A New Study Adds to the Evidence That Drug Busts Result in More Overdose Deaths
The researchers found that drug seizures in San Francisco were associated with a substantial increase in fatal opioid overdoses.
Prohibition makes drug use more dangerous by creating a black market in which quality and potency are highly variable and unpredictable. Ramped-up enforcement of prohibition magnifies that problem, as dramatically demonstrated by the deadly impact of restricting access to pain medication at the same time that illicit fentanyl was proliferating as a heroin booster and substitute. That sort of perverse effect pervades drug law enforcement, as illustrated by a new study that found drug seizures in San Francisco were associated with a substantial increase in overdose risk.
The study included 2,653 drug seizures and 1,833 opioid-related deaths from 2020 to 2023. "Within the surrounding 100, 250, and 500 meters," RTI International researcher Alex H. Kral and his two co-authors reported in JAMA Network Open on Wednesday, "drug seizures were associated with a statistically significant increase in the relative risk for fatal opioid overdoses."
That is not the result that local authorities expected. "Since fentanyl entered the unregulated drug supply in San Francisco, California, around 2019, overdose mortality rates have reached record highs," Kral et al. note. "This has sparked increased enforcement of drug laws."
In December 2021, then-Mayor London Breed "declared a state of emergency in the Tenderloin neighborhood of San Francisco to enable 'more coordinated enforcement and disruption of illegal activities.'" District Attorney Brooke Jenkins, who took office in July 2022, "made combatting open-air drug markets and holding drug dealers accountable a top priority of her administration," her office brags. In May 2023, Kral et al. note, Gov. Gavin Newsom "authorized the assignment of California Highway Patrol and California National Guard personnel to a new multiagency operation with the San Francisco Police Department aimed at 'targeting fentanyl trafficking, disrupting the supply of the deadly drug in the city, and holding the operators of drug trafficking rings accountable.'"
How did all of that work out? The day after cops busted drug dealers, Kral et al. found, the risk of fatal overdoses rose by 74 percent, on average, within 100 meters. The increase in risk persisted for as long as a week, falling to 55 percent after two days, 45 percent after three days, and 27 percent after seven days. That pattern reinforces the conclusion that these police interventions, which aimed to reduce drug-related deaths, had the opposite effect.
Why? When regular opioid users are cut off from their usual suppliers and begin "experiencing withdrawal symptoms," Kral et al. note, "many will go to great lengths to urgently procure and use opioids to stave off these symptoms." They may therefore be less cautious, even as they are forced to rely on unfamiliar dealers whose products may be less reliable or more potent.
Based on interviews with 51 drug users, a study published by the International Journal of Drug Policy in 2020 concluded that "interpersonal relationships between individuals who use drugs and their suppliers strongly influence the risk and protective factors experienced by people who use drugs." Many of the subjects "indicated that long-term relationships with trusted dealers represent a key strategy" for reducing drug-related risk. They cited those dealers' "alleged adoption of consumer protection strategies," such as "refusing to sell fentanyl," and "quality assurance measures," such as "testing batches of drugs for fentanyl prior to sale."
Since disrupting local drug markets interferes with these relationships, it tends to increase drug risks. As a result of drug busts, the Cato Institute's Jeffrey Singer suggests, "people who use drugs in those neighborhoods had to turn to unfamiliar and potentially less trustworthy suppliers. Without an established relationship, they couldn't be certain about the strength or purity of the drugs they purchased." He adds that "disruptions caused by the seizures may have compelled dealers to alter their supply chains, leading them to change formulations or adjust doses." Both of those factors, he says, "could contribute to an increase in overdoses following drug enforcement actions."
Kral et al.'s findings are consistent with the results of a study that the American Journal of Public Health published in 2023. As Reason's Elizabeth Nolan Brown noted at the time, the authors of that study found that drug seizures in Marion County, Indiana, were associated with increased overdoses in their vicinity. The researchers concluded that "supply-side enforcement interventions and drug policies should be further explored to determine whether they exacerbate an ongoing overdose epidemic and negatively affect the nation's life expectancy."
Kral et al. reach similar conclusions. "The findings of this cross-sectional study suggest that the enforcement of drug distribution laws to increase public safety for residents in San Francisco may be having an unintended negative consequence of increasing opioid overdose mortality," they write. "To reduce overdose mortality, it may be better to focus on evidence-based health policies and interventions."
The alternatives that Kral et al. mention include "medications for opioid use disorder" (MOUD), which replace iffy street drugs with reliably dosed buprenorphine or methadone. For people who stick with it, MOUD—also known as "medication-assisted treatment" (MAT)—substantially decreases overdose risk. According to a 2019 review of the evidence published by the National Academies of Sciences, Engineering, and Medicine, opioid users are "up to 50 percent less likely to die when they are being treated long term with methadone or buprenorphine."
Although buprenorphine and methadone currently are the only drugs approved for MAT in the United States, there are other possibilities. Kral et al. note that "randomized clinical trials have shown that providing a regulated supply of diacetylmorphine (the active ingredient in heroin) to people dependent upon opioids is a more effective way to retain people in treatment and to reduce their involvement in illicit drug use and other criminal activities than standard methadone treatment."
Kral et al. also mention supervised drug consumption sites, which offer a safe setting where clean injection equipment and medical assistance are available, and Portugese-style decriminalization, which "brought down overdose mortality and HIV rates in Portugal without raising crime rates." While both of those approaches can reduce drug-related harm, they do not directly address the hazards inherent in consuming black-market drugs of uncertain composition.
That problem was illustrated by what happened after Oregon decriminalized low-level drug possession in 2020. Although voters approved that reform by a 17-point margin, public opinion soon turned against decriminalization, and state legislators restored criminal penalties for drug possession last year, largely because overdose deaths in Oregon were still rising. But that was not surprising, because decriminalization did not make black-market drugs any safer.
In particular, decriminalization did not address the proliferation of illicit fentanyl, which made potency even less predictable, increasing the risk of lethal dosing errors. That hazard emerged in Western states like Oregon relatively late, which explains the overdose trends that opponents of decriminalization cited as evidence that the policy had been a failure. The problem was not that decriminalization went too far; it was that decriminalization did not go far enough.
The central danger that prohibition poses to drug users (aside from the risk of arrest and incarceration) is that they typically do not know exactly what they are consuming. That danger will persist as long as politicians insist on dictating which psychoactive substances people may consume. Attempts to enforce those pharmacological prejudices cannot resolve this situation, but they can always make it worse.
