A Record Number of Drug-Related Deaths Illustrates the Lethal Consequences of Prohibition

The war on drugs is not just ineffective; it exacerbates the problems it is supposed to alleviate.

The United States saw a record number of drug-related deaths in 2020. The total exceeded 93,000, which was up 29 percent from 2019, according to the latest estimates from the Centers for Disease Control and Prevention (CDC). The 2020 spike—the largest ever recorded—was largely attributable to the COVID-19 pandemic and the legal restrictions it provoked. But drug-related deaths already were rising before anyone had heard of the coronavirus, not just despite but also because of the government's efforts to prevent people from using psychoactive substances.

The new CDC numbers confirm the folly of relying on supply control measures to reduce drug fatalities. Those policies are based on the premise that drug availability by itself causes drug-related deaths, which is clearly not true in light of the social, economic, and psychological factors that plausibly explain last year's surge. In any case, attacking production and distribution through legal restrictions, interdiction, seizures, and arrests rarely has a significant or lasting impact on prices or availability. Worse, those interventions drive substitutions that make drug use deadlier, as illustrated by the rise of illicit fentanyl and the crackdown on prescription pain medication, which accelerated the upward trend in opioid-related deaths.

Three-quarters of the drug-related deaths that the CDC is projecting for 2020 involved opioids, and the vast majority of those (about 83 percent) involved "synthetic opioids other than methadone," the category that includes fentanyl and its analogs. The total number of opioid-related deaths has more than tripled since 2010, while the share involving synthetic opioids has nearly sextupled. Those two developments are clearly related, because fentanyl is much more potent than heroin, which means that using it as a heroin booster or substitute makes the composition of black-market opioids more variable and unpredictable, increasing the chances of lethal errors.

Nowadays fentanyl is showing up in black-market pills sold as hydrocodone or oxycodone and even in stimulants such as cocaine and methamphetamine. Its proliferation is a response to the very supply control measures that were supposed to reduce drug-related deaths. To the extent that the government succeeds in exerting pressure on the supply of illegal intoxicants, it encourages traffickers to distribute more-potent drugs, which are easier to conceal and smuggle.

Since fentanyl is far more potent than heroin, a package weighing less than an ounce can replace one that weighs a couple of pounds. Synthesizing opioids is also a less vulnerable and much cheaper process than production that relies on poppy crops. Researchers at the RAND Corporation estimate that heroin is at least 100 times as expensive to produce as fentanyl, adjusting for potency.

Black-market drugs were already iffy because of prohibition; the prohibition-driven rise of fentanyl has made them even more of a crap shoot. And these are the substitutes nonmedical opioid users resorted to after drug warriors succeeded in driving down prescriptions of analgesics such as hydrocodone and oxycodone. That shift replaced legally produced, reliably dosed pharmaceuticals with illegal drugs of unknown provenance and composition. The result was predictable (and was in fact predicted): As opioid prescriptions fell, opioid-related deaths rose.

The New York Times story about the surge in drug-related deaths glides over this perverse policy. The paper acknowledges that social distancing requirements and recommendations may have backfired during the pandemic, making people not just more inclined to use drugs but also more likely to do so on their own, meaning that no one was around to help if they ran into trouble. But when it comes to restrictions on pain pills, the Times merely notes that Congress passed legislation "meant to reduce the death toll by limiting overuse of prescription drugs." How did that work out? Not so well, as you can surmise from the numbers the Times is discussing.

"The combined pressures of the COVID-19 pandemic, an increasingly toxic illicit drug supply, and an overwhelmed and under-resourced public health system have driven the overdose epidemic to catastrophic levels," Daliah Heller, director of drug use initiatives at Vital Strategies, says in a press release. "These data are an urgent call to action for federal, state, and local governments: we need to mount a massive public health response to overdose that emphasizes harm reduction and support instead of punishment for people who use drugs. We need to prioritize a community-based response that includes syringe service programs, naloxone distribution, medications for opioid use disorder, and mobile outreach. It is time we stop investing in strategies that stigmatize and punish people for using drugs."

I question the medicalization of human behavior implicit in the term epidemic, and I am skeptical about the cost-effectiveness of whatever "massive public health response" politicians might settle on. But I agree with the general proposition that harm reduction is preferable to the current approach, which is more like harm maximization.

Harm reduction recognizes that drug-related deaths are not a simple function of drug use or addiction. Between 2002 and 2019, according to the federal government's survey data, the number of Americans who had a "substance use disorder" involving heroin roughly doubled. During that same period, according to the CDC's data, the annual number of heroin-related deaths septupled, while the total number of opioid-related deaths quadrupled. The war on drugs helps account for that disparity, since it has made opioid use more dangerous in the ways I've just described, which suggests that repealing prohibition would be the single most effective harm reduction strategy.

But it also seems likely that drug mixtures, which account for the vast majority of so-called overdoses, have become more common, more reckless, or both. To understand why that might be, you have to consider the conditions that encourage people to seek oblivion even at the potential cost of their lives. Someone who dies after consuming a dangerous combination of drugs may not be deliberately killing himself, but the fact that he accepts the possibility of that outcome suggests that his life lacks the rewards that would deter most people from taking such a chance. The factors that can lead people to that dark place include unemployment, financial insecurity, emotional stress, social isolation, and disengagement from meaningful activities.

The pandemic amplified those problems, but it did not create them. A 2019 Joint Economic Committee report on "deaths of despair" noted that "drug-related deaths have been rising since the late 1950s." Reversing that trend is no simple matter, since it depends on public policies and private initiatives that replace despair with hope. But one thing should be clear by now: Attacking drug-related deaths of despair by attacking drugs only makes a bad situation worse.