PROVIDENCE – Last year’s 7.3 percent decrease in our state’s drug overdose death rate is consistent with the rest of New England [the range of decrease in the other five states was from a low of 4.1 percent in Vermont to a high of 16.2 percent in Maine. The national death rate decreased by 3 percent].

We all fervently wish that 2023 marked a turning point. At the least, we hope that it will be a trend that continues.

The policy changes and initiatives that preceded the death-rate decrease indicate that we also have developed some individual, collective and systemic understandings.

We understand that the decrease is primarily due to the result of the collaborative work, effort and sacrifice of staff from recovery community organizations, recovery centers, treatment organizations, prevention organizations, community health organizations, governmental departments, academia, public health workers, and informed legislative allies.

We understand that the decrease is, at best, secondarily, the result of the present national drug policy.

We understand that given the amount of time, effort, thought and resources dedicated to dealing with the nation’s drug problem, last year’s decreased rates, although encouraging, seem minimal.

We also understand that the barriers and obstacles that must be overcome in order to attain even a single figure decrease affirms the complexity and the intransigence of our national drug problem, our national overdose death rate, and the addiction dynamic that drives them.

What will future generations understand?    
We understand why Anne Foster wrote that, “Future generations won’t understand how America could tolerate more than 100,000 overdose deaths a year, shattering families across the country, and the high rates of crime and homelessness that flow from addiction. It should be a national scandal that fewer than one-quarter of Americans with substance use disorder get actual treatment.”

• As the Surgeon General’s 2016 Report on Alcohol, Drugs, and Health stated, only 1 in 5 people who currently need treatment for an opioid use disorder actually received it, and that only 1 in 10 people who meet the criteria for a substance use disorder received any type of treatment.

We understand that although medication for opioid use disorder is demonstrably effective, the high barriers to treatment access – the misunderstanding, stigma, and over-regulation [especially with methadone maintenance treatment] still remain.

We understand that the meaningfulness of system responsiveness to a problem is best measured by its funding – and not by its aspirational and often performative policies and proclamations.

Following the flow of money    
 The 2025 proposed budget from the Office of National Drug Control [ONDC] is $44.5 billion. 

•    Treatment, Prevention, and Recovery received $25 billion: $22 billion for treatment; and $3 billion for prevention and recovery.
•    In comparison, law enforcement received $19 billion, which included $8.7 billion to Homeland Security and the Department of Justice; $4 billion to the Bureau of Prisons, and $3.3 billion to the Drug Enforcement Agency.

We understand that every dollar that is spent on law enforcement is a dollar that is not spent on prevention, treatment, or recovery.

We understand that while the policing and the supply-side-control policy [eradication, interdiction, prosecution, and incarceration], with the goal of use reduction, has never fully worked, but it has also never lost its appeal.

We are able to control the legal production and consumption of alcohol, tobacco, and medical market marijuana. However, since 1971, our drug control policy has cost us more than $1 trillion – and the result has been increased drug availability, addiction, incarceration and fatalities.

We understand Gabriel Mate’s accurate characterization of our problematic drug policy:

•    “When we create a system where you ostracize and marginalize and criminalize people, and force them to live in poverty with disease, you are basically guaranteeing they will stay at it.”

Mark Kleiman has written that the goal of drug policy ought to be to minimize the aggregate damage created by drug taking, drug trafficking, and the enforcement effort. That is, we ought to judge drug control efforts as we judge other public policies – by their results in producing benefits or avoiding harm to individuals or institutions.

The major barrier to more effective drug-control policies is that effectiveness, measured in terms of damage control, has not been at the center of policy-making in this arena.

We understand the observation of Leo Beletsky and Corey Davis that we are subject to the unintended but predictable impact of supply-side interventions on the dynamics of illicit drug markets.

Under the “Iron Law of Prohibition,” crackdowns and prohibitions produce economic and logistical pressures that lead to the rise of more potent forms of drugs.

In other words, due to the illegality of drugs, dealers have incentives to produce drugs in more powerful and concentrated forms that are more profitable because they require less storage space, they can be sold for higher prices, and they weigh less in transportation.

From the predominance of more potent liquor over beer and wine during alcohol’s prohibition to today’s fentanyl crisis, the outcome is nearly always the same: it creates harm production on a massive scale.

We understand that the initial acceptance of harm reduction principles and practices at the national and state level has saved lives, and that it is the most cost-effective, achievable, and pragmatic way of managing our overdose death crisis.

We understand the fact that “harm reduction” services are delivered most effectively by people who have lived experience.

Investing in harm reduction.  
We understand that this acceptance of harm reduction may be the start of a societal shift in our attitude/assumptions about people who use drugs – from a stereotype of depraved, immoral people to an understanding that they are human beings whose lives have value.

Despite our knowledge that “harm reduction” philosophy, strategies and practices save lives, the national budget to support such programs is almost an afterthought.

While the 2024 National Drug Control Strategy lists “Expanding Access to Evidence-Based Harm Reduction Strategies” as a primary element, the proposed $44.5 billion 2025 ONDC Budget earmarks only $460 million for harm reduction strategies and interventions 

We understand that a primary cause of our national drug problem, of our national overdose death rate, and of the addiction dynamic that drives them is that we are a nation that loves our drugs and have been living in what Benjamin Fong calls the “21^st century binge.”

The old slogan of the Dupont Company, “Better things for better living…through chemistry,” seems to have been societally internalized:

•    25 percent of Americans [70 million people] admitted to using illicit drugs in 2022. Almost 50 percent of Americans who are 12 or older admitted they used illegal drugs in their lifetime.
•    In 2022 Rhode Island ranked 4^th in the nation in cocaine use, 8^th in the nation in “alcohol abuse” and 11^th in marijuana use.
•    We nationally spend $500 billion a year on pharmaceuticals, and $150 billion on illegal drugs. By contrast, in 2023, we spent $580 billion on new cars, and $58 billion on washing machines.

This spending is not a new development. In 1988, we spent over $60 billion on 400 tons of cocaine. At 4 percent of world’s population, we consume 80 percent of its opioids, including 99 percent of its hydrocodone.

Smoke, smoke, smoke that cigarette    
We understand that our national drug problem is not even close to just being about opioids.

In 2022, over 105,000 Americans died from alcohol-related deaths.

In 2021, an estimated 28 million people still smoked cigarettes, and there were over 447,000 smoking-attributable deaths. That is more deaths than those caused by AIDS, alcohol, illegal drugs, homicides and suicides combined. The tobacco companies spent over $8 billion dollars marketing their products.

According to the Campaign for Tobacco Free kids, 1,800 Rhode Islanders die every year from smoking. The $27 million spent marketing cigarettes in our state directly results in an annual health care cost of $744 million.

As Robert Proctor has noted: Cigarettes are “the only consumer product that kills when used as directed.”

We understand that the underpinnings of addiction are, at least, biological, chemical, neurological, psychological, medical, emotional, social, political, economic, and spiritual. 

The permutations and interactions of these elements result in a condition that is far too complex to be addressed simply by a shifting policy that reflects our decades long conflict between proponents of prohibition versus proponents of legalization.

Prevention, treatment and recovery are all necessary but are not sufficient. Control and regulation of alcohol and other drugs is necessary but not sufficient.

We understand that our drug problem can no longer be dealt with by drug policy alone.

Good jobs, better health care    
We understand why Benjamin Fong [among many others] observed that the problems related to drugs in our state and our nation are a function of the more fundamental problem of social and economic inequality and alienation, two especially salient social determinants of health.

Fong asserts that two particular improvements that would transform our drug consumption are “good jobs” and “improvements in America’s disastrous health care system.”

That seems like a reasonable and obvious starting point.

Ian Knowles is a frequent contributor to ConvergenceRI and a long-time member of the recovery community in Rhode Island.