The Drug Problem in the U.S. Is Not What We Think It Is

We have a drug problem in the country — an observation that presumably few would deny. Opioid abuse and addiction has been the subject of much hand wringing in the past two or three years, but the problem is much broader and deeper than that.

There are over 22 million individuals in the U.S who have a substance abuse problem (including alcohol). At any given moment, there are about 4.5 million individuals who have a substance use disorder due to the abuse of illicit and prescription drugs.

The public health consequences of substance abuse are staggering. There were over 70,000 drug overdose deaths in 2017, the majority due to opioids. This represents a doubling of drug related deaths in just 10 years.

The more extensive health and mental health consequences of drug abuse are equally troubling. For example, nearly eight million individuals have a co-occurring mental health and substance abuse disorder. All of this says nothing about the impacts on individuals, families and communities.

The economic consequences are just as stunning. Recent estimates put the crime, lost productivity and health care costs of abuse of alcohol, illicit drugs, and prescription opioids at over $500 billion annually.

The illicit drug economy is alive and well. Estimates indicate that Americans spend $100 billion annually on just four drugs — marijuana, cocaine, heroin and methamphetamine.

The Mexican cartels are one of the primary beneficiaries of this thriving market. The economics of the drug trade paint a compelling picture. A kilogram of cocaine from Colombia can be purchased for $2,000. Once the cartels move it to Mexico, that same kilo increases in value to $10,000. Once it crosses the U.S. border, its value jumps to $30,000. When it is broken down into grams and sold on the street, it can net $100,000. That is a 4,900 percent increase.

Since the 1970s, we have been waging a war on drugs. We have spent $1 trillion on this war and made 45 million drug arrests. The vast majority of drug law violation arrests are for possession (84 percent).

Today, nearly one-third of prison admissions are for a drug offense. Our go-to solution to the drug problem has been the criminal justice response and the intention has been to reduce the amount of drugs crossing the borders, and limiting what is distributed, sold and possessed. This effort has included a wide variety of federal, state and local law enforcement and intelligence gathering agencies.

Looking at U.S. drug policy — the relentless efforts to control the supply and availability of drugs — would lead one to conclude that the real drug problem here is that we have too many drugs.

I suggest that is the wrong conclusion. We have a drug problem not because there are too many drugs. We have a drug problem because there too many people who want to take drugs, in turn leading for many to abuse and substance use disorders. I argue that the real problem, which has remained essentially unaddressed, is excessive demand for drugs.

The opioid crisis is a good example of where our misplaced priorities have taken us. Our solution has mainly focused on a criminal justice response and imposing restrictions on prescriptions for opioids. What we have seen is that as prescription opioids become more difficult to obtain, there has been a migration to heroin and synthetic opioids, which are largely responsible for the increase in overdose deaths.

We saw a similar response when access to the precursors for the manufacture of methamphetamine was restricted. That did impact domestic production, which in turn opened up a new and very profitable market for the Mexican cartels. Demand drives supply.

If supply control sounds like prohibition of alcohol, that is because it is. And we get the same result. A quick and dirty metric of the effectiveness of our drug prohibition policies is the street level price of illicit drugs. All else equal, as supply declines and demand is constant, the price will increase. We have seen precisely the opposite.

It is time to raise the white flag, get honest about our failed attempts to effectively control supply, and turn our attention to serious efforts at demand reduction.

Until policy makers appreciate that addiction and substance abuse are medical disorders, something the American Medical Association declared in the 1950s, we will continue down this failed and very expensive path. After all, it would be medical malpractice to incarcerate someone for having diabetes or cancer. Why does it make sense to punish someone for a substance use disorder?

Addiction Essential Reads

Are There Racial Differences in Opioid Misuse Among Seniors?

Addicted to Food

Demand reduction has several facets, but the most important is effective treatment. Only a fraction of those with substance use disorders receive any treatment, either in the community or in the criminal justice system.

Much of the problem is an inadequate public health system that lacks capacity and funding for effective substance abuse treatment. A key word in that sentence is “effective.” Much of the substance abuse treatment that does exist is based on a 12-step model derived from Alcoholics Anonymous. While a 12-step program can be helpful for ongoing sobriety maintenance, it is not evidence-based treatment.

The clinical evidence is clear. We know what can effectively treat substance use disorders. What is needed is for policy makers to set aside politics and personal opinion, stop dumping the problem into the criminal justice system, and get to work solving one of the greatest public health crises in our history. We have the tools. What has been lacking is the political will.