West Virginia and Vancouver, Canada, could not be more different in their responses to the opioid crisis. In West Virginia, addiction treatment programs are in short supply, with waiting lists as long as a year, and many people can't access existing programs because they lack health insurance and are too poor to pay out of pocket. The state's most populous city, Charleston, has exactly one needle exchange program, after political opposition closed another one. Meanwhile, city, state and federal law enforcement officials regularly make arrests designed to cut the supply of drugs in West Virginia. Vancouver, by contrast, is in a country that provides universal health insurance and has much less economic inequality than the United States. The city offersa range of addiction treatment services, needle exchange programs, supervised drug consumption rooms and a clinic that prescribes heroin.
Yet both places have nearly identical rates of drug overdose deaths - 58 per 100,000 people for West Virginia and 55 per 100,000 people for Vancouver in 2017 - appalling numbers that are triple those the United States experienced at the height of the HIV/AIDS epidemic. How can we hope to stop this crisis if two utterly different drug policies still lead to the same result? The answer is that controls on both demand and supply are essential, and neither, by itself, is sufficient.
Vancouver, where activists recently marched through the streets calling for an end to drug-supply control, embodies a soft, demand-focused policy of abundant treatment and harm-reduction services. Two conservative former U.S. drug czars, William Bennett and John Walters,ridiculed this approach as akin to dealing with a cholera epidemic by giving antibiotics to the sick - but ignoring the bad water causing the disease. As part of the decades-long "war on drugs" philosophy, aspirations to expand health services and ameliorate social determinants of addiction are often mocked in this fashion, as well as underfunded and underappreciated. Status and resources flow instead to police and prison wardens.
Others are sympathetic to Vancouver's system, arguing that if the government just had the courage to get the cops out of the way and put the social welfare brigade in charge, we health professionals could turn the opioid epidemic around. The British Columbia Center for Disease Control's executive medical director, Mark Tyndall, recently expressed this view in explaining why he wants to make hydromorphone,a potent opioid that unlike heroin would offer consistent doses and content, available through clinics or vending machines in Vancouver: "It's a very novel idea and it actually goes against what the common narrative is, that there are too many of these drugs out there already and that's what's caused the problem." This demand- and harm-reduction camp holds that a massive expansion of health services would treat addicted people and reduce the ugly consequences of opioid use, such as violence, overdose and disease transmission.
Meanwhile, new social and economic policies would create a gentler, more equitable society; we could stop fretting about the availability of opioids, because absent the "root causes" - misery and alienation - fewer people would want to use drugs in the first place. Another Vancouver resident, Bruce Alexander, famously advocated this view after his "Rat Park" experiments showed that rats were less interested in taking opioids if they had richer social environments.
U.S. law enforcement organizations around the country have become more open to letting health and social welfare workers take a bigger role in drug policy. After years of making busts and sending hundreds of thousands of people to prison as drug epidemics worsened, police no longer believe they can reverse drug epidemics on their own. During my time in the White House Office of National Drug Control Policy, I got used to police chiefs telling me that what they really wanted was more addiction treatment. I didn't need to lecture them with cliches like "You can't arrest your way out of drug problems," because they had figured that out a long time ago.
Having rarely if ever been allowed to lead society's response to drug problems, physicians, social workers and counselors have been insulated from the humbling experience of impotence that law enforcement has endured. The closest that health and social welfare experts have come to running the show may be in Vancouver, which is precisely why bringing up its sky-high overdose rate is not met with gratitude in my circles. The usual reaction when I raise the awkward facts with my public health colleagues is shock and disbelief, coupled with the warning "that's a dangerous thing to bring up," as one professor whispered to me at a scientific conference panel.
My colleagues' not-unreasonable fear is that the similarity between Vancouver's and West Virginia's overdose rates would lead lawmakers and appropriators to conclude that social services are a waste of money. Some unimpeachable science demonstrates otherwise. For example, rigorous studies show that Food and Drug Administration-approved medications like methadone,buprenorphine and long-acting naltrexone save lives by replacing illicit opioids or blocking their highs. If West Virginia had more such services, its overdose rate would be lower; if Vancouver had fewer, its overdose rate would be higher.
But in both locales, the rates would remain high for an important reason that fantasy-prone members of the health and social welfare community shouldn't ignore: Both places are in countries that have been utterly flooded with opioids. Prescribing in the United States nearly quadrupled over a 15-year period beginning in the mid-1990s, and the only country that came anywhere near matching us was Canada. This was followed in both places by a second tidal wave, of heroin, much of it laced with fentanyl. We've repeatedly seen - Afghanistan in the aughts, Hong Kong in the 1950s, China under British imperial rule - that a rapidly rising supply of cheap, potent opioids leads to increased addiction and overdose rates. In short: Sometimes it's the drugs, stupid. Astonishingly, some health professionals still deny that the explosion of opioid prescribing was harmful, and they recommend distributing hydromorphone through vending machines and setting up heroin buyers clubs. They are ignoring the lessons of history.
Expanding health insurance and access to evidence-based treatment will indeed save lives, but health professionals are swimming up a waterfall if this isn't matched with strong drug supply control. That doesn't mean throwing addicted people in jail; it means reversing the over-prescription of opioids. The benefits of this tactic are clear elsewhere in Canada. Thanks to a long-established, careful prescribing culture among patients and doctors, Quebec has the lowest rate of high-dose oxycodone and morphine prescribing in the country - less than half that in Vancouver - and less than a quarter of its opioid overdose death rate. Sensible supply control also means using law enforcement and diplomacy to disrupt the international production and delivery of fentanyl both here and abroad.
Police can't arrest away the opioid epidemic, but without better drug supply control, health professionals can't treat it away, either.
Keith Humphreys
Keith Humphreys is a professor of psychiatry at Stanford University and is an affiliated faculty member at Stanford Law School and the Stanford Neurosciences Institute.