What do do about Opioids?

I went to a great event yesterday where a friend of mine brought together various non-profit leaders (and me) from around the community.  There were people leading non-profits working on homelessness, affordable housing, drug addiction, helping low-income college students, etc.  Probably the most interesting conversation I had was with a person leading a local non-profit working with people facing drug addiction and homelessness.  We bonded over our fandom of Keith Humphrey’s take on drug policy, which Humphreys expanded upon in a recent Ezra Klein podcast.  Here’s Claude’s summary of Humpheys’ views:

Some key points from Humphreys:

• Different drugs have very different properties in terms of addictiveness and effects. Making all “drugs” legal is not a panacea, as legal alcohol and tobacco still cause major societal problems.
• Oregon’s decriminalization effort saw a surge in overdoses and public disorder from open drug use. The promised treatment resources did not materialize as hoped. In 2023, Oregon restored some criminal penalties.
• Humphreys argues decriminalization advocates sometimes misunderstand the nature of addiction. Most addicts are ambivalent about treatment and only seek it under external pressure. Removing all pressure backfires.
• Elite drug culture celebrating psychedelics and recreational use doesn’t match the reality that most drug use, like cannabis, is very heavy daily use by lower-income less educated people. Policies need to account for this.
• Humphreys believes the right balance is: certain but modest criminal justice involvement (like 24 hour holds), combined with major investments in accessible treatment and harm reduction services. The goal should be pressuring addicts into recovery, not long-term incarceration.

In summary, Humphreys argues for a nuanced middle-ground between the drug war and full liberalization – smartly using criminal justice as a tool to guide addicts to a hugely expanded voluntary treatment system. But he says finding this balance is politically and culturally challenging.

What was particularly interesting to me, was how this person working on the front lines had very similar views that the “harm reduction” approach can go too far into a “drugs are just fine” approach, that, ultimately is harmful.  This morning I decided I was going to write a post on this today and then I pulled up the latest Freakonomics podcast for my morning run and who was the guest, but Keith Humphreys!  So, yeah, I really had to share this today.  Both of the podcasts are worth a listen and also offer full transcripts.  What I really liked in the Freakonomics episode was the emphasis on how effective certain, swift, and very modest punishment can be (swiftness and certainty are so much more important than severity in deterring behavior):

Humphreys himself has done some work on a program like this, for alcohol abuse; it’s called 24/7 Sobriety.

HUMPHREYS: It was invented by a county prosecutor named Larry Long. Remarkable guy. He was seeing people he grew up with, in a small town in South Dakota, cycling through the court over and over with alcohol problems. And he felt bad for them because he knew — you know, we threaten you, we take away your car, we throw you in jail. Nothing works. And he said, the problem isn’t driving; the problem is drinking.

24/7 Sobriety is a court-mandated program for people who’ve been arrested multiple times for drunk driving. It involves constant and frequent testing.

HUMPHREYS: Every morning, you have to come in, and you blow a breathalyzer. If it shows negative, you get immediate reward: “Have a great day, Keith.” You know, another day of freedom. If, on the other hand, it’s positive, there’s an immediate consequence: you’re arrested on the spot. Not maybe — certainly. And you are held in a cell for just one night. But it starts that night, immediate. Now you’d think in a way, a lot of these folks have been in prison, why would they care about one night in the jail system? It’s because it’s a swift and certain consequence. And all those other consequences in criminal justice are very probabilistic and distant. So when I heard about this program, I was in the Obama administration, I thought, “Oh, come on, half these people are going to show up drunk and the other half are going to be rampaging around the countryside.” And I went there the first morning, I remember this, in Sioux Falls, and watched 200 people go straight through — all 200 showed up, all 200 blew negative. In South Dakota now, they’ve done over 10 million tests, and the success rate — meaning, the proportion of times people show up and are not drinking — is 99.1 percent.

So, short version, we almost surely do need to use the criminal justice system to combat this problem, but we need to do it in a way that is all about swiftness and certainty, not severity of punishment.