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- Herausgeber: John Wiley & Sons
- Kategorie: Geisteswissenschaft
- Sprache: Englisch
We are in the midst of the worst drug crisis in American history. What are we going to do about it?
Around 100,000 Americans died of a drug overdose last year – nearly double the number who died in Vietnam. More than 1,000,000 have perished since 2000, thanks largely to an explosion of fentanyl and other addictive opioids. But fentanyl, abundant methamphetamine, and other lethal drugs are not the only things that are killing us: our policy is. So far, America has lacked the will to do better. That must change, and this book tells us how.
No one is immune, which is why Kevin Sabet has authored this remarkable book. Sabet, dubbed the “the quarterback of the new anti-drug movement” by Salon, has spent most of his life battling the destructive effects of drugs. In One Nation Under the Influence, he asks hard questions and provides clear answers, taking readers from the streets of San Francisco and New York to the southern border, up to Canada, and across to Europe to show how we can chart a necessary way forward. The solutions are out there, if only we have the will to apply them.
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Veröffentlichungsjahr: 2025
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CONTENTS
Cover
Table of Contents
Title Page
Copyright
Dedication
Acknowledgments
Quote
Introduction
Notes
Part I Where We Are, Where We Have Been
Harlem
Notes
1. Yesterday in America: A Brief History of the Drug Wars
Addiction: A Choice, a Disease, a Failing?
The Debate over Addiction
The Movement to Legalize Drugs
Notes
2. Harm Reduction in Words, Legalization as Deeds
Hypedelics
Notes
3. Oregon’s Woes
Notes
4. A Tale of Two Countries
A Complicated Picture
The Dissuasion Commission
A Foundation for Change
O, Canada
Notes
Part II Looking for Solutions
San Francisco
Notes
5. Beyond Our Borders
Ghost Wars
The Cat-and-Mouse Game at the Port of Nogales
Nabbing the Kingpin
Notes
6. Zooming In on Local and National Solutions
What the Death of Joe Camel Can Teach Us
Notes
7. Hope and Help Whether You Like It or Not
Carrots, Sticks, and Drug Treatment Courts
“Officer Traci” and the Venice Beach Mission
Where There’s Breath, There’s Hope
Notes
Conclusion
Prevention as a Centerpiece for a New Drug Policy
Intervention – and a National Treatment System
Using the Criminal Justice System to Achieve Recovery
Putting More Pressure on Mexico
Political Ramifications
Final Thoughts
Notes
Index
End User License Agreement
Guide
Cover
Table of Contents
Title Page
Copyright
Dedication
Acknowledgments
Quote
Begin Reading
Conclusion
Index
End User License Agreement
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One Nation Under the Influence
America’s Drug Habit and How We Can Overcome It
KEVIN A. SABET, PhD
polity
Copyright © Kevin A. Sabet 2025
The right of Kevin A. Sabet to be identified as Author of this Work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988.
First published in 2025 by Polity Press
Polity Press65 Bridge StreetCambridge CB2 1UR, UK
Polity Press111 River StreetHoboken, NJ 07030, USA
All rights reserved. Except for the quotation of short passages for the purpose of criticism and review, no part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the publisher.
ISBN-13: 978-1-5095-6071-4
A catalogue record for this book is available from the British Library.
Library of Congress Control Number: 2024951825
The publisher has used its best endeavours to ensure that the URLs for external websites referred to in this book are correct and active at the time of going to press. However, the publisher has no responsibility for the websites and can make no guarantee that a site will remain live or that the content is or will remain appropriate.
Every effort has been made to trace all copyright holders, but if any have been overlooked the publisher will be pleased to include any necessary credits in any subsequent reprint or edition.
For further information on Polity, visit our website:politybooks.com
Dedication
To parents and grandparents everywhere
Acknowledgments
This book would not have happened without the constant encouragement of Shahrzad and Lua. They have inspired and pushed me at every stage of the project.
I want to also give top thanks both to my colleagues in this field, and to the whole team – board, staff, and all – at the Foundation for Drug Policy Solutions and at Smart Approaches to Marijuana. Both organizations have risen above my wildest dreams, and they would have gone nowhere without the tireless, passionate people behind every report, every social media post, every piece of testimony created to address the drug problem.
Special thanks go to my brother in this field, Luke Niforatos. His consistent enthusiasm for this project from day one is much of the reason there is a final product. For this, and so much more, I am eternally grateful to him and his wife, Eliza, and their children, Shiloh and Eden.
The project took me to the four corners of North America, and so many selfless people helped me along the way – from agreeing to be interviewed to helping with key facts and points of research. I am grateful to all of them. I also want to thank the drug czars who were so generous with their time, and the people who reviewed earlier drafts of the book, including Luke Niforatos, John Coleman, Charles Lehman, Bertha Madras, and Bob DuPont, as well as others who helped me think through parts of it, including Keith Humphreys.
I am especially thankful to my teachers in this field, who, starting more than thirty years ago, remained patient and wise. Richard McCoun saw something in me at age 17 I certainly did not see in myself. The late Sandy Muir, my first undergraduate teacher at Berkeley, is always on my mind, as is his incredible colleague in the PoliSci department, Bruce Cain. Rob MacCoun and Beau Kilmer at Berkeley let a precocious kid into some of their seminars and forced me to think in new ways that still serve me today. At Oxford, George and Jane Smith, James Sandham, Don Operario, Gillian Peele, and others helped shape much of the substance of this book during my doctorate studies. Along the way, Mark Gold, Bob DuPont, the late David Musto, and others remain a source of constant knowledge and inspiration. The late Mark Kleiman, with whom I discussed many of these themes, was always encouraging in his praise and cutting in his criticism – it made me a better thinker, and I miss him. I especially thank Connor Kubeisy for his thorough research assistance, as well as Sally Satel for the section on compelled treatment, which came from an opinion piece we wrote together for The Wall Street Journal.
To those from whom I continue to learn every day, people like Barry McCaffrey and Gil Kerlikowske, thank you. And finally, to the families of lost children – some of whom I got to talk to for this book, and others I have simply corresponded with – this book is for you.
Those who do not learn history are doomed to repeat it.George Santayana
Introduction
Over a hundred thousand Americans – many of them children – died of drug overdoses in 2023, more than double the number in 2015.1 And although some regions of the United States are finally beginning to see a reduction in deaths, more than 1 million Americans have succumbed to drug overdoses since 2000. We are expected to lose another million-plus people over the next decade, according to a Stanford University study.2 The numbers go deeper: More than 48 million Americans have a substance use disorder.3 The toll in human life and suffering is unfathomable. Never before have opioids, methamphetamine, cocaine, and other drugs affected so many people.
These aren’t just statistics. People are dying, or just barely hanging onto life. Drugs have broken families. No community has been left untouched.
Nearly as many Americans have died from the drug epidemic as have died from the Covid-19 pandemic. And yet, while scientists were able to react to the pandemic and develop vaccines in record time, the drug epidemic has continued to rage on largely unchecked. The pandemic was accompanied by minute-by-minute media coverage, while the drug epidemic garners only the occasional middle-page article when, for example, a public figure dies from an overdose.
The problem has left parents, users, social workers, and policymakers exasperated.
Cheryl Juaire of Boston, for one, is more than just exasperated. She has felt it in her own family. Cheryl lost not one, but two of her three sons to fatal drug overdoses.
Two.
“There are no words,” she says. Her youngest, Corey, died on February 24, 2011. The cause: heroin. He was 23. Corey left behind a four-and-a-half-month-old daughter, Faith.
Cheryl’s second son, Sean, died on June 25, 2021. The cause: cocaine laced with fentanyl. He was 42. Sean left behind a son, a daughter, and two grandchildren.
How did this happen?
“I didn’t raise my kids to be like this,” says Cheryl, a former dental assistant and church secretary. But she looks back, seeking answers, and sees a lethal combination of debilitating factors – genetics, family trauma, and the unyielding grip of addiction.
Her oldest son, Robert, is a police sergeant in Hudson, Massachusetts, outside Worcester, who regularly sees drug users break into storefronts and steal cars – and yet, “Bobby doesn’t understand the disease of addiction,” Cheryl says. “He gets very angry.”
Mother and son have a hard time talking about the searing losses they have experienced due to drugs.
For Cheryl, all she could do was not put up a Christmas tree. When people heard about this on Facebook, hundreds of other grieving moms sent her ornaments – angel wings.
So, she put up the tree after all.
“It turned into my angel tree,” Cheryl says.
She has also channeled her unfathomable grief into setting up a nonprofit to help other families who have lost and suffered from drug addiction. It’s called Support After a Death by Overdose, or SADOD. “So that our children didn’t die in vain,” explains Cheryl, now in her mid-sixties.
The tragedy that befell Cheryl is unfolding all over the country, from California to New York, and spanning the heartland from Nebraska to West Virginia. So too is the dissolution and decay that drug use has brought to places like San Francisco. There are, of course, many causes. But one stands out: the misguided policies and practices that have inadvertently unleashed the worst drug crisis in American history.
“The crisis is national,” former President Joe Biden said in an address. Drawing on his son’s highly publicized experience with addiction, he continued: “A lot of families have loved ones who have overcome addiction and know what we mean.”4
What about the impact of the drug epidemic in financial terms? About 1.5 trillion – with a T – dollars a year, by some estimates.5 Meanwhile, the size of the illicit drug market in the United States is estimated at $150 billion, as synthetic drugs smuggled from countries like China and Mexico have become increasingly common and lethal.6
Though it’s a connection largely not talked about, one might argue the legalization of marijuana opened Pandora’s Box. Now, “drug policy reform” proponents seek to commercialize psychedelics and legalize virtually all other illicit substances, including fentanyl and heroin. They use euphemisms like “harm reduction” – a well-intentioned idea originating from the AIDS movement of the 1980s to reduce the consequences of drug use, like infectious disease – and “decriminalization” – rallying the popular notion that those whose only crime is using drugs should get help rather than jail – to get their way. They’ve set up “supervised consumption sites” – places where drug use is tolerated, staffed by harm reduction activists – in communities of color, like Harlem, New York, despite misgivings from residents there. And they argue that we can give addicts a “safe supply” of drugs in the form of pharmaceutical pills, since they are “known” and “controlled.”
Everyone from illegal underground players to multinational corporations to deep-pocketed nonprofit organizations are among the chief beneficiaries of the push to normalize drug use. “Traditional” drug dealers ply their deadly trade with impunity, with many using the dark web and social media to sell illicit substances, such as fentanyl. On the popular platform Snapchat, some dealers have sold marijuana, offering to throw a couple of fentanyl pills into the bargain. Indeed, many unsuspecting teenagers have died of fentanyl poisoning because they took a pill without realizing what was in it. Meta is now facing a huge lawsuit that contends its platforms – including Facebook and Instagram – have served as virtual marketplaces for drugs like opioids, cocaine, and methamphetamine.7 Surveys show that an alarming number of teenagers still do not realize the dangers posed by fentanyl.8 Lost in the debate is the massive and growing number of people in the grips of addiction who have become homeless. You can see the staggering camps of homeless people in nearly every major American city, from Los Angeles to New York.
So, what do we need to do to address the crisis?
A further legal crackdown? A renewed war on drugs?
Or should we simply learn to live with drugs, an age-old vice?
Or is that a false dichotomy? Can we find common ground?
Even more importantly, is there an effective path forward to save lives?
Given the fatal implications of the drug epidemic for the future well-being of our country, there is an urgent need for a dispassionate and in-depth examination of this crisis. That is why I have written this book, which will look at different places, and our own history, for answers. San Francisco, for example, known for its “free drugs” mantra of the 1960s, was actually one of the first cities in the country to ban drug use a couple of hundred years ago – and is now starting to come around full course and reverse its libertarian drug policies in the wake of extraordinary destruction.
* * *
Why has addiction defied a clear explanation for its causes and a viable course for its treatment while many other health-care problems have benefited from the miracles of scientific research and innovation?
“In search of answers,” writes Carl Erik Fisher, an addiction physician and bioethicist, “I immersed myself in the field, studying the psychology and neuroscience of addiction … The field seemed to be in chaos. Scientists and other scholars seemed bitterly divided, always talking past one another. Some insisted that addiction was primarily a brain disease. Others claimed that this brain-centric view blinded us to the psychological, cultural, and social dimensions, including trauma and systems of oppression.”9
Not only are the experts unable to agree on the causes of addiction, they are engaged in a fierce debate over its treatment and, in some cases, whether treatment is necessary at all. Numerous approaches to treatment range from the traditional twelve-step model to a medical approach that favors biological alternatives such as buprenorphine and other medications, to therapeutic communities that stress long-term residential behavior modification. These should not be seen as mutually exclusive. They are all useful and effective.
If you read authors like Carl Hart, a professor at Columbia University and author of Drug Use for Grown-Ups: Chasing Liberty in the Land of Fear, you may believe drug use is a safe, truly recreational activity. “I am now entering my fifth year as a regular heroin user,” he writes. “I am better for my drug use.”10
Hart argues that drug use isn’t only not harmful, it is helpful. Lost in his personal experience are the horrors drug addiction can afflict on others, even as he speaks with young people around the world about what he describes as the joys of heroin and hallucinogens. Hart is not some fringe figure. His work is praised regularly in mainstream media outlets, papers like The New York Times, and by witty TV entertainment programs like The Daily Show. He’s a popular professor at an Ivy League school.
Some pro-drug-legalization organizational staff are now sponsoring studies to normalize the use of drugs among researchers. One such study, published in 2024, found that more than 85 percent of drug researchers reported using drugs. The authors concluded that “drug use experiences can positively inform research, but stigma is a barrier” and that “researchers believe drug use could strengthen research questions.”11
What’s more, the same forces pushing so-called “safe” or supervised drug consumption sites are trying to create a so-called “safe” or “safer” supply movement, which would prescribe opioids and stimulants to people with a substance use disorder. Note that word again – “safe.” The logic goes like this: If we provide unadulterated drugs to drug users, they would be harmed to a lesser degree than by potentially tainted illicit drugs (for example, not overdose on a substance unknowingly laced with fentanyl). Dr. Robert DuPont, who served as the White House drug czar for two presidents, strenuously disagrees.
“Drug use is not safe,” he told me in an interview. “Addiction hijacks the brain, changing the person with a substance use disorder.” He went on to write in an article: “The tragedies of addiction are both widespread and uniquely personal. As a psychiatrist, I am amazed by the power of addiction, which has been rightly called a ‘cunning, baffling, and powerful’ disease.”12
The lack of consensus in the drug policy community is a cause for despair, among some. “In the United States … close to 10 percent of all health-care expenditures [around $40 billion] go toward prevention, diagnosis, and treatment of people suffering from addictive diseases,” writes Judith Grisel, a professor of psychology and a behavioral neuroscientist. “Despite all this money and effort, successful recovery is no more likely than it was fifty years ago … Hundreds of scientists working today have spent their entire careers studying addiction: therapists and teachers of other kinds strive to treat the illness. The scope of suffering is so broad and so deep that the possibility of effective treatment, let alone a cure, is a holy grail for much of humanity.”13
Over the years, many different approaches have been discussed – and many of them tried – to stem the tidal wave of drug addiction. They fall along a spectrum with criminalization at one end and legalization at the other. Criminalization – a.k.a. prohibition or the war on drugs – aims to deter substance misuse by increasing the penalties for use, an approach which relies on the criminal justice system. Included in this philosophy are interventions like the death penalty for drug dealing or use, incarceration, and other similar approaches. Countries like Singapore and Saudi Arabia have taken this line. At the other end of the spectrum is the full legalization of drugs, resulting in the acceptance of them in the eyes of the law.
In the middle are policies like decriminalizing possession (where use does not result in jail time, but selling does) or diverting people at time of arrest to non punitive interventions. Many of these middle approaches attempt to link the criminal justice system with the public health system, as opposed to seeing them as an either-or proposition.
Which is the best combination of policies? And for whom? What weight should policymakers give to users of drugs and nonusers alike?
Desperate for improvements, some have turned to more radical approaches. If we can’t stop all drug use, can we make it “safer” to engage in? In fact, a recent consensus has emerged around harm reduction as an intervention; for example, the use of products like naloxone, which reverses opioid-induced overdoses, or drug testing kits to detect the presence of deadly substances like fentanyl. But our recent obsession with these kinds of programs raises a new question: If we double down on these approaches, will we actually stem the tide of overdoses today? Do we neglect other, more impactful programs when we try to simply bandage addiction with interventions meant to make drug use less risky? Is there any such thing as a “safe” or “safer” way to use drugs? Is addiction, as some advocates think, simply a lifestyle choice that can be managed? Or is it a brain disease with deadly consequences? It was to address these questions about drugs – and the anguish that goes with them – that I decided to write One Nation Under the Influence. For the first time in a book, this work will include interviews with almost every living former White House drug czar – from the Nixon era to Trump – as well as interviews with those at the cutting edge of international law enforcement on the one end, and of harm reduction and legalization on the other.
This book argues that we need more than Band-Aids – we need bold new policies. To draw a comparison: The key to reducing heart disease isn’t just to ensure we have defibrillators at every fast-food joint, ready to revive someone who suffers a heart attack after consuming a 2,000-calorie burger. Sure, we need those defibrillators on hand. Get them installed everywhere. But is that enough? Should we not focus on prevention, long-term treatment, and changing people’s habits? Do we really think we will reverse the unprecedented drug crisis with a lot of little Band-Aids, simply reducing the harm from drug use?
I argue that the path we have been going down of late won’t get us out of our current situation. In fact, it may make things worse. This isn’t a call for a renewed enforcement-centered war on drugs approach, however. Rather, our history shows us that when we enable drug use – or choose to try and “live with it” – things don’t improve. Today, when we have the tools to prevent drug use from starting as well as get people into recovery from addiction, we must instead turn to scaling up big ideas that can move the needle. The time for small thinking is over.
What we need first and foremost is a comprehensive national approach to tackling the issue. That means eschewing both excessive punitiveness that treats addiction like a moral choice and the kind of laxity that treats addiction like an inevitable, insurmountable condition. We have the know-how to do this. We don’t need to invent a flying car or a spaceship capable of reaching Jupiter. The answers are right in front of us. They’re found in communities across our country and abroad.
In fact, we’ve done this before. Back in the 1960s, almost half of Americans smoked cigarettes daily. Daily. Think about that. Now think about where we are today. Kids think smoking is a turn-off. Most adults don’t dare light up a cigarette. Businesses forbid it. Public places eschew it. We’ve stigmatized and de-normalized the act of smoking. And we’ve offered smokers compassion in the meantime. We haven’t destroyed their lives over their addiction; we’ve made help easy to get, and we’ve nudged them in the right direction. “You can’t come here if you smoke. You can’t work here if you smoke.” It worked. Can these lessons of de-normalization work for other drugs?
Second, we need to acknowledge that we know most of the people who cause most of the damage related to addiction. Not by first name, necessarily. But we know where they are: over 70 percent of them are caught up in the justice system for committing crimes, like those to support their addiction. Stealing. Mugging. Shoplifting. When you use drugs, you need money. You also behave differently. These are just some of the ways crime and drugs are linked. So, we know them. And they cycle in and out of the system faster than anyone can imagine. And then we wonder, “Why do we have such a problem?” This cycling represents an enormous opportunity for disruption. If we could implement programs to help people get into recovery, we could actually start to make a difference. And some places are doing that already. Hawaii. Indiana. Michigan. But most people – most federal officials in charge of drug policy even – will have never heard of these programs because too many of them remain provincial in every sense of the word. We have to change that, radically scale up what works, and implement it on the federal level.
Third, we know that for most kids, if they haven’t touched drugs by age 21, they are unlikely ever to become addicted to drugs in the future. That is a remarkable statistic that “makes sense” but most of us take for granted. Yet it has giant implications for policy. It means we must do everything we can to stop drug use before it starts. Iceland has done it. We have done it in certain places. Why can’t we apply this everywhere? The answer is we can, but we don’t. We’ve become paralyzed into thinking that “nothing works.” That drug use is “inevitable.” That “kids will be kids.” And we’ve been blinded by shiny Band-Aids, and think that by employing them we’ve done our job. But guess what? We haven’t. Kids keep dying, and at a time when these Band-Aids are more ubiquitous than ever. They have given us a false sense of hope. A dangerous sense. A danger that has translated into more and more broken families, crushed dreams, and unsafe communities.
This book addresses these issues and calls for a new kind of scaled up, balanced policy. You probably can’t fit anything I write here on a bumper sticker, which is perhaps a drawback politically. But this complex problem requires a comprehensive solution. Part I of the book outlines where we are now as a country, and how we got here. History tends to repeat itself, and we don’t have that luxury anymore if we want to save lives. I open with a story from Harlem, New York – a sort of accidental epicenter of today’s debates about drug policy, representing not only the present but, as I lay out, also the past. Part II looks to small US communities and to other countries for solutions, starting with a story out of America’s west coast hub for drugs, San Francisco. The remaining part of the book is a call to action. It outlines what is, I fear, the best chance our country has to get above the influence and out from under our current, undeniable national catastrophe.
Notes
1.
Centers for Disease Control and Prevention (2024). Wide-ranging ONline Data for Epidemiologic Research (WONDER),
https://wonder.cdc.gov/wonder/help/main.html
.
2.
Humphreys, K. et al. (2022). Responding to the opioid crisis in North America and beyond: Recommendations of the Stanford–Lancet commission.
Lancet
399(10324): 555–604.
3.
Substance Abuse and Mental Health Services Administration (2024). National Survey on Drug Use and Health,
https://www.samhsa.gov/data/sites/default/files/reports/rpt47100/NSDUHDetailedTabs2023/NSDUHDetailedTabs2023/2023-nsduh-detailed-tables-sect5pe.htm
.
4.
Bidgood, J. (2024, June 7). The Biden family’s public reckoning with addiction.
The New York Times
,
https://www.nytimes.com/2024/06/07/us/politics/biden-hunter-addiction.html
.
5.
United States Senate Joint Economic Committee (2022). The economic toll of the opioid crisis reached nearly $1.5 trillion in 2020,
https://www.jec.senate.gov/public/index.cfm/democrats/issue-briefs?ID=CE55E977-B473-414F-8B88-53EB55EB7C7C
.
6.
RAND Corporation (2019). What America’s users spend on illegal drugs, 2006–2016,
https://www.rand.org/pubs/research_reports/RR3140.html
.
7.
Rodriguez, S. (2024, July 31). Meta has run hundreds of ads for cocaine, opioids and other drugs.
Wall Street Journal
,
https://www.wsj.com/tech/meta-cocaine-opioids-ads-dea8e0fc?st=r2iv35fykpo7hx5&reflink=article_imessage_share
.
8.
Hoffman, J. (2022, May 19). Fentanyl tainted pills bought on social media cause youth drug deaths to soar.
The New York Times
,
https://www.nytimes.com/2022/05/19/health/pills-fentanyl-social-media.html
.
9.
Fisher, C. E. (2022).
The Urge: Our History of Addiction
. Penguin.
10.
Hart, C. L. (2021).
Drug Use for Grown-Ups: Chasing Liberty in the Land of Fear
. Penguin.
11.
Ompad, D., Shrader, C., Snyder, K., Netherland, J., Vakharia, S., and Walker, I. (2024). “He’s used drugs – he’s biased! He’s not a drug user – what would he know!”: A cross-sectional, online study of drug researchers’ experiential knowledge of drug use and disclosure.
Drug and Alcohol Dependence Reports
12(100256).
12.
Mentor USA (2021, December 13). Youth substance use is not inevitable. Dr. Robert DuPont on substance misuse, and the power of prevention,
https://mentorfoundationusa.org/blog/2021/12/13/youth-substance-use-is-not-inevitable-dr-robert-dupont-on-substance-misuse-and-the-power-of-prevention
.
13.
Grisel, J. E. (2019).
Never Enough: The Neuroscience and Experience of Addiction.
Doubleday.
Part IWhere We Are, Where We Have Been
Harlem
It’s library quiet as you enter the reception area, where you’re greeted by a collection of large stuffed giraffes, the kind you want to hug. The children – from three months to four years old – are taking their midday naps. The walls are accented in bright hues of orange and yellow, along with the names of wealthy New Yorkers who have donated generously to make this place possible. Indeed, the Association to Benefit Children, or ABC, is the archetype of what you would imagine a safe and comfy daycare center to be.
Except for one unusual fact: Just across the street in a well-worn brick building – not even fifty yards away and in plain sight of the children and their parents – people struggling with addiction are smoking and shooting up illegal drugs. And this is occurring with the blessing of the New York City government.
The building was the first “official” supervised injection site in the United States, and its innocuous name – the New York Harm Reduction Educators’ East Harlem site – obscures another fact: Its creation late in 2021 reignited a nationwide debate over what The New York Times called “the legal and moral implications of sanctioning illegal drug use.”1
This bold proposal came after New York City lost more than 2,000 residents to overdose deaths in 2020, representing a 37 percent increase from 2019. Nearly eight in ten of these deaths were due to fentanyl.2 Some in the city pointed to the rising death rate as evidence that the traditional approach to addressing addiction had been failing to prevent overdoses.
The supervised injection site is sandwiched between a bodega – a New York-style Spanish grocery – and a homeless shelter, and it does little to announce its presence. The weathered green awning gives away nothing apart from the street address. The scuffed beige double doors offer not much more than a Covid mask reminder. A few down-and-out people huddle by the front, not far from a couple of others hobbling down the street while inhaling a substance of unknown provenance.
The city authorized the site with the stated aim of stemming the rising tide of overdose deaths caused by street drugs. To justify its creation, the office of outgoing New York Mayor Bill de Blasio pointed to the existence of supervised injection sites in Europe and Canada, where people bring their own drugs but are supplied with clean syringes and other drug materials. De Blasio’s successor, Mayor Eric Adams, has said he supports the project. Dr. Dave A. Chokshi, the city’s health commissioner, noted to The New York Times: “Every four hours, someone dies of a drug overdose in New York City. We feel a deep conviction and also a sense of urgency in opening overdose prevention centers.”3
The Harlem center says that trained staff will provide not just clean needles but options for treatment as well as the equipment to administer naloxone, a medicine also known as Narcan that can rapidly reverse the effects of an opioid-induced overdose.
If an individual overdoses on his or her drug of choice, staff will be on standby to provide medical assistance – if they overdose elsewhere, nobody will be present to help them, the thinking goes. Supporters of supervised injection sites also argue that the facilities serve as potentially life-saving touchpoints that can connect drug users to treatment, counseling, and support services. To the credit of these sites, a report from the National Institute on Drug Abuse (NIDA) stated: “Published evidence and unpublished reports from stakeholders suggest that no client of an OPC [overdose prevention center] has ever experienced death from an overdose within a facility.”4 The arrival of the East Harlem site was initially met with alarm and resentment by residents, who worried that rather than combating drug use, the site would actually encourage more drug use and dealing – right in front of the children of the ABC daycare center across the street.
Skepticism toward safe injection sites isn’t unique to Harlem; it’s nationwide. A 2018 study in Preventive Medicine found that only 29 percent of Americans supported opening injection sites in their communities, ranging from 18 percent of Republicans to 39 percent of Democrats.5 (More recent polls show more support, however.6)
New York City allowed the Harlem site along with another, not in the tony Upper East Side or trendy Soho but in Washington Heights, a north Manhattan neighborhood predominantly inhabited by people of color. “The pattern reinforces the white supremacist idea that addiction is a Black problem to be contained in Black neighborhoods,” Shawn Hill, co-founder of the Greater Harlem Coalition, a grassroots organization of more than twenty Harlem neighborhood associations, said in an interview for this book. Here, a supervised injection site naturally attracts dealers who, in turn, attract more users in search of a hit. “It’s a vicious cycle; more arrests, a rise in drug overdoses, and more buying and selling of drugs.”
Hill’s concerns are shared in the neighborhood. “As a parent, I was a little nervous,” said a young mother I spoke with, Tara, who works at ABC and whose six-month-old son attends the center. Off to fetch a cup of tea on a brisk winter day, Tara said she’d noticed an increase in drug use and homelessness on 126th Street, a barren place marked by barbed wire and graffiti.
But as time has gone on, there has been a gradual acceptance by many neighbors of the government-authorized injection site.
In response to an initial surge of controversial media coverage (including graphic images of people with addictions shooting up heroin or cocaine in mirrored booths), the people who run the Harlem site hired a public relations firm to curate who gets a view of the inner sanctum. They rebuffed repeated attempts to obtain a tour of the facility for the benefit of readers of this book. They did, though, give one to The New York Times, which glowingly featured the site’s executive director wearing a shirt with “NJ GREEN SCENE” sprawled across it – referring to a website that describes itself as “a place for cannabis enthusiasts to share info about their favorite flower.”7 You’d be forgiven for being perplexed at the sight of the leader of a crusade to treat addiction like a health issue wearing a shirt encouraging drug use.
“The facility seems to be well run by caring people,” said Hill. That may be true. But the city failed to obtain required approval from the state’s department of health to launch the sites. As a result, there is no structure to track drug deaths, establish standards, or regulate who can work there. It’s not even clear that a promised registered nurse is on site. Preliminary statistics provided by the sites show the majority of participants, about 71 percent, received harm reduction education (e.g. on how to use drugs “safely”), while a mere 5 percent received some kind of psychological or other counseling service. At the Washington Heights site, only three people out of 738 participants received any kind of counseling.8
“These things are run by private organizations, and I don’t know that they operate under any kind of rules,” Bridget Brennan, the city’s special narcotics prosecutor, told me.
The Harlem and Washington Heights sites are the natural outgrowth of the more extreme corners of the harm reduction movement, which favors legalizing all drugs and is popular among some New York City officials.
A recent study was lauded for finding that crime and 911 calls had not increased since the opening of the sites.9 The headline “Overdose prevention sites not associated with increase in crime, according to study” graced dozens of newspapers and media sites. But further digging has found that crime did indeed go up, as was laid out by Howard Husock in City Journal:
The study appears to contain a crucial error: its conclusion minimizes the importance of an increase in aggravated assaults in the vicinities (roughly a six-block area) of the injection sites after those sites’ opening, compared with the vicinities of 17 safe-syringe-program sites in NYC that did not offer “safe injection” services. Specifically, the authors include the assault data in a paragraph about findings not deemed “statistically significant,” despite data in a table of the report that indicates otherwise.10
Indeed, the study reports that a broader definition of “violent crime” did not “significantly change.” The drop happened mainly because of a decrease in “simple assault.” They attempt to explain this away by noting, with no citation, that “the distinction between aggravated and simple assault can be arbitrary.”
In the comment section of the article published through JAMA Network Open, a UCLA doctoral student wrote that the positive claim by the study authors was “overly rosy as not all crimes are equally severe, and a potential ‘safe injection site’ attributable increase in aggravated assaults is undoubtedly a matter of public concern.”
Regardless, it is clear the jury is still out on a number of measures. It is concerning, though, that a 2019 panel discussion at Fordham Law School included one of the authors of the above study as an advocate in favor of injection sites.11
Civil rights advocacy groups in New York’s neighborhoods of color have been lobbying for years against stringent drug laws, which they argue discriminate against Black and brown people. Funding for these groups comes from a variety of pro-drug organizations, including the Drug Policy Alliance, the most prominent and deepest pocketed pro-legalization organization in the world. As a result of all this pressure, four of the city’s five district attorneys have promised not to take any enforcement action against the injection sites, even though, under a federal law often referred to as the “crack house statute,” it’s illegal to operate such facilities. And so the reasoning goes: If civil rights leaders and local government officials don’t object to the sites – and the federal government hasn’t stopped them from operating – why should the residents of Harlem and Washington Heights care?
Many in the Harlem community appear to be more unhappy about how the supervised injection site was established than about the ongoing program. The community wasn’t consulted before the site was approved and, as community leaders point out, there was already a saturation of programs aimed at addressing substance misuse in the neighborhood. Residents were concerned that these programs would concentrate the unwelcome side effects of addiction in their communities.
Nonetheless, the people who run the two facilities, which merged to form the nonprofit OnPoint NYC, talk as if their interests go beyond the local communities they serve. They are on a crusade to normalize supervised injection sites – and “safe” drug use generally – throughout the United States.
“I just got a text from [a group in] San Francisco showing me photos of their setup and how they’re preparing to do it,” Sam Rivera, the executive director of OnPoint NYC, told a reporter from the news site Gothamist. “I’m on the phone every day, including Saturday and Sunday, with someone from somewhere in the country saying, ‘We’re next,’ and I’m cheering them on.”12
Not long after the Harlem site opened, bullet-proof glass was installed across the street at the daycare center in response to a shooting on the block. Think of it as a metaphor for a frightened neighborhood, a country in pain, unsure what to do. Searching for new answers, the sites are a stark example of the themes that make up our drug picture today. But do they really represent the best in new, innovative, twenty-first-century thinking to deal with the scale of the problem we face?
Forthcoming research on the effectiveness of these programs, and of harm reduction in general, has already been called into question. In a leaked “hot mic” transcript of their Zoom interview with the Harlem Coalition, researchers from Yale University were recorded indicating their bias toward supporting the injection site and expressing their disgust at those members of the coalition who have concerns.
Working on a National Institutes of Health–funded study examining drug use, homelessness, and the community, Yale’s Ryan McNeil, Director of Harm Reduction Research at the university and a long outspoken advocate of extreme harm reduction measures, interviewed the coalition to ask about their role in the community. The final words said by McNeil to Shawn Hill were: “Thank you so much for taking the time. The time to connect with us. Really appreciate it.” But that wasn’t all McNeil and his colleague, Gina Bonilla, really had to say. The AI generated transcript, later automatically sent to Hill, revealed more sinister intentions. When they thought the mic was off, Bonilla cried: “That dude sucked … the little coalition … they just want these people dead.” McNeil chimed in: “This group that wants to, like, lock people up and shit … [Drug dealers] might meet up with six people [in Harlem]. That honestly, is a positive outcome, because it’s a hell of a lot more efficient for everybody.” McNeil ended his discussion with Bonilla with an astonishing statement about recruiting future research subjects: “Let’s try to get some more interviews with people who suck. I want to find someone who we can give enough rope to hang themselves with.”13
Needless to say, Hill and his colleagues were appalled. “Casually using the phrase, ‘I want to find someone who we can give enough rope to hang themselves with’ in the context of finding future Harlem research subjects is profoundly disturbing with its echoes of the toxic history of lynching in this country,” they wrote on their website. They appealed to Yale directly for answers, and the university said it was investigating and pausing McNeil and Bonilla’s research for now.
No matter what happens to their research project, however, the notion of using drugs safely and applying extreme harm reduction measures is becoming more commonplace, while efforts to protect kids from drugs and advance recovery among users are frowned upon. At best, this reflects a desperate search for answers. At worst, it is fueling the flame of addiction to unprecedented levels.
Notes
1.
Mays, J. and Newman, A. (2021, November 30). Nation’s first supervised drug-injection sites open in New York.
The New York Times
,
https://www.nytimes.com/2021/11/30/nyregion/supervised-injection-sites-nyc.html
.
2.
New York City Department of Health (2023). Unintentional drug poisoning (overdose) deaths in New York City in 2022,
https://www.nyc.gov/assets/doh/downloads/pdf/epi/databrief137.pdf
.
3.
Mays and Newman, Nation’s first supervised drug-injection sites open in New York.
4.
National Institute on Drug Abuse (n.d.). Overdose prevention centers,
https://nida.nih.gov/sites/default/files/NIH-RTC-Overdose-Prevention-Centers.pdf
.
5.
McGinty, E., Barry, C., Stone, E. Niederdeppe, J., Kennedy-Hendricks, A., Linden, S., and Sherman, S. (2018). Public support for safe consumption sites and syringe services programs to combat the opioid epidemic.
Preventive Medicine
111: 73–7.
6.
Dandekar, A. (2022). Bipartisan majority of voters support harm reduction measures and decriminalizing small amounts of drug possession.
Data for Progress
,
https://www.dataforprogress.org/blog/2022/4/20/bipartisan-majority-of-voters-support-harm-reduction-measures-and-decriminalizing#:~:text=can%20be%20found-,here,-
.
7.
NJ Green Scene (n.d.). About,
https://njgreenscene.com/pages/about
.
8.
OnPoint preliminary data (2023, August),
https://docs.google.com/spreadsheets/d/1ucC2JpltDjyllinlH8DVp-0AMNcSGVfh142dLbJKXEk/edit?gid=254157546#gid=254157546
.
9.
Chalfin, A., Del Pozo, B., and Mitre-Becerril, D. (2023). Overdose prevention centers, crime, and disorder in New York City.
JAMA Network Open
6(11).
10.
Husock, H. (2023). Safe-injection sites and crime.
City Journal
,
https://www.city-journal.org/article/safe-injection-sites-crime
.
11.
Fordham Law News (2019, March 5). Does supervised injection make it safe?,
https://news.law.fordham.edu/blog/2019/03/05/does-supervised-injection-make-it-safe
.
12.
Lewis, C. (2021, December 17). A look inside NYC’s supervised drug-injection sites, the first in the nation.
Gothamist
,
https://gothamist.com/news/inside-nycs-supervised-drug-injection-sites-the-first-in-the-nation
.
13.
See
https://greaterharlem.nyc
.
1Yesterday in America: A Brief History of the Drug Wars
The notion of “safe” drug use – reducing the harm from using drugs, but not necessarily stopping, preventing, or treating addiction itself – is, in fact, nothing new. Indeed, the relatively short history of drug policy in the West can be summed up briefly, albeit somewhat simplistically, as a near constant back and forth between lax and strict approaches. The Harlem example above, a program promoting safer drug use rather than a drug-free policy, is an outgrowth of ideas dating back at least a couple of centuries.
Though the first federal narcotic law was passed in 1914, the contours of America’s relationship with drugs took shape long before then. In the nineteenth century, drugs like cocaine and opium were fully legal, with for-profit companies advertising and promoting their use. Like the pharmaceutical companies of the 1990s, the companies of the 1890s regularly advertised and pushed the use of their narcotics. Parke-Davis pharma, for example, devoted 237 of 240 pages of a publication to the virtues of coca and cocaine.1
Narcotics could also be found slipped into a variety of patent medicines (Abraham Lincoln was once thought to have unknowingly bought cough drops laced with opium, and others with coca).2 The industrial age brought on unprecedented stress and pressure that pushed some into addiction. Drugs were cheap and easily available. Some localities banned opium smoking, but this was rarely enforced. Opium dens – equivalent to today’s “supervised consumption sites” – flourished in major cities. Many doctors gave large amounts of drugs to individuals to “maintain” their habit. Leading drug policy historian David Courtwright notes that the “result of all this was a narcotic problem of considerable dimensions, with perhaps as many as 300,000 opiate addicts at the turn of the century, plus an unknown number of irregular users.”3 Though the coalition of progressive and puritanical Americans saw alcohol as their common enemy, resulting in the period known as Prohibition (which in any case was not full prohibition, as only sale, not use, was disallowed), narcotic drugs – used by Chinese laborers, white criminals, and upscale housewives alike – soon worried more Americans too, and pressure mounted for uniform federal legislation.
