit pills passed off as prescription analgesics or anti-anxiety drugs like Xanax. That phenomenon vividly illustrates the hazards of the black market created by the war on drugs that Trump thought the government was finally winning.
Joe Biden, a supposedly reformed drug warrior, is still keen on “going after drug trafficking and illicit drug profits,” a strategy that has failed for a century but, he figures, might just work this time around. At the same time, Biden talks a lot about drug treatment and other forms of “harm reduction,” including “key tools like naloxone and syringe services programs.” He proudly proclaims that his drug control plan is “the first-ever to champion harm reduction to meet people where they are and engage them in care and services.”
The New York Times takes Biden at his word, saying he is “the first president to embrace harm reduction.” While it may be true that Biden is the first president to utter the phrase “harm reduction,” his predecessors have adopted elements of that agenda.
Donald Trump supported sentencing reform. Barack Obama backed needle exchange programs as well as sentencing reform and drug treatment. Even Richard Nixon, who famously declared drug abuse “America’s public enemy number one,” was big on treatment, saying “enforcement must be coupled with a rational approach to the reclamation of the drug user himself” and urging “compassion, and not simply condemnation , for those who become the victims of narcotics and dangerous drugs.” Nixon also criticized harsh penalties for drug users—unlike Biden in his decades as a senator, when he declared that “we have to hold every drug user accountable” and cited the five-year mandatory minimum sentence for possessing tiny amounts of crack as evidence that he was serious.
If we focus on substance rather than words, the real breakthrough will come when politicians understand and acknowledge the nature of the harm that needs to be reduced. It is not just the harm caused by drug abuse but also the harm caused by misguided and counterproductive efforts to address that problem. Prohibition itself is the most obvious example.
Consider one of the harm reduction measures that the Times mentions: the distribution of test strips that can alert drug users to the presence of fentanyl in a substance sold as something else. Those test strips don’t tell you how much fentanyl a bag of powder or a pill contains; they just tell you whether there is a detectable amount. But even that much knowledge is an improvement in a black market where people routinely buy drugs of unknown provenance, composition, and potency.
The danger that fentanyl poses to drug users is not inherent in the drug itself, which can be used safely when you know the dose, as demonstrated by its various medical applications. I was recently given fentanyl, along with midazolam, as a sedative during dental surgery, and I was not at all worried that it would kill me. Patients who receive fentanyl injections in the hospital or use fentanyl patches, lozenges, or nasal spray to relieve severe chronic pain likewise are not dropping dead left and right.
In the black market, by contrast, drug users may not even realize they are buying fentanyl; hence the test strips. Even if they do realize that, they still don’t know the concentration. That potentially lethal ignorance is entirely a product of prohibition. While the proliferation of illicit fentanyl has made drug use more dangerous by increasing variability and uncertainty, those problems are not new. They are inevitable when the government tries to prevent the use of psychoactive substances by banning them.
Given those long-recognized hazards, it was entirely predictable that cracking down on pain medication, in addition to depriving bona fide patients of desperately needed relief, would increase drug-related deaths by driving nonmedical users into the black market. And that seems to be exactly what happened: As the government succeeded in reducing opioid prescriptions, the upward trend in opioid-related deaths not only continued but accelerated.
To the extent that fentanyl has compounded the dangers of the black market, that is also a predictable result of prohibition. Biden thinks that “going after drug trafficking” will help prevent drug-related deaths. But the pressure from enforcement drives drug agents toward more-potent products, which facilitate smuggling by allowing them to pack more doses into the same volume. Alcohol prohibition shifted consumption from beer and wine toward distilled spirits. Drug prohibition gave us heroin instead of opium, fentanyl instead of heroin, and sometimes even-more-potent fentanyl analogs instead of fentanyl.
Given the economics of the black market, interdiction has always been a hopeless proposition. That should be clearer than ever today as the government vainly tries to intercept little packages of fentanyl, each of which contains thousands of doses. But while “going after drug traffickers” has never been a cost-effective way to reduce drug consumption, that does not mean it has not accomplished anything. It has been remarkably effective at making drug use deadlier.