The 50-year-old policy of the "war on drugs" must now be declared a failure. Every measurable outcome is worse, despite all the time, money and effort spent: more drug users, more trauma, more deaths, more imprisonment, increased health care costs, adverse impacts on neighborhoods and destruction of families.
The murder rate in Baltimore City and the region continues at historic high levels. Changes to law enforcement are being considered, but the issue cannot be dealt with until the connection of violence and drugs is addressed head-on.
Violence originates from three major causes: illegal drug trade, domestic abuse and mental illness. Of these, the drug wars are at the root of most violence, and their impact spills over onto the other two.
My perspective comes from my 35 years as an emergency medicine physician.
Begin by looking at the role of money in the drug trade. Estimates are that there are over 30,000 daily illicit drug users in the greater Baltimore region. Maintaining that habit averages $50 a day (a range is $10-$100), so over $1.5 million is spent daily just to buy illegal drugs. Statewide, Marylanders are spending over $1 billion per year on illegal drugs. One patient — a former drug kingpin — revealed to me that he was making "$25,000 a week, tax-free," and that was in 1990 dollars.
Where does all this money come from? My patients tell me their drug money comes from legitimate work, then petty crime, prostitution, major crime, and almost always drug dealing. Substance users develop addiction in others to maintain their own habits with the marginal profit from selling to others. Addiction breeds addiction, so every time a person gets treatment, the spread of addiction is reduced.
Where does all this money go? Much of it goes to overseas drug cartels and terrorist organizations.
Our current policies are destroying our society from the inside while shipping vast sums to those who would destroy us from the outside.
It's time to consider new approaches.
Think of substance abuse as a chronic disease, with stable periods and relapses, as is done for diabetes, asthma or cancer. Treatment must be individualized to the patient, and treatment dogmas should be avoided. All modalities have a role to play: extended in-patient stays, faith based programs, medicated assisted treatment, abstinence, recovery centers, Narcotics Anonymous, Al-Anon and other efforts can work. Connecting users with the program that fits their unique circumstances is the first step to recovery.
Almost all drug users end up in an ER sooner or later, typically without insurance. ER charts are coded to the final diagnosis but not the underlying reasons for the visit. Data do not reflect reality. For example, a chart coded as "laceration forearm" could refer to a fall, a wood working accident or breaking a window to steal something to sell to buy drugs. Treatment should be available 24/7/365 via immediate referrals from ER's to an appropriate plan. Additionally, this will reduce uncompensated health care costs, a major driver of the increased insurance rates we all pay.
In 2016, Maryland enacted the Justice Reinvestment Act. This landmark legislation focuses on persons upon release from prison, channeling them into treatment. But why not apply the same concepts to people before they get arrested? Many patients told me that their first arrest and conviction for possession of small amounts of drugs closed doors to employment, education and housing, pushing them into a life of crime. What if these people were given a civil penalty and referral to treatment? With a second arrest, the same but with a greater civil penalty or fine. With the third arrest, the criminal justice system would take over. What if police officers could issue citations and refer users to treatment instead of arrest? That's the Law Enforcement Assisted Diversion (LEAD) program, and it's working in many U.S. cities.
New models of care must be considered, especially those backed by solid evidence, even if these conflict with our previous notions. One is Supervised Consumption Facilities (SCF's). These are safe, clean, regulated facilities where users can bring drugs and take them under supervision. This is not "approving" of drug use but rather a proven path into treatment for the most hardened users.
Researchers at the Johns Hopkins Bloomberg School of Public Health recently reported data showing that as patients get connected with SCF caregivers, more get into treatment. Disease rates go down. Discarded needles are reduced. Local crime decreases. Most importantly, the death rate in SCF's is zero because a rescuer is always present. The American Medical Association (AMA) supports SCF's.
Imagine if 10,000 Marylanders with substance use disorders could get into treatment tomorrow, a realistic proposition. The criminal justice and health care systems would be decompressed overnight, and violence would decrease. Anti-social behavior — and harm to the rest of us — would be reduced.
Isn't it time we shift from policies that haven't worked to ones that do?