A lot has been written about the current crisis of opioid addiction and overdose, which is now the leading cause of death for Americans under 50. Even if this dramatic development affects almost solely North America, there are many parallels to situations that other countries have experienced, and the solutions developed there can also help in the current crisis.
When we were the presidents of our respective countries, Switzerland and Portugal, they were in the grip of serious heroin epidemics. In the early ’90s, Switzerland had the biggest open drug scene in Europe and the region’s highest HIV transmission rate due to needle sharing. Thousands a day frequented the infamous “needle park” in Zurich to buy and inject heroin. In the late 1990s, Portugal was facing one of the highest prevalence rates for problematic drug use, in particular heroin.
But Switzerland and Portugal dramatically changed their drug policies respectively in 1994 and 2001, marking a turning point for the two countries and a milestone in international drug policy. Switzerland and Portugal now focus on reducing the harms of drug use ― on keeping people alive.
In Switzerland, we offered access to opioid substitution therapy (OST), mainly through methadone and buprenorphine but also medical heroin, and substance analysis (drug checking). We also created supervised injection facilities, in which no one has died from an overdose to date. We introduced a balanced four-pillar strategy with similar focus on prevention, treatment, repression and harm reduction.
Portugal embraced a harm reduction approach as well. The new measures still consider drugs illegal but no longer seek to reduce demand by punishing users. Drug consumption and the possession of small quantities are treated as a public health issue, not as a criminal offense, so that people in need of health and social services can access them freely and without fear of being jailed.
The results are in. Drug-related deaths have been reduced by 50 percent and HIV prevalence has dropped. Positive outcomes go beyond those health-related, however. For example, property crime committed by people who use drugs is reduced as well – by 90 percent for those enrolled in OST. While there was opposition at first, these policies now enjoy popular support. In Switzerland, referendum votes on the four-pillar approach have repeatedly succeeded.
Reactions to the opioid crisis, however, so far indicate that U.S. leadership is still hesitating to take actions that have proven so effective in our countries and others around the world. There is a focus on reverting overdoses with naloxone and on expanding treatment, including OST – which, at the moment, is available in fewer than 10 percent of treatment centers in the U.S. ― and these are very welcome steps. But it is crucial to highlight that not everyone who is addicted to opioids is ready, physically and psychologically, to enter treatment. Other harm reduction measures that have helped save the lives of thousands are also necessary, particularly needle and syringe programs, supervised injection facilities, drug checking and heroin-assisted treatment for those who do not respond medically to methadone.
Furthermore, while better training for prescribers is essential, it is also necessary to address the wider issues of perverse incentives and problematic relationships which doctors in the U.S. health system have with pharmaceutical companies. This situation, as well as the fact that advertising medicines to consumers is allowed in the U.S., has contributed to this crisis by exponentially expanding the supply of prescription opioids.
Adopting and quickly scaling up the full range of harm reduction approaches would help curb opioid-related mortality in the United States. But it would not address the root causes, as pointed out in the position paper published early October by the Global Commission on Drug Policy, of which we are both members. “Deaths of despair” has become a buzzword, but whether and how efforts will be made to address the economic upheaval, unemployment, inequality and other systemic problems that underpin the opioid crisis seems to be unclear.
There is another factor, however, that is crystal clear. The initial response by authorities has focused on reducing the supply of prescription opioids without first putting supporting measures in place. This has led an important minority of those dependent on them to turn to street heroin, which has increasingly been cut with fentanyl, a very concentrated synthetic opioid. It is cheaper to make, about 50 times more potent per gram than morphine, and therefore also easier to hide and transport.
Its arrival on the illegal market is a clear demonstration of the “iron law of prohibition”: substances become more concentrated and more dangerous under repressive policies. The same forces were at play under prohibition in the 1920s and 1930s: When alcohol was illegal, high-proof distilled spirits became the bootleggers’ product of choice instead of beer and wine. Deaths in which fentanyl has played a role have risen from 3,000 only three years ago to more than 20,000 deaths last year. The substance displacement toward more harmful substances has to stop.
The Global Commission on Drug Policy argues the most effective way to reduce the harms of both drugs and current drug control policies is to get drugs under control through responsible legal regulation. Different drugs need careful legal regulation according to their potential harms. The way prescription opioids have been handled until recently is an illustration of precisely where a substance was legally available but was not regulated according to its potential harms – in this case, too loosely.
In contrast, studies suggest that a substance that was, and for the most part still is, illegal has helped decrease harm. States with access to medical marijuana have 25 percent lower opioid addiction and overdose rates. In these states, each doctor writes 1,800 fewer annual opioid prescriptions.
What is therefore needed is a balanced legal regulation of drugs. In the meantime, what can be done to immediately curb overdose deaths is well-known. It is time for the U.S. to act and provide its citizens with the full range of treatment and harm reduction services.