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What science says works in addressing overdose and substance use — and what doesn’t | COMMENTARY

Sociologist Nuno Capaz serves on a health commission in Portugal, where officials decriminalized drugs in 2001. in this 2018 photo, Capaz talked about the policies at Roosevelt University and what the U.S. can learn from them.
Sociologist Nuno Capaz serves on a health commission in Portugal, where officials decriminalized drugs in 2001. in this 2018 photo, Capaz talked about the policies at Roosevelt University and what the U.S. can learn from them. (Alex Garcia, Chicago Tribune)

Following Baltimore City State’s Attorney Marilyn Mosby’s recent announcement that she will no longer prosecute drug possession, there has been a great deal of debate in The Baltimore Sun about how society should grapple with the persistent and escalating public health crisis of substance use and overdose. As public health researchers, we welcome these discussions as an opportunity to critically evaluate the available data and guide evidence-based policy decisions that could save lives. Unfortunately, some of the claims made in letters to the editor and elsewhere are not grounded in scientific evidence, and risk ignoring historical and contemporary lessons from the U.S. and beyond.

The claim that arresting “addicted” people saves lives by keeping them away from the drug supply may seem intuitive, but it has been consistently refuted. First, this argument presumes that people fall into a binary categorization of being addicted or not, whereas the research with people who use drugs shows they exist on a continuum ranging from sporadic, recreation and non-problematic use to serious substance use disorders that harm their health. There are numerous evidence-based interventions along this spectrum that can prevent progression to more dangerous patterns of use, but arrest and incarceration are not among them. There is no statistically significant relationship between a state’s drug imprisonment rate and drug use or overdose deaths among its population. Arrests for drug possession have more than tripled since 1980, but there has been no commensurate decrease in overdoses. On the contrary, data illustrate that arrest and incarceration escalate rather than reduce risk of overdose and other harms.

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Arrest and the subsequent legal process that is triggered — including booking, bail hearings, jail time, incarceration, parole and probation — collectively incur financial, health and social costs to people who use drugs, as well as their families. This further entrenches low-income groups in poverty and debt, and interrupts access to housing and employment, all of which are shown to increase the risk of overdose and other drug-related harms. Those who can make bail are released after a short time and thereby not “kept away from the drug supply,” and those who are incarcerated face substantially worse health outcomes. Mental health services and treatment and highly effective medication for opioid use disorder can be more difficult to access in jails and prisons; in Maryland, the crisis of unmet mental health needs during incarceration has received national attention. And critically, evidence shows that people leaving prison substantially increase their substance use and have significantly greater risk of fatal overdose. A study of over 30,000 recently released individuals found overdose was the leading cause of death among them.

There are also indirect ways arresting people who use drugs can exacerbate this crisis. Data from the U.S. and abroad show that fear of police leads to reluctance to call 911 during an overdose, increasing the likelihood that it becomes fatal, and reluctance to use or carry sterile syringes, increasing risk of HIV and other infections. Concerns about arrest can also lead to rushed drug use, which increases the chance of overdose, particularly in the context of a changing and increasingly potent drug supply.

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The evidence therefore suggests that the status quo — criminalizing drug possession — is ineffective (at best) at reducing drug-related harms. But is there evidence that decriminalization is a workable and effective alternative?

Data from the European Union is indeed promising. Portugal in particular has gained international attention for its reversal of a catastrophic drug-related public health crisis, in part using this method.

In the late 1990s, Portugal had among the highest rate of injection-related HIV and AIDS in the EU, and overdose rates were soaring. The public cited drug-related issues as the main social problem in the country. In 2001, the country decriminalized the possession and consumption of illicit drugs. In the years that followed, HIV transmission and overdose declined among people who use drugs by more than 80%. Injection became a less common route of drug administration, and voluntary entry into treatment increased. Portugal’s drug-related mortality is now among the lowest in EU. The success cannot be attributed wholly to one policy; rather, it represented a broad effort to route people away from the criminal legal system and into the public health system. Nonetheless, decriminalization was a crucial part of the equation.

In a city that has long suffered the consequences of substance use and crime crises alike, community concern about how best to approach these issues is completely understandable. However, the people of Baltimore have also acutely suffered the consequences of systemic racism, mass incarceration and police violence and overreach, for which drug laws have notoriously been a vehicle. Decriminalizing drug possession offers an opportunity to adopt a public health approach to substance use and mental health issues in our communities, one that doesn’t actively increase overdose risk and disproportionately punish people of color. It will likely need to be accompanied by robust wraparound health and social services to attend to the multiple needs of those in question. If even a fraction of the $300 million Maryland taxpayers spend on incarcerating residents of Baltimore City annually were used to scale up access to such services, we could have the chance to truly test the impact of a comprehensive public health approach to substance use here in Baltimore.

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Saba Rouhani (srouhan1@jhu.edu) is an assistant scientist and Susan G. Sherman (ssherman@jhu.edu) a professor in the Department of Health, Behavior and Society at Johns Hopkins Bloomberg School of Public Health.

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