Criminalization is an outdated approach to the US addiction crisis
(And why now is the perfect time to change it)
The first time I heard the word prohibition was in eighth grade. The 18th amendment banned alcohol in 1918 in response to a sharp increase in use and the growing temperance movement. However, this 15-year experiment in criminalizing a recreational drug to curb its use proved to be ineffective. Although alcohol use declined within the first few years of Prohibition, this trend was short-lived. By 1921, three years into Prohibition, consumption began to rebound back to two-thirds of pre-Prohibition levels. Crucially, these new laws incited the development of a (often violent) black market for illegal substances and made previously legal activities grounds for incarceration.
What I didn’t learn in class that day was that prohibition still exists. The ban of alcohol was predated by the ban of opiates and cocaine through the Harrison Act of 1914, which, unlike prohibition, was never retracted. A century of criminalization later, the market for illegal drug trafficking still thrives. As substance abuse continues to claim hundreds of thousands of American lives. Since the year 2000, the National Center for Drug Abuse Statistics (NCDAS) has reported 700,000 drug overdose deaths. To this day, US policy remains committed to criminalization, spending 35 billion dollars on drug control in 2020 alone.
“A century of criminalization later, the market for illegal drug trafficking still thrives.”
→ What is addiction, really?
The US takes a punitive approach to drug use, based on the assumption that without legal consequences, addicts will simply be unable to control their physiological need for substances. This fear certainly isn’t unjustified. However, this narrative is reflective of a societal misunderstanding of what causes addiction
Until the early 2000s, the dominant narrative in the field of addiction research was that addictive drugs invariably alter brain chemistry. Psychological researcher and journalist Johann Hari uses the term “chemical hooks” to describe drug tolerance and dependence. The mesolimbic reward system comprises many of these mechanisms. Drugs bind with various cellular receptor systems, and these interactions work to increase extracellular concentrations of dopamine, which contributes to the rewarding and reinforcing effects of drugs.
Tolerance and dependence develop when the brain cells with receptors for a drug become less responsive to stimulation with repeated use. So, greater amounts of the drug become necessary to achieve the same reward effect.
This is all true. The ‘chemical hooks’ of addiction are physically devastating. It’s why medical supervision is typically necessary to cope with the agonizing side effects of withdrawal.
The problem with this narrative isn’t that it’s false — it’s just outdated and incomplete. The biopsychosocial explanation provides a great model for understanding the causes of any mental illness. Chemical hooks are the ‘bio’ part of this model. But what about psychological and social causes? Individuals suffering from substance abuse disorders face many barriers to societal reintegration. Criminalization policies focus on punishing offenders through legal charges and incarceration. Isolating addicts further from society actually puts them at a higher risk to continue using, as loneliness is a strong risk factor for addiction. Further, there are a number of barriers for recovering addicts to re-enter society. Studies have cited low levels of education and technical skills, weakened interpersonal skills, and societal stigma as obstacles to seeking employment and job security.
→ Portugal’s radical approach
As substance abuse issues became increasingly prevalent in the 1970s, the US waged the “War on Drugs” to fortify its putative approach to substance abuse. Meanwhile, other countries were grappling with the same issues: For example, 1 in every 100 people in Portugal suffered from heroin addiction by the late 80s. Unlike the US, however, Portugal eventually shifted its response to focus on rehabilitation instead of incarceration. What resulted from these two countries’ divergent strategies?
The peak of Portugal’s heroin crisis was marked by high rates of overdose and a sharp rise in incarceration. Then, in 2001, they flipped their approach completely: all drugs, including heroin and other opiates, were decriminalized. This decision was informed by a government advisory committee that recommended a more human-centered philosophy. After decades of increasing opioid use, limited public education, and violence under António Salazar’s authoritarian rule, leaders decided it was time to change their strategy.
Portugal expanded their harm-reduction practices, like the distribution of sterile syringes, hygiene materials, and prescribed buprenorphine and methadone for individuals using on the street. More importantly, Portugal refocused on the individual. Individuals suffering from addiction were treated by the legal system on a case-by-case basis. For example, when individuals were found using or possessing drugs, they might receive a small fine as opposed to incarceration and legal charges. More importantly, many were required to appear for a Dissuasion Commission. These local commissions of doctors, lawyers, and social workers helped individuals suffering from substance abuse disorders to access treatment and other support services. These services also implemented job referral programs to help remove barriers to re-employment for addicts. Portugal swapped legal punishment for societal reintegration and saw significant sustained results.
“Instead of enabling addicts and further increasing overdose rates, Portugal’s drug problem stabilized. “
Instead of enabling addicts and further increasing overdose rates, Portugal’s drug problem stabilized. By 2007, rates of continuation of drug use among adults, use among 15-24 year olds, and newly diagnosed cases of drug-related illnesses (e.g., HIV and AIDS among drug users) decreased substantially. By 2018, Portugal’s drug-related death rate dropped to five times lower than the EU average (and one-fiftieth of the US’s).
Portugal isn’t the only nation to successfully implement this kind of policy. Switzerland, amidst a similar rise in drug use, legalized heroin and saw a 50% decrease in overdose deaths between 1991 and 2010.
Now, let’s return to the biopsychosocial model. The success of psychological and societal support in drastically reducing negative health outcomes underlines psychological distress and isolation as crucial contributors to addiction and barriers to recovery. Portugal and Switzerland addressed the very real dangers of chemical hooks by including medical professionals on their commissions, but they also addressed how (logistically and socially) difficult it is for addicts to rejoin society when they are treated exclusively as criminals. When we punish addicts for substance abuse and throw them in jail rather than providing support, we increase the distress and isolation that drives so many to abuse drugs in the first place.
Where are we now?
Portugal and Switzerland’s successes were hugely influenced by a larger cultural shift towards de-stigmatization of substance abuse disorders and more willingness to support rather than punish addicts. Of course, their radical policy changes expedited this transition, but their societies were ready to make that change by the late 90/early 2000s–America was not. But we might be now.
And at 23 months into the covid-19 pandemic, none of us are strangers to psychological distress or social isolation. There’s been an overall increase in mental health problems, especially substance abuse. Within the first few months of the pandemic, the American Medical Association reported an 18% nationwide increase in overdoses. This has not changed—as of late 2021, 1,300 people still die every week from opioid-related overdoses.
However, this pandemic-adjacent mental health crisis has prompted much-needed change, both in policy-making and in our collective understanding of mental health problems. Now, everyone’s talking about it (re: “Zoom fatigue”), and, crucially, normalizing seeking treatment. While it’s disheartening that this change is a response to a nation-wide need for professional support, the shift indicates that perhaps the US is ready to approach the substance abuse conversation from a more empathetic standpoint.
“US outcomes are worsening, and structural changes to our mental health system are more urgent than ever.”
US outcomes are worsening, and structural changes to our mental health system are more urgent than ever. Whether the steps taken by other countries to decriminalize and/or legalize all drugs would be effective in the US is unclear given the vast historical differences in not only policy but cultural attitudes towards drugs and alcohol. Still, we can take advantage of a nationwide focus on mental health by taking small steps toward a support model rather than a punitive one.
Policymakers and the advocates who influence their decisions are in a position right now to allocate funds towards these small steps: harm reduction through the provision of safe drug use materials, social programs for treatment referrals, and awareness campaigns to build public support for a psychosocial approach. Many states have already legalized cannabis, and continuing to advocate for federal approval would allow decision makers and skeptical citizens to witness the outcomes of nationwide decriminalization for the first time.
US drug prohibition has not worked for over a century, yet it remains our primary strategy amidst a grave substance abuse epidemic. While fear of worsening the epidemic with decriminalization is understandable, psychosocial interventions have already been tremendously successful in other countries.
We are at a crucial transition in our cultural understanding of mental illness, which provides ample opportunity to leverage legal and public support for a new approach to mental healthcare. American society has seen firsthand that the psychological distress and social isolation of the pandemic has resulted in devastating substance abuse outcomes. We understand many common psychosocial causes for mental illness, like loneliness and isolation, in a way that we never have before. Now, we’ve all lived it. Now more than ever, it feels possible that this understanding could translate to structural changes that effect real and meaningful change for the millions of Americans whose lives have been touched by addiction.
Written by Cecilia Rabayda
Edited by Yuki Hebner and Zoe Guttman
Adinoff, B. (2004). Neurobiologic Processes in Drug Reward and Addiction. Harvard Review of Psychiatry, 12(6), 305–320. https://doi.org/10.1080/10673220490910844
American Civil Liberties Union. (n.d.). Against Drug Prohibition. Retrieved March 30, 2022, from https://www.aclu.org/other/against-drug-prohibition
Ashley Abramson. (2021). Substance use during the pandemic. American Psychological Association, 52(2). https://www.apa.org/monitor/2021/03/substance-use-pandemic
Claire Felter. (n.d.). The U.S. Opioid Epidemic (Backgrounder). Council on Foreign Relations. Retrieved March 30, 2022, from https://www.cfr.org/backgrounder/us-opioid-epidemic
Clinton, A.B. (2018, July). The Portuguese approach: Addiction, migration and education. Psychology International. https://www.apa.org/international/pi/2018/07/addiction-migration-education
Drug Policy Alliance. (2019). Drug Decriminalization in Portugal Learning from a Health and Human-Centered Approach. Drug Policy Alliance. https://drugpolicy.org/sites/default/files/dpa-drug-decriminalization-portugal-health-human-centered-approach_0.pdf
Drug Trafficking. (n.d.). United Nations : Office on Drugs and Crime. Retrieved March 30, 2022, from //www.unodc.org/unodc/en/drug-trafficking/index.html
Ferreira, S. (2017, December 5). Portugal’s radical drugs policy is working. Why hasn’t the world copied it? The Guardian. https://www.theguardian.com/news/2017/dec/05/portugals-radical-drugs-policy-is-working-why-hasnt-the-world-copied-it
Goldman, M. L., Druss, B. G., Horvitz-Lennon, M., Norquist, G. S., Kroeger Ptakowski, K., Brinkley, A., Greiner, M., Hayes, H., Hepburn, B., Jorgensen, S., Swartz, M. S., & Dixon, L. B. (2020). Mental Health Policy in the Era of COVID-19. Psychiatric Services (Washington, D.C.), 71(11), 1158–1162. https://doi.org/10.1176/appi.ps.202000219
Hari, J. (2015, June). Everything you think you know about addiction is wrong.
Hosseinbor, M., Yassini Ardekani, S. M., Bakhshani, S., & Bakhshani, S. (2014). Emotional and Social Loneliness in Individuals With and Without Substance Dependence Disorder. International Journal of High Risk Behaviors & Addiction, 3(3), e22688. https://doi.org/10.5812/ijhrba.22688
Jay Zagorsky. (2020, January 17). POV: The 100th Anniversary of Prohibition Reminds Us That Bans Rarely Work. Boston University. https://www.bu.edu/articles/2020/pov-the-100th-anniversary-of-prohibition-reminds-us-that-bans-rarely-work/
Kosten, T. R., & George, T. P. (2002). The Neurobiology of Opioid Dependence: Implications for Treatment. Science & Practice Perspectives, 1(1), 13–20.
Miriam Wolf & Michael Herzig. (2019, July 22). Inside Switzerland’s Radical Drug Policy Innovation (SSIR). Stanford Social Innovation Review. https://ssir.org/articles/entry/inside_switzerlands_radical_drug_policy_innovation
Miron, J. A., & Zwiebel, J. (1991). Alcohol Consumption During Prohibition (Working Paper No. 3675; Working Paper Series). National Bureau of Economic Research. https://doi.org/10.3386/w3675
Naina Bajekal. (2018, August 1). Want to Win the War on Drugs? Portugal Might Have the Answer. Time. https://time.com/longform/portugal-drug-use-decriminalization/
National Safety Council. (2021, March 29). Substance Use and Stigma: Considerations for Employers. https://www.nsc.org/safety-first/substance-use-and-stigma-considerations-for-employ
NCDAS: Substance Abuse and Addiction Statistics. (2022). NCDAS. https://drugabusestatistics.org/
Nuamah, J. K., Sasangohar, F., Erraguntla, M., & Mehta, R. K. (2019). The past, present and future of opioid withdrawal assessment: A scoping review of scales and technologies. BMC Medical Informatics and Decision Making, 19(1), 113. https://doi.org/10.1186/s12911-019-0834-8
Ramachandran, V. (2021, February 23). Stanford researchers identify four causes for ‘Zoom fatigue’ and their simple fixes. Stanford News. https://news.stanford.edu/2021/02/23/four-causes-zoom-fatigue-solutions/
Recovery Centers of America. (2020, January 31). How Loneliness Fuels Addiction. https://recoverycentersofamerica.com/blogs/how-loneliness-fuels-addiction/
Sigurdsson, S. O., Ring, B. M., O’Reilly, K., & Silverman, K. (2012). Barriers to Employment among Unemployed Drug Users: Age Predicts Severity. The American Journal of Drug and Alcohol Abuse, 38(6), 580–587. https://doi.org/10.3109/00952990.2011.643976
The success of Portugal’s decriminalisation policy – in seven charts. (2018, November 15). Transform: Drug Policy Foundation. https://transformdrugs.org/blog/the-success-of-portugals-decriminalisation-policy-in-seven-charts
Worsening mental health crisis pressures psychologist workforce: 2021 COVID-19 Practitioner Survey. (2021). American Psychological Association. https://www.apa.org/pubs/reports/practitioner/covid-19-2021