Drug Addiction and Deaths
Trends in Drug Addiction and Deaths
Drug overdoses are today the number one cause of accidental death in the United States as a result of America’s historic addiction and overdose epidemic.
Overdose deaths rose from 17,415 in 2000 to 93,330 in 2020, a 536 percent increase.
The overdose crisis is worse in San Francisco than in most other cities. In Seattle, Phoenix, and Chicago, there were 23, 46, and 48 overdose deaths per every 100,000 people, in 2020. In San Francisco, there were 81. Overdose deaths rose from 196 in 2015 to 713 in 2020.
San Francisco gives away more needles to drug users, six million per year, than New York City, despite having one-tenth the population.
The number of opioid-using Americans who also used methamphetamine rose 83 percent between 2011 and 2017, from 18.8 percent to 34.2 percent.
Drug overdose is the leading cause of death among the homeless.
And about two-thirds of the time of hospital emergency departments in San Francisco is spent serving the homeless.
The number of adults who had ever used heroin rose fivefold from 2001–02 to 2012–13, to 3.8 million, found a study of nearly 80,000 people published in the Journal of the American Medical Association. The share suffering addiction rose threefold to 1.1 million.
The number of opioid-using Americans who also used methamphetamine rose 83 percent between 2011 and 2017, from 18.8 percent to 34.2 percent.
The estimated share of 18- to 25-year-olds suffering prescription opioid use disorder, or addiction, rose 37 percent from 2002 to 2014, and the odds of heroin use rose fourfold among adults ages 18–25 illicitly using prescription opioids, and ninefold among adults 26–34 illicitly using prescription opioids, over the same period. The National Survey on Drug Use and Health found heroin use disorder doubled between 2002 and 2019.
Researchers in 2017 estimated the cost of heroin addiction alone to be $51 billion annually, or $51,000 per heroin user, an amount calculated by looking at the loss of productivity from death or incarceration, as well as negative health effects associated with heroin.
In 2019, San Francisco has the fourth-highest drug overdose death rate of any major city in the United States. In 2020, 713 people died of accidental drug overdoses, a 61 percent increase from 2019. San Francisco’s overdose deaths rose from 11 per 100,000 people in 1985 to 81 per 100,000 in 2020, an over sevenfold increase. Today, drug overdoses are the leading cause of death for non-elderly San Franciscans, accounting for 29 percent of deaths of residents under sixty-five in 2019.
Today, many progressives advocate for the decriminalization of all drugs, including heroin, meth, and fentanyl. They propose that cities build special facilities where people can inject or smoke heroin, meth, and fentanyl.
The War on Drugs
Law enforcement has been unable to stem the tide of illicit drugs, despite intense efforts.
In the twenty-five years after 1980, cocaine prices fell by two-thirds, in inflation-adjusted terms, even though the number of people arrested and incarcerated increased tenfold.
From 1981 to 2012, heroin and meth prices in the United States declined 86 and 72 percent, respectively.
Since 2007, heroin street prices have hovered around $300 per gram, in constant 2017 dollars, while wholesale prices have declined from $84 to $53 per gram.
The price of meth fell from $10,000 per pound in 2010 to $1,200 to $1,400 per pound in 2019. Meth users in the Central Valley of California can buy two doses for as little as $2.50 to $5.50.
In 2014, California voters passed Proposition 47 to make three grams of hard drugs for personal use a misdemeanor instead of a felony. Proposition 47 also ended jail sentences for people convicted of many nuisance crimes, including possession of three grams of hard drugs and shoplifting under $950 worth of property.
In June 2020, San Francisco’s Board of Supervisors voted to allow nonprofits to operate supervised injection sites where people can use heroin and other hard drugs safely.
Portugal never legalized drugs. It only decriminalized them, reducing criminal penalties but maintaining prohibition. Drug dealers were still sent to prison even after the 2001 decriminalization. And Portugal does not let people addicted to hard drugs with behavioral disorders off the hook like progressive West Coast cities have done. It’s true that Portugal massively expanded drug treatment, but people are still arrested and fined for possession of heroin, meth, and other hard drugs. And drug users are typically sent to a regionally administered “Commissions for the Dissuasion of Drug Addiction,” composed of a social worker, lawyer, and doctor who encourage, push, and coerce drug treatment.
People are not dying from drug overdose deaths in San Francisco because they’re being arrested. They’re dying because they aren’t being arrested. Decriminalization reduces prices by lowering production and distribution costs, which increases use.
In Portugal, drug overdose deaths and overall drug use rose after decriminalization.
President Jimmy Carter in 1977 came out for the decriminalization of marijuana and for drug policies to not “be more damaging to an individual than the use of the drug itself.”
President Ronald Reagan increased the US government funding and focus on law enforcement responses to drug dealing. First Lady Nancy Reagan launched the “Just Say No” campaign urging children not to use drugs.
After the federal government put in place regulations to restrict pharmaceutical opioids, many users turned to heroin, which is far cheaper. A study of young, urban injection drug users in 2012 determined that 86 percent had taken opioid pain relievers nonmedically before using heroin.
Mass Incarceration
The US is home to less than 5 percent of the world’s population but has 25 percent of its prisoners.
There are 157,000 people in federal prisons and 1.4 million in state prisons.
47 percent of inmates in federal prisons are in for nonviolent drug convictions.
Only 3.7 percent of state prisoners are there for nonviolent drug possession. 14.1 percent are locked up for any nonviolent drug offense.
According to a 1997 national survey of state prisons, 20 percent of those serving time for drug charges said they had used a firearm in a previous crime, and 24 percent had a prior conviction for a violent crime.
Today, incarceration rates in the United States are at a thirty-year low. In 2019, the state and federal imprisonment rate of 419 prisoners per 100,000 US residents was the lowest it had been since 1995, and was a 17 percent decrease from 2009.
Of the people convicted of drug offenses, 62 percent never went to prison and one-third never went to prison or jail.
If everyone in prison whose top charge was a drug offense was released, the white percentage of all prisoners would rise one percent, the black percentage would fall one percent, and the Hispanic percentage would remain unchanged.
From 1990 to 2010, two-thirds of the increase in inmates nationwide came from people convicted of violent offenses. Some of those convicted of nonviolent offenses may also have committed violent acts, but had plea-bargained away.
America’s high incarceration rate of African Americans resulted in large measure from concerns among black Americans about rising crime and violence starting in the 1960s. By 1971, African Americans were two-thirds of all people arrested for homicide and robbery, despite being less than 10 percent of the population. In 1975, black people were murdered at a rate nearly seven times higher than white people.
The Congressional Black Caucus worked with then-senator Joe Biden, President Bill Clinton, and Senator Bernie Sanders to pass the 1994 crime bill.
Proposition 36, passed in a referendum in 2000, allowed drug drug treatment to be used in place of incarceration. The problem was that just 12 percent of Californians sentenced under Proposition 36 received inpatient care, which has been shown to be more effective than outpatient care.
Solutions
Research finds that mandated drug treatment through specialized “drug courts” aimed at addressing the underlying cause of crime, addiction, is effective in reducing drug use and recidivism, or repeat offending.
One study concluded that people sentenced through drug courts were two-thirds less likely to be rearrested than individuals prosecuted through the normal criminal justice system.
Another study found that a group of participants in drug courts had its rate of recidivism lowered from 50 percent to 38 percent.
Researchers estimated that every dollar allocated to drug courts saves approximately $4 in spending on incarceration and health care.
In five European cities, Amsterdam, Lisbon, Vienna, Frankfurt, and Zurich, police and social workers broke up open drug scenes by arresting dealers and ticketing addicts who use in public. Addicts who don’t pay their tickets, which is often, are offered mandatory drug treatment as an alternative to jail. This effectively ended open air drug scenes.
Contingency management is a treatment program based on giving clients rewards in exchange for making progress towards their goals, like abstinence, accepting treatment, or job seeking. Some rewards that have been implemented in contingency management programs include cash, gifts cards, and housing.
In a major recent review of the literature, out of 176 controlled studies, 151 of them, or 86 percent, found contingency management to be effective for treating addiction, with the average effect size ranging from moderate to large. Additionally, it significantly increased participation in therapy, a key component of addiction recovery.
Contingency management harnesses well-established psychological principles, which is likely why it works for such a wide number of people and such a large spectrum of drugs, including both opioids and stimulants. Contingency management is based on the psychological theory of operant conditioning. It emphasizes the need for concrete and immediate reinforcements, such as housing or a gift card, in exchange for good behavior, including abstinence, work, and compliance with psychiatric medicines. Contingency management swaps one set of rewards, such as meth and heroin, for another set of rewards, such as gift cards and apartment units.
Contingency management has been included in the National Registry of Evidence-Based Programs and Practices, adopted and implemented by the Department of Veterans Affairs, as well as by the governments and medical establishments of the United Kingdom, Brazil, and China. Hundreds of studies, meta-analyses, and reviews published in the world’s leading scientific journals conclude that contingency management works as well as, and often better than, any other drug treatment.
One concern is that people need internal motivation to stay abstinent and cannot depend on external reinforcements because once the external reinforcements are gone, their self-destructive behaviors will return. But there is evidence that external reinforcements build internal strength over time. And even if contingency management only kept people externally motivated, that might be okay, given the high cost to society of addiction and the cost savings from abstinence.
Cities should break up open drug scenes to make it harder for users to buy drugs and which will promote public safety and sanitation, and revive public spaces.
Cities and states should massively expand inpatient drug treatment so that rehab beds are available immediately to whoever needs them. The price of inpatient treatment should be subsidized and the length of the treatment increased so that care is affordable and so recovering addicts do not have to leave rehab right when their cravings are peaking.
Cities should implement contingency management when working with people suffering from substance abuse disorder.
California should create a new state agency dedicated to implementing solutions to the drug deaths, homelessness, and mental illness crises. Let’s call it Cal-Psych (“Psych” because a major component of the agency would be dedicated to universal psychiatric care.)
Cal-Psych would be based on the evidence-based approaches outlined above and centered around empowered caseworkers who have the tools they need to help their clients. Caseworkers would be able to track whether their clients entered rehab, relapsed, end up in jail, or lost their housing. These caseworkers would successfully help the downtrodden in ways the current system never will.