America’s drug overdose problem is severe, persistent, and still deteriorating. For years, states and the federal government have taken drastic action to curb drug deaths, from restricting painkiller prescriptions, to cracking down on drug cartels, to cutting the overall production of legal opioids.

But the problem is only getting worse. In 2017, according to the CDC, over 70,000 people died from a drug overdose—nearly 7,000 more than 2016 and three times as many as in 2002. This means that overdoses have claimed nearly 650,000 lives in the last fifteen years.

The number of overdoses has increased

from about 23,000 to over 70,000 since

2002. Credit: Freethink / CDC

This spiraling public health disaster—and the ineffectiveness of the government’s response so far—has many people rethinking traditional drug policy. A growing coalition of activists and health experts is pushing for an alternative strategy, broadly dubbed “harm reduction,” to minimize the health risks associated with drug use.

In essence, harm reductionists argue for making drug use safer in order to reduce the dangers of overdose, disease, and addiction, rather than simply discouraging it entirely. They say that stopping drug use altogether is an unrealistic and ineffective approach that can even make things worse.

On the other hand, some experts worry that making drugs safer runs the risk of increasing addiction and abuse, which could lead to still more risky behavior. Others argue for a treatment-based approach that combines harm reduction with therapy for addiction, while others think we need to address the problem at its source, dealing with “root causes,” such as mental health, depression, hopelessness, poverty, or other social problems.

Whatever the answer, it’s clear we need to think differently about this problem, because hundreds of thousands of lives are at stake, and the approach of the last two decades hasn’t worked.

How We Got Here

The overdose crisis has largely been blamed on opioids, a class of drug that includes heroin, prescription painkillers, and the ultra-potent drug known as fentanyl. Deaths involving these drugs have quadrupled in the last fifteen years, hitting record highs year after year.

But it’s worth noting that overdoses involving non-opioid drugs—like cocaine, methamphetamine, antidepressants, and benzodiazepines (like Valium and Xanax)—have also risen, more than doubling since 2002.

Credit: Freethink / CDC

Although prescription drugs like Oxycontin and Vicodin have received an enormous amount of media attention in recent years (likely because they are so familiar and commonly prescribed), a deeper look into “opioid deaths” shows that pills are only part of the picture.

Fentanyl is now responsible for most

opioid overdoses. Credit: Freethink / CDC

Deadly Waves

The CDC describes the opioid crisis as coming in three overlapping “waves.”

The first wave, from about 2000-2010, was driven by painkillers (whether legally prescribed by a doctor, or illegally taken from friends, family, or dealers). The overdose rate for painkillers alone more than tripled from 2000 to 2010. But since 2011, during the worst part of the crisis, deaths involving prescription opioids alone have actually declined by nearly 25%.

A combination of well-intentioned policies succeeded at reducing painkiller overdoses. Unfortunately, the pills were replaced by something even worse, and a second wave, this time involving heroin, crashed onto the scene.

In 2010, responding to mounting concerns about painkiller addiction, health authorities began to crack down on prescription pills. According to the CDC, opioid prescriptions are down 28% since 2010, and high-dose prescriptions have fallen by 56%.

Prescriptions for opioids are in

decline. Credit: Freethink / CDC

Besides cutting down on high-dosage scripts, doctors also scaled back the number of small prescriptions they write. Prescriptions for less than a 30-day supply—what you might get for a root canal or another minor, one-off procedure—have declined by nearly 40% since 2010.

Another key change in 2010 was the reformulation of OxyContin (one of the most widely abused painkillers) to discourage misuse. The new Oxy was hard to crush or dissolve, which made it harder to abuse by injecting or snorting it.

The new formula succeeded at reducing abuse of OxyContin, but users didn’t just quit drugs. Instead, they turned to heroin, an even riskier way to get high. Combined with cuts to the prescription supply, the shift to heroin spawned the “second wave” of heroin deaths.

In 2019, a RAND Corporation study confirmed the link between the reformulation of Oxy, the switch to heroin, and a spike in hepatitis C infections. The study’s lead author, David Powell, concluded, “These results show that efforts to deter misuse of opioids can have unintended, long-term public health consequences. As we continue to develop policies to combat the opioid epidemic, we need to be careful that new approaches do not make another public health problem worse.”

The overdose rate for heroin—relatively flat up to that point—tripled in just four years. After peaking in 2015, overdoses on heroin alone suddenly fell by 28% through 2017.

Unfortunately, something even worse was about to contaminate not just heroin but the entire illegal drug market: synthetically manufactured fentanyl.

The fentanyl wave began in 2013, and it has been simply devastating. Fentanyl-related deaths increased by almost an order of magnitude in just four years, from about 3,100 in 2013 to over 28,000 in 2017. That’s 2.5 times as many deaths as painkillers alone and 4 times as many as heroin alone.

The overdose picture is now mostly about

fentanyl, with pills and heroin taking a

back seat. Credit: Freethink / CDC

So, while headlines might lead you to think that the 70,000 overdoses in 2017 were mostly about prescription pills, the reality is very different. Fentanyl (usually mixed into other drugs) is now responsible for 58% of the increase in overdoses since 2002, with non-opioids (like cocaine, meth, and Valium) accounting for 24% of the rise, and regular opioids (about half heroin and half prescription pills) accounting for just 18% by themselves.

A huge part of the reason why fentanyl became so deadly is that dealers started cutting it into everything—from pills and heroin to cocaine and even meth. The drug is dozens of times more potent than heroin, and so a tiny amount can make almost any drug feel “stronger.”

But by the same token, a tiny amount can also kill you. According to some experts, as little as a couple milligrams can kill a person, depending on their size and tolerance level. This makes fentanyl extremely tricky to work with, and even small variations in the consistency of a mixture can create lethal doses (or “hot shots”) within a batch of heroin or cocaine.

A lethal dose of heroin (30 mg) and a

lethal dose of fentanyl (3 mg), for a

typical person. Credit: STAT / NH State Police Forensic Crime

Lab

After marijuana was legalized in several US states in 2013, legal marijuana squeezed out pot smuggled from Mexico, cutting off a major source of revenue for the drug cartels. They had to adapt to the new market, and unfortunately, they did.

Following the surge in demand for heroin, cartels hit on a new source of revenue from synthesizing fentanyl, first importing it from China and then manufacturing it in Mexico. Unlike heroin, which is almost entirely derived from opium grown in south Asia, fentanyl can be synthesized in labs—and, by mixing it into other drugs, cartels can multiply the effective amount of drugs smuggled into the US without bringing in any more weight.

It’s a clever innovation—but it is killing nearly 30,000 people a year.

By 2017, fentanyl was involved in 40% of all overdoses, and it is increasingly being found even in stimulants, like cocaine and meth, which are normally harder to overdose on. Cocaine overdoses, which had been in decline, are now spiking again, thanks to fentanyl.

Fentanyl is being mixed with almost

every illegal drug. Credit: Freethink / CDC

Fentanyl has even started turning up in psychedelic drugs, like LSD, which is almost impossible to overdose on by itself.

Harm Reduction

To unwind this crisis, we need to follow the Hippocratic principle “first, do no harm”—not the Yes, Minister principle: “Something must be done... this is something… therefore we must do it!” Well-intended policies backfired terribly in 2010, turning a painkiller problem into a heroin problem, which turned into a deadly risk for nearly all drugs.

Instead of trying to control the health risks of drugs by attacking drug use, a growing movement of doctors, activists, and policy experts now argues that we should follow “do no harm” to its logical conclusion: do less harm. They’re calling for a shift in our approach from a “war on drugs” to a “harm reduction” mindset, tackling the risks of drug use at their most basic and immediate level.

If people are overdosing on opioids, they argue, let’s make Naloxone, the overdose-reversal drug, available over the counter (and stop prosecuting people who bring friends to see a doctor). If people are dying from fentanyl, help users avoid fentanyl-laced drugs by distributing test strips. If reused needles are spreading HIV or hepatitis C, a needle exchange program allows users to turn in dirty needles for sterile syringes.

Other proposals include supervised-injection facilities, where people can take drugs in a safe, controlled, supervised environment, where they’ll also get information about safe use, treatment for withdrawal, and how to talk to a doctor about quitting.

Safe injection sites like this are (probably) illegal in the United States (and the Justice Department has sworn to shut down any that try to open), but many are operating in Canada, Australia, and Europe. One facility in Vancouver, called Insite, has been operating successfully for 15 years, as NPR’s Elena Gordon notes:

In 2002, Portugal tried a more radical approach to harm reduction, which included decriminalizing personal use of all illegal drugs. Combined with a boost in social services, the new strategy dramatically cut rates of addiction or “problematic drug use,” as well as infections transmitted by IV-drugs and overall overdose deaths.

Does Harm Reduction Work?

Critics argue that harm reduction means “giving up” or “signaling defeat” in the fight against drug abuse, while harm reductionists say that we have to be realistic about how we help people. Some people worry that harm reduction policies will increase drug use, and that might lead to a new generation of addicts who will require more needles, Naloxone, rehab, and supervised injection sites, without addressing the larger issue.

These arguments reveal a split on priorities, not just tactics. Some people think the goal should be reducing everyday drug abuse, which affects millions of people struggling with addiction (or related behaviors) that can disrupt jobs, families, and daily life—even when it doesn’t kill. By contrast, harm reduction emphasizes reducing the worst risks of abuse, whether that means helping people who want to quit get treatment or helping those who don’t to avoid hurting themselves.

To oversimplify it, harm reduction targets overdoses directly, while traditional drug policies target recreational drugs broadly, hoping to stop the progression toward abuse, addiction, and (eventually) overdose.

It’s tempting to dismiss this as a false dichotomy—of course, we can have some policies to make drugs safer and others that help people quit—but we shouldn’t ignore the tension between these goals. Making drugs safer reduces the risks of using, and that could (theoretically) increase use enough to balance out the benefits.

Unfortunately, there is some evidence that the critics have a point:

· A 2019 paper found that syringe exchange programs (SEPs) reduced new cases of HIV by as much as 33%, but at the same time, it found “new evidence that SEPs increase rates of opioid-induced mortality and opioid-related hospital admissions, especially in rural and high-poverty areas, suggesting that needle exchanges may be less effective than other interventions at stimulating recovery.”

· A study in 2018 found that increasing access to Naloxone had mixed results: some areas had fewer opioid deaths, but others had more. On average, “broadening naloxone access led to more opioid-related emergency room visits…with no reduction in opioid-related mortality.” The authors suggest this could be caused by “saving the lives of active drug users, who survive to continue abusing opioids” (a feature, not a bug) but also “that broadening access to naloxone encourages riskier behaviors.”

· Studies on safe injection sites are more positive: “there is evidence of a reduction in overdose deaths, injections done in public, blood-borne disease infections, discarded injection equipment, and perceived neighborhood disorder.” But other reviews argue that more research is needed, because almost all of that data come from just two cities.

The authors of the Naloxone study acknowledge their results are controversial (and “strongly contrast” with some previous research), but what is not controversial is the idea that reducing danger can sometimes lead to riskier behavior. (For example, consider whether you would drive more carefully if you knew your seatbelt or airbag didn’t work.)

That doesn’t mean that these programs aren’t worth doing (seatbelts and airbags are good!), but it does mean we should take these studies seriously. Even in Portugal, while addiction, problematic use, disease, and overdoses went down, overall drug use went up for most of the population (except for high schoolers).

What everyone does seem to agree on is that treatment works, and that harm reduction policies coupled with treatment options work as well or better than either by itself.

Conclusion

Drug policy is complicated, and history shows good intentions are not enough to make good policies. At the same time, we need a new approach. While harm reduction creates tradeoffs, the existing approach has created an unmitigated crisis.

More importantly, the theory that reducing drug abuse will reduce overdoses doesn’t even apply to our current overdose epidemic. Thanks in large part to fentanyl, whatever link there was between overall rates of drug abuse and overdoses has been bent or even broken: more people are dying from drugs, but not because more people are misusing them.

The government’s own data shows a sharp divergence between overdoses and rates of abuse for heroin, cocaine, and meth. At the same time, nonmedical use of opioid pain relievers has been falling for almost every age group since 2002.

Credit: Freethink / CDC / SAMHSA

The problem is that drugs are becoming deadlier, not simply that too many people are abusing them, and that suggests that making them less deadly really is the key to saving lives—regardless of whether it’s the right way to deal with addiction in general.

More experiments with life-saving programs like safe-injection sites, needle programs, and Naloxone access can help guide us toward the best combination of policies. But research is difficult: supervised-use facilities are illegal, funding for syringe programs is heavily restricted, and users are understandably reluctant to talk.

Simply making it legal for forensic labs to test and report on street drugs’ purity, potency, and safety could save thousands of lives, but the DEA currently forbids the practice, for fear of providing “quality control” to black market drug dealers. But, from a harm reduction standpoint, that’s exactly what the black market desperately needs.

Nobody knows the easiest way out of this mess, but it won’t be doubling down on all of things that got us into it. We need to think differently about drugs, because hundreds of thousand of lives depend on our having the creativity to discover new ideas and the courage to try them.