Brian Anderson: Welcome back to the 10 Blocks podcast. This is Brian Anderson, the editor of City Journal. Joining me on the show today is Charles Fain Lehman. Charles is a fellow at the Manhattan Institute and a contributing editor of City Journal. His work focuses on a variety of issues—policing, public safety, drug abuse—and he’s appeared in a number of publications, including the Atlantic, Wall Street Journal, National Affairs, National Review, and of course, City Journal. He’s discussed public- safety policy before the House of Representatives and the U.S. Commission on Civil Rights, and is a 2023-24 Robert Novak Fellow with The Fund for American Studies. Today we’re going to be discussing his recent writing on the nation’s increasingly dire crisis of drug overdose.
Charles, great to have you back on 10 Blocks.
Charles Fain Lehman: Absolutely, always glad to be here.
Brian Anderson: This current crisis does seem a little different, at least in the way it’s being perceived, to past drug crises, when the chief impact or the focus was on social health or individual health, so whether this was physical illness, social dysfunction, frayed relationships, public disorder. All of that’s part of what’s going on today, but, as you’ve been emphasizing, the real outcome is death. In a striking way, fatal drug overdoses have risen exponentially over the past decade and a half probably, maybe a little longer. They’re now the leading cause of nonmedical death in the United States. I think the number is over 100,000 people died from overdoses last year. What, in your view, to start off, explains this sharp increase in overdose fatalities?
Charles Fain Lehman: There’s a contingent reason, which is that we’re in the middle of an opioid overdose crisis. Although we’ll talk in a second, there’s also methamphetamine. We’re in the middle of an opioid overdose crisis, and the OD death risk from opioids is higher than from stimulants because the mechanism of action suppresses central nervous system, reduces breathing, you fall asleep, you don’t wake up. And that is contingently a function of the explosion of supply in the illicit market at the turn of the millennium facilitated by Big Pharma, unethical practices in prescribing, a story we all know, but that’s the seed in one way.
What really, to mix the metaphor, lights the fire, is there’s been a dramatic transition in the kind of drugs that are being sold, and in particular, the kind of drugs that are being sold are now highly potent synthetic drugs. Here, I am talking about . . . many people will probably have heard of fentanyl, which is a highly potent synthetic opioid, a variety of variants of fentanyl, drugs like carfentanil or sufentanil, but also methamphetamine, which is much more potent and much purer, and that reflects upstream in the drug supply, the American illicit drug supply, a change in how the producers of those drugs produce drugs, where once historically, for most of modern drug history, those drugs were produced organically. They were grown in fields and then refined.
That’s actually not true of methamphetamine, methamphetamine’s recent, but all opioids, cocaine as well, grown in fields, refined, and then shipped across the border, and today, most drugs are synthesized in a laboratory. And, as a result of that, you can get a much potent product, you get a much purer product, you can get the product much more reliably, much more cheaply. And so American illicit drug markets have been swamped by a wave of incredibly potent product at very low, rock-bottom prices, and as a result, people are consuming it. And many of those people are unable to dose precisely enough to avoid overdose, which is a problem intrinsic to the potency of these substances, and so they die much more frequently than they would have 30, 40, 50 years ago.
Brian Anderson: And so that number is right though? It’s over a 100,000 last year.
Charles Fain Lehman: It’s over 100,000 probably for the past two years, the 2022 figures are preliminary, and it’s likely to stay at or around that level for the foreseeable future.
Brian Anderson: Wow. One approach to this, in fact, it’s probably the predominant approach, has been harm-reduction programs. These operate needle exchanges. They set up safe consumption sites. The proponents of these strategies claim that we can cut down the number of overdoses by encouraging safer use of these illicit substances. What does the increased lethality of the drugs that you’ve just described suggest about the effectiveness of harm reduction? Can you really utilize these drugs in a safe way?
Charles Fain Lehman: Well, the short answer is no. And I think the reaching for harm reduction by some big-city, big-state executives reflects a dearth of other ideas about what to do. But the pitch, as you’ve alluded to, of harm reduction interventions is you can reduce the riskiness inherent in any given use session, therefore you reduce the risk of overdose death. And we now have a fair amount of high-quality research. We have research on naloxone distribution. There are recently a couple of studies looking at the number of supervised consumption sites they’ve set up in Canada, and overwhelmingly, pick your intervention, they do not have an appreciable or statistically significant impact on drug overdose death rates.
And the reason for that is, in some senses, these interventions are band-aids. If you talk to advocates of supervised consumption sites, they’ll say, “Well, nobody’s ever overdosed at a supervised consumption site,” and that’s probably true, certainly true with illicit ones, as far as we know, but that doesn’t mean that people don’t then leave the site and continue to use compulsively, including not at the site, not under the supervision of others, and that’s when they overdose. And the thing about overdose death is you only need to overdose once to die. No matter how many times you are dosed with a fentanyl supervised consumption site, if you are dosed once, there’s a risk of death, an appreciable risk of death.
In other words, harm reduction interventions do not address the underlying risky behavior, which is the addictive use of lethal substances, and insofar as they don’t do that, we shouldn’t expect them to have an appreciable impact on overdose death rates, and the evidence seems to say that they don’t. And so, as a result, we’re in this situation now where these services are the front line in some jurisdictions for combating the drug crisis, even though they aren’t particularly efficacious, but they do soak up large amounts of public funding, in part because anyone who opposes them is framed as regressive and opposed to solving the problem and wanting people who are addicted to drugs to die.
Brian Anderson: What’s a saner alternative here?
Charles Fain Lehman: That’s the million-dollar question. I think that it is not an easy answer and people are still trying to figure it out. When you think about drug policy conventionally, we talk about the four pillars of drug policy, which are enforcement, prevention, treatment, and harm reduction. And there’s a place for harm reduction, properly understood, within that framework, but it can’t be the only pillar, which is part of the problem today. But I think my argument has been the two components of that we aren’t doing enough about, are, A, treatment, and B, prevention. When you talk about treatment, we still have a very patchwork system of treatment. There’s a great deal that we don’t know about where people are in treatment. There’s a lot of evidence that people are not getting the treatment they need, and treatment, as unreliable as it is, it is the only tool that we have for getting people to stop using substances that are likely to kill them, so there are lots of steps we need to take in that domain.
And then prevention, I like to say it’s a little bit like the screenshot from the Simpsons, we’ve tried nothing and we’re all out of ideas. It gets a bad rap because DARE was less than effective in the ‘80s, but the reality is we have some idea how to do prevention. We had a great deal of success doing teen smoking prevention over the past several decades, but there’s a lot that we still don’t know about how to do primary prevention and how to do targeted prevention, which, just at the front end of that, the research isn’t very good.
And so I think that it is worth investing a great deal more in that than we currently do. The reality is, if you don’t initiate drug use by the time you’re 25, or really 30, depending on the substance, but certainly 25, you’re almost certainly not going to initiate drug use. And, as a result, the more you can prevent young people from consuming drugs, the more you can persuade them not to consume drugs, make it harder for them to obtain drugs, the lower your stock of users is going to be, the lower your overdose death rate is going to be.
Brian Anderson: You recently traveled to Portland, a city that’s become known for a very severe homelessness problem and addiction crisis. This you did to report a story for us for our summer issue, which was really terrific. In 2021, more than one in every 2,000 residents in the surrounding county of Portland died from drug overdoses. This was most often from fentanyl and meth that you had mentioned earlier. Two years ago, Oregon decriminalized possession of illegal drugs entirely, making it punishable by just a maximum fine of $100. I wonder if you could sketch what you saw in Portland and what lessons we should take from the state’s experiment with decriminalization.
Charles Fain Lehman: Yeah, absolutely. And, as you alluded to, there’s a very visible homelessness crisis, at least when I was there. And I was told by basically everyone, when I was there, that it was actually better than it had been, which was shocking to me because there were many blocks that were lying with tents, just people living out, consuming drugs publicly. Frequent public disorder, frequent public disturbance, frequent public untreated mental illness, all of these are very visible problems in Portland at present, and they’re really struggling to get it under control. I think many people, as they argued to me, I think correctly, that the underlying problems were exacerbated by Covid and interventions focused on Covid. If you empty out your shelters, people have to go somewhere, and they end up on the street, and then it’s hard to bring them back into shelters. That’s a real problem.
But it’s clearly the case that uncontrolled public drug use, open-air drug use, about which the police could not do anything, was exacerbating the public order problem, was making it worse to be on the streets of Portland. As you alluded to, the most they can do is issue a ticket. The ticket doesn’t ever get paid, and nobody ever calls the hotline that is associated with the ticket to hear about treatment services because there’s no compulsory element. And so, as a result, the effect is mostly that people are less inhibited in using drugs and using drugs openly. There’s a live empirical debate about whether or not this has raised overdose death rates. My read of the literature is it is more likely than not that it has raised overdose death rates, but there is room for debate. Basically, nobody, at this point, will argue that it has lowered overdose death rates.
This, by the way, is what you see across decriminalization in other political contexts, is that, mostly, they have no effect, or they can be offset if you substantially increase treatment at the same time, which Oregon didn’t do. And so I think it is almost certainly the case that, A, the city has been left with no tools to combat public drug use and all the harms that attend. The mayor Ted Wheeler, who’s a progressive, has been trying to get a public use ban, in the process of a big fight about that, and then B, it is almost certainly, insofar as it is facilitating continued drug use, it is making the lives of the people who are using worse up to and including quite arguably increasing their risk of death.
Brian Anderson: Turning to New York, in 2021, the city became, I think, the first in the United States to open supervised-consumption sites, and this is where anybody can go to use controlled substances, again, under the supervision of staff, trained staff. The organization that operates these, I think it’s two sites in the city, claims that its staff members reversed more than 1,000 overdoses during the first 18 months that they were running and that the city should open more of these sites.
What’s your view of these supervised-consumption efforts in the city, and have they had an appreciable impact on overdoses in New York?
Charles Fain Lehman: Yeah. A, I think that the best evidence that we have is they are not having an appreciable impact on overdoses in the city. I produced some data looking at the borough level. Our friends at the Greater Harlem Coalition recently published some data looking at trends at the neighborhood level, showing that East Harlem has seen a precipitous increase in overdose deaths since the supervised consumption site there was opened. I looked at data, and I published it in City Journal, I looked at data that the site itself released, that was then forwarded to me, which showed they handle a certain number of visits every day, but that number is almost certainly only a minuscule fraction of the total number of use sessions that occur in any given day.
They are not actually supervising most of the drug use that goes on around them, which means they aren’t going to have any meaningful impact on the overdose death rate. We shouldn’t expect them to. Lots of cities have scaled. I was just, yesterday, in Vancouver where they have 12 overdose prevention sites, which 10 of them are clustered in the major skid row area, the Downtown Eastside. I was also told by a former city official that there are probably another 20 that are operating illicitly. The Downtown Eastside has one of the worst drug overdose death rates in North America, it’s very hard to argue, and again, we have now high-quality evidence that there’s really no effect. We shouldn’t expect there to be much in effect in New York opening one of these sites. What it does appear to do—
Brian Anderson: Charles, what’s the effect on the surrounding neighborhoods that these sites are situated in?
Charles Fain Lehman: Right. Well, so what they do appear to do, and this varies by site, there’s some evidence that, for example, the first Vancouver site, Insite, which is really the one that’s best studied, did not have an appreciable effect on public order. There’s been some evidence out of Alberta that says their supervised consumption sites did have a dramatic effect on public order. I’ve talked to the folks at the Greater Harlem Coalition, who have done their own survey, showing that yes, the supervised consumption site in East Harlem is a dramatic hotspot, a magnet for disorder, and there are a host of reasons for that. If you concentrate people who use drugs in one place, you’re going to concentrate drug dealers, who are not great guys. You’re also going to create a space that is defined as safe for drug use, and so people will be more likely to use there.
And, as I like to say, there are economies of scale to this kind of thing. Two people using drugs together is different from 10 people using drugs together. There are more than linear effects from that. Clearly, you’re going to have disorder spillovers. The other thing that I would flag, by the way, is that supervised consumption sites are usually justified as disorder reducing, insofar as they get people off of the street to use drugs out of sight. And my view is, if they actually did that, I would be very much more sympathetic to them, but they mostly don’t do that. Mostly, there is no police presence deterring public drug use otherwise. Mostly, they’re seen as part of a broader infrastructure of benign neglect that tends to take over neighborhoods that are dominated by drug use.
Brian Anderson: A final question, and this is a bit narrower, over the past couple of years, xylazine, which is a horse tranquilizer, has made its way into the U.S. drug supply. It’s now commonly added to fentanyl to extend its effects. This tranquilizer is a nonopioid sedative. I guess it enhances the drug’s toxicity. This, I imagine, must be increasing the risks of overdose significantly, and what is being done about it?
Charles Fain Lehman: Not a huge amount. As you alluded to, xylazine is added to increase the quality of the high. Fentanyl, a fairly fast-acting high, xylazine extends that because it’s a sedative. It also is seriously debilitating. Continual xylazine use leads to these horrible gaping sores that necrotize and don’t heal. It’s really quite bad. I think some cities have started trying to roll out xylazine testing services, but we know from the literature on fentanyl test strips that they don’t really deter use. They inform people about use, but they don’t really change their behavior. And we should expect the same thing to be true of xylazine.
The reality is xylazine is a response to demand. It’s improving the quality of the product from certain perspectives. And so, insofar as cities are just trying to harm-reduce their way out of this problem, they’re not really going to be able to get at it that way. There is no naloxone for xylazine. You can’t reverse it. Really, all you can do is, in jurisdictions that don’t yet have it, try to differentially enforce against it, really target drug dealers who are lacing the xylazine for aggressive punishment with the explicit message that you’ll be much harsher on them, and the jurisdictions that already have it really need to focus on treatment and prevention as tools for getting people to not be exposed to the drug supply at all.
Brian Anderson: And all of the cannabis legalization that’s been going on in municipalities, what kind of an effect is that having on some of these more serious drug problems?
Charles Fain Lehman: That’s always the million-dollar question is marijuana gateway. It’s hard to assess empirically. There’s lots of evidence in either direction. What is persuasive to me is that it seems unlikely that marijuana is making the situation better. There was some argument that marijuana legalization would produce marijuana as a substitute for opioid use, which would reduce addiction. We now have a fair amount of evidence that says that’s not true. Marijuana legalization may be associated with a slight increase in opioid overdose deaths, but that’s a little ambiguous and depends on specification.
I think what I would say is that you can situate marijuana legalization alongside a host of other changes in our attitudes towards drugs, and here I’m talking about on the illicit side, marijuana, but also the growing tide of psychedelic legalization that we’re in the middle of, but increases in illicit drug use, but also increases in licit substance use. Americans are consuming far more pharmaceutical medication, including amphetamines, than they have in the past 20 years. And that, to me, represents a substantial shift in our attitude about substances generally.
When you read the history of drug use, so when you read the history of drugs in America, we go through these waxing and waning cycles where we get very excited about drugs. We are very sanguine about drugs. We try them. We discover the effects. We go, “Wow, that was a bad idea.” We crack down on them, and then because we cracked down on them, we forget how bad they were, and so we go back to using drugs. And it seems to me that we are in one of these upswings again, where, in general, we are much more willing to try addictive psychoactive substances than we were 30 years ago. And to that I would add, and this goes back to marijuana, the corporate element of it is stronger than ever. The capability of businesses to profit off of addictive substances is stronger than it was 30, 40, 50 years ago, which adds a new dimension to a new extent of the phenomenon, adds to that.
Brian Anderson: All right. Well, that’s a good note to end on, or a troubling note. Don’t forget to check out Charles Lehman’s work on the City Journal website. That’s at www.city-journal.org. You can find him on X @charlesflehman, and we’ll link to his author page in the description, where you’ll be able to find his work. You can also find City Journal on X, @CityJournal and on Instagram @cityjournal_mi. And, as usual, if you like what you’ve heard on this podcast, please give us a nice rating on iTunes. And, Charles Lehman, thanks very much again for that illuminating walkthrough.
Charles Fain Lehman: Absolutely. Thanks so much for having me on as always.