In February 2021, Oregon decriminalized possession of small amounts of all drugs, via a ballot initiative known as Measure 110. The idea was to treat addiction as a public health problem, based on overwhelming evidence that jailing people for having small amounts of drugs for personal use is both [ineffective](https://www.nature.com/articles/s41386-021-01087-2) and [counterproductive](https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(20)30283-8/fulltext). Since then, decriminalization has been widely blamed for increased homelessness, soaring rates of public drug use and a 68 percent rise in the overdose death rate in its first two years. This spike was far greater than the [14 percent rise](https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm) in the nation’s overall overdose deaths during the same period. Although Measure 110 passed [with nearly 59 percent support](https://ballotpedia.org/Oregon_Measure_110,_Drug_Decriminalization_and_Addiction_Treatment_Initiative_(2020)), [many](https://www.oregonlive.com/politics/2023/08/oregon-voters-souring-on-measure-110-with-many-in-favor-of-a-complete-repeal-new-poll-find.html) Oregon voters are now calling for drugs to be recriminalized, citing these worsening conditions. The state legislature, which convenes on Monday, is [considering new legislation](https://olis.oregonlegislature.gov/liz/2023I1/Downloads/CommitteeMeetingDocument/279826) that would, among other things, restore a criminal penalty of up to a month in jail for low-level possession. Repealing decriminalization would be a mistake. Researchers studying Measure 110’s effects [recently presented compelling evidence](https://www.rti.org/event/oregons-ballot-measure-110-symposium) that the current law is extremely unlikely to have done the harm for which it is being blamed. But rampant misinformation — often being spread for political gain — means that the legislature is likely to return to its old-school drug war approach. With overdose deaths still on the rise and other states considering decriminalization, a reversal could undo vital national progress in fighting addiction, which is far more effectively resolved with care, not coercion. If we really want to end the overdose and homelessness crises — in Oregon and around the country — we have to understand and follow the evidence, not the fearmongering. When events occur in rapid succession, it’s easy to assume that the first one caused the second. But correlation isn’t all that’s needed to prove causation. For something like a change in drug laws to have an impact, certain conditions need to be met. Thank you for your patience while we verify access. If you are in Reader mode please exit and [log into](https://myaccount.nytimes.com/auth/login?response_type=cookie&client_id=vi&redirect_uri=https%3A%2F%2Fwww.nytimes.com%2F2024%2F02%2F05%2Fopinion%2Foregon-decriminalization-drugs-reversal.html&asset=opttrunc) your Times account, or [subscribe](https://www.nytimes.com/subscription?campaignId=89WYR&redirect_uri=https%3A%2F%2Fwww.nytimes.com%2F2024%2F02%2F05%2Fopinion%2Foregon-decriminalization-drugs-reversal.html) for all of The Times. Thank you for your patience while we verify access. Already a subscriber? [Log in](https://myaccount.nytimes.com/auth/login?response_type=cookie&client_id=vi&redirect_uri=https%3A%2F%2Fwww.nytimes.com%2F2024%2F02%2F05%2Fopinion%2Foregon-decriminalization-drugs-reversal.html&asset=opttrunc). Want all of The Times? [Subscribe](https://www.nytimes.com/subscription?campaignId=89WYR&redirect_uri=https%3A%2F%2Fwww.nytimes.com%2F2024%2F02%2F05%2Fopinion%2Foregon-decriminalization-drugs-reversal.html).

London Breed, the Democratic mayor of [San Francisco](https://www.theguardian.com/us-news/san-francisco), is pushing a pair of controversial public safety proposals on the 5 March ballot, including one that would require single adults on welfare to be screened and treated for illegal drug addiction or else lose cash assistance. Breed also supports a ballot measure that would give police access to more technology, such as the use of drones and surveillance cameras. In November, she will face voters in a competitive re-election bid. San Francisco is in a struggle to redefine itself after the pandemic left it in economic tatters and highlighted its longstanding problems with homelessness, drugs and property crime. Opponents say both ballot measures are wildly out of step with San Francisco’s support for privacy and civil liberties and will only hurt the marginalized communities the city prides itself on helping. But Breed, the first Black woman to lead San Francisco, said at a January campaign stop that residents from poorer, Black and immigrant neighborhoods were pleading for more police, and recovery advocates are demanding change as more than 800 people died of accidental overdoses last year – a record fueled by the abundance of cheap and potent fentanyl. “They said San Francisco makes it too easy for people to access and to use drugs on the streets of the city and we need to do something a lot more aggressive,” Breed said at Footprint, an athletic apparel and shoe store that has been repeatedly burglarized. While Breed’s name isn’t on the presidential primary ballots going out now – San Francisco uses a method where residents rank mayoral candidates by preference a single time in November – the two measures she’s pushing are. They serve as an opening salvo for her re-election campaign as she faces off against fellow moderates who say her approach to the city’s problems has been weak. Violent crimes are low in San Francisco, but the city has long struggled with quality-of-life crimes. Breed said rates of retail theft and auto smash-ins have declined recently, thanks in large part to strategic operations by city police. Similarly, police have stepped up enforcement of drug laws, including by issuing citations to people using drugs in public as a way to disrupt the behavior and an opportunity to persuade the person cited to seek help. But she said San Francisco needs to do more. If approved by voters, Proposition F would offer another way to compel treatment, by allowing the city to screen single adults on local welfare for substance abuse. People found to be abusing illegal drugs would be required to enroll in treatment if they want to receive cash assistance from the city, which maxes out at just over $700 a month. Opponents say coercion doesn’t work and homelessness may increase if the measure passes. Drug addicts are not criminals, they say, and there are not enough treatment beds and counseling services as it is. A crackdown on drugs is reminiscent of the failed war on drugs that disproportionately harmed Black families, said Chris Ballard, co-executive director of Coleman Advocates, which pushes for improvements for Black and Latino youth in San Francisco. “There are more ethical ways to address the issue aside from punitive measures, and that’s the proper way to take care of a community, to show true support,” he said. Yet Trent Rhorer, executive director of the San Francisco Human Services Agency, which provides cash assistance and employment services to low-income residents without dependent children, said the current situation is in conflict with the agency’s mission: to improve lives. “To give someone who’s addicted to fentanyl $700 a month, I don’t think it helps improve their lives,” he said. “In fact, I think it does the opposite.” Compelling treatment has become more acceptable in Democratic California, despite angst over the potential loss of civil liberties, as visible signs of homelessness and mental illness, fentanyl addiction and unsafe street behavior surge. Last year, several counties rolled out an alternative mental health court created by Gavin Newsom, the Democratic former mayor of San Francisco and now governor of the state, to fast-track people with untreated schizophrenia and related disorders into care, and in March voters will take up a statewide mental health proposition that some say will increase involuntary treatment. Rhorer said the welfare program for single adults – which serves about 9,000 people a year – already asks applicants about substance abuse, with about 20% self-reporting an issue. A data check with the department of public health revealed that almost one-third of recipients had been diagnosed with a substance use disorder, he said. The ballot measure would replace that question with a more rigorous screening test that would be verified by an addiction specialist. If substance abuse is found, Rhorer said, the specialist and applicant would agree on treatment options that include residential care, a 12-step program, individual counseling and replacement medication. There is no requirement that the person be sober, only that they make good-faith efforts to attend their program, with the hope that “at one point a light bulb will go off”, Rhorer said. The measure calls for the city to pay the rent of those accepted into the program for 30 days or longer to avoid eviction. About 30% of the people who fatally overdosed in 2023 were unhoused, and more were living in subsidized city housing. .

 Officer Yoo gives a citation to a man he stopped for using fentanyl in public. Yoo said handing out citations doesn't appear to move people from using drugs on the streets into treatment programs. Kristyna Wentz-Graff/OPB Oregon voters passed the most liberal drug law in the country in November 2020, decriminalizing possession for small amounts of hard drugs. Under Ballot Measure 110, instead of arresting drug users, police now give them a citation and point them towards treatment. [The law passed](https://www.opb.org/article/2020/11/04/oregon-measure-110-decriminalize-drugs/) with 58% of the vote and also funneled hundreds of millions of dollars in cannabis tax revenue to fund new recovery programs. But more than three years later, the drug crisis in Oregon – like many other places battling the [fentanyl crisis](https://www.npr.org/2023/12/28/1220881380/overdose-fentanyl-drugs-addiction) – [has gotten worse](https://www.cdc.gov/drugoverdose/fatal/dashboard/index.html#:~:text=SUDORS%20provides%20comprehensive%20data%20on,and%20full%20postmortem%20toxicology%20findings). And that's prompted a fierce political debate in Oregon about whether Measure 110 has succeeded or failed. Addressing Measure 110 is one of the priorities for Oregon lawmakers, as they start their new legislative session this week. Democrats, who control the legislature and the governor's office, have indicated they're open to recriminalizing drugs, which could effectively end the most controversial piece of this legislative experiment. **A citation system many say isn't working**  On a gray November afternoon in downtown Portland, Officer Joey Yoo stood hunched over a city-issued mountain bike. The sidewalk was dotted with tiny scraps of tinfoil used for smoking fentanyl. Down the block, a man officers said was high on meth was raging about his stuff being stolen. "Do you have any questions while I'm talking to you about why I'm giving you this citation?" Yoo asked a young man he stopped for using fentanyl in public. NPR is not using his name because he was in no condition to give us permission to do so. The man was staring down at the ground, not making eye contact with Yoo. The little he said was hardly audible. "What brought you out here?" Yoo asked. "Drugs, I guess," the man replied. "Do you have any family here?" Yoo asked. The man didn't appear to respond. Then, Yoo handed the man several slips of paper. One was a $100 citation. Another had the phone number to a state-funded hotline. If the man were to call and get assessed for addiction, the fine and citation would go away. "You don't have to go into treatment, but they'll give you information about how to get the treatment," Yoo said. "That's all you have to do." Court records show the man never made the call. And that's typical. So far, police have handed out more than 7,000 citations, but as of December, only a few hundred people had called the hotline to get assessed for a substance use disorder. And even fewer accessed treatment through the citation system. This exchange – a citation for drug use, instead of an arrest – is a direct result of Measure 110. Advocates for the measure argued the criminal justice system didn't [effectively](https://www.prisonpolicy.org/blog/2024/01/30/punishing-drug-use/) [treat addiction](https://www.pewtrusts.org/en/research-and-analysis/issue-briefs/2018/03/more-imprisonment-does-not-reduce-state-drug-problems). They also said it disproportionately harmed people of color. Before it passed, the state [estimated](https://multco-web7-psh-files-usw2.s3-us-west-2.amazonaws.com/s3fs-public/book13_web.pdf) it would reduce racial disparities in conviction rates. Back on the street, Officer Yoo said handing out citations doesn't appear to move people from using drugs on the streets into treatment programs. "The same people I gave a citation to yesterday, today I see doing the same thing," Yoo said. **A heated debate in the state capital**  Portland Police Sgt. Jerry Cioeta checks for a pulse after giving a third round of opioid reversal medication to a man found unresponsive in downtown Portland, Ore. The man was revived. Kristyna Wentz-Graff/OPB What's happening here on the streets of Portland has led to a passionate debate about substance use and drug policy in Oregon. Opioid overdoses have surged across the state since Measure 110 passed. In 2019, 280 people died from unintentional opiate overdoses in Oregon. In 2022, that was up to 956 deaths, [according to the state health authority](https://www.oregon.gov/oha/PH/PREVENTIONWELLNESS/SUBSTANCEUSE/OPIOIDS/Documents/quarterly_opioid_overdose_related_data_report.pdf) – a 241% increase. A number of [researchers](https://www.rti.org/event/oregons-ballot-measure-110-symposium) have said there isn't evidence that Measure 110 is the cause. [One study](https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2809867) published [in September](https://www.opb.org/article/2023/09/27/oregon-drug-decriminalization-measure-110-overdose-deaths/) by the Journal of the American Medical Association Psychiatry, looked at Oregon and Washington, where drug possession was also decriminalized for several months in 2021. Researchers say they found no evidence between "legal changes that removed or substantially reduced criminal penalties for drug possession in Oregon and Washington and fatal drug overdose rates." At least one study, however, did find that Measure 110 caused 182 additional overdose deaths in Oregon in 2021. That study, published in the [Journal of Health Economics](https://www.sciencedirect.com/science/article/abs/pii/S0167629623000759), said those additional deaths represented, "a 23% increase over the number of unintentional drug overdose deaths predicted if Oregon had not decriminalized drugs." [Brandon del Pozo](https://vivo.brown.edu/display/bdelpozo), an assistant professor of medicine at Brown University who studies the overdose crisis and substance use, [said that study should be taken](https://www.youtube.com/watch?v=lXTi4t1Je1w) with a "grain of salt" because it doesn't control for fentanyl's entry into Oregon's drug supply.  A used Narcan bottle lays on the ground in Portland, Ore. Kristyna Wentz-Graff/OPB "In virtually every state, fentanyl is intimately linked to overdose," said del Pozo, who also spent 23 years as a police officer, in January during a symposium on Measure 110 in Oregon. During the past several months in Salem, Oregon's state capital, health experts, law enforcement, and members of the public have offered deeply divided testimony to Oregon lawmakers about what should happen to Measure 110. Hundreds of [people submitted testimony](https://olis.oregonlegislature.gov/liz/2023I1/Committees/JACSR/2023-12-04-09-00/MeetingMaterials), including some who argued that taking away criminal penalties for drug use hadn't worked. Others said they're concerned about safety. "The police occasionally come in and clean up a specific area with their superficial presence and the drug market moves along to another corner," Lisa Schroeder, who owns Mother's Bistro & Bar in downtown Portland, testified. "The quality of life of our citizenry, from the user to the general population, is suffering." Cat and Chad Sewell own Sewell Sweets, a bakeshop in Salem. In written testimony, the Sewell's said they've witnessed drug use leading to conflicts outside their business. "The scenes that we see day in and day out leave us frustrated and questioning just how safe the longevity of our business and livelihood is," they wrote.  Addiction doctors and criminal justice experts in Oregon said that a lot happened between 2020 and now besides Measure 110: not just the fentanyl crisis, but also the pandemic, which taxed the healthcare system, and [a growing crisis of homelessness.](https://www.opb.org/article/2022/12/24/federal-data-confirms-spike-oregon-homelessness/) Dr. Andy Mendenhall is an addiction medicine physician and the CEO of Central City Concern, a social service organization in Portland that gets a small amount of money from Measure 110. He testified at one of the hearings in Salem, and in an interview after, said it's understandable people are frustrated. "They're reasonably questioning why this is happening – why it's all not fixed," he told OPB. "Folks are experiencing their own despair, seeing the suffering of others... There's a ton of compassion fatigue."  During the past several months in Salem, Oregon's state capital, health experts, law enforcement, and members of the public have offered deeply divided testimony to Oregon lawmakers about what should happen to Measure 110. Kristyna Wentz-Graff/OPB Mendenhall said people are pointing at Measure 110 and saying it's the reason for Oregon's problems, "when in reality it is our decades-long, underbuilt system of behavioral health, substance use disorders, shelter and affordable housing – that are the primary drivers." Some treatment providers have testified that if lawmakers recriminalize drugs it will just take Oregon back to a different system that wasn't working. "Arrest records – it impacts people looking for employment, it impacts their housing, it perpetuates a cycle of poverty," testified [Shannon Jones Isadore](https://www.oregonchangeclinic.com/ourteam), CEO of the Oregon Change Clinic, a recovery program that specializes in working with African American and veteran communities in Portland. "A better solution is to dramatically increase our street services and outreach where there can be adequate care available for everyone," she said. Amid the debate about how – or even whether to change the law – there's general agreement that whatever should happen next to Measure 110, Oregon made a radical change to its drug laws before the infrastructure was in place to really support it. **Still, treatment has expanded**  Recovery Works Northwest counselor Damian Thomas, left, talks with Joe Bazeghi, director of engagement for the organization, in the Portland, Ore. area. Kristyna Wentz-Graff/OPB There are parts of the law that aren't being debated. The influx of money towards recovery expanded the state's detox capacity, funded new staff such as drug and alcohol counselors, and increased culturally specific treatment programs. Still, a [recent study](https://www.opb.org/article/2024/02/01/behavioral-health-care-oregon-cost/) from state health officials found Oregon was years away from being able to treat everyone who needed it. Joe Bazeghi helps run Recovery Works Northwest, which opened a [new 16-bed detox facility during the fall of 2023](https://www.opb.org/article/2023/08/29/fentanyl-detox-center-portland/). "It's Measure 110 funded," Bazeghi said, during a tour in December. "The purchase, the retrofit, the remodel as well as supplying of this facility was accomplished with support from Measure 110."  The facility opens to a high ceiling with a staircase that goes to a second floor. There's a dining room, game area and off to one side, a living room for recovery group meetings. The detox center is evidence that Measure 110 is working, Bazeghi said. "Measure 110 is providing treatment resources that otherwise would not exist," he said. "It's working as well as could ever possibly be expected of a brand new system that had to be built." Most of the people here are really sick, withdrawing from fentanyl. A woman named Aleah is one of them. NPR is just identifying her by her first name, because she was still a patient in the detox facility when we spoke with her.  Unable to have visitors, Aleah and her boyfriend press their hands together, separated by the screen of an open window, as Aleah stays at Recovery Works Northwest's detox center. Kristyna Wentz-Graff/OPB "I feel a lot better than I did yesterday," Aleah said. She'd been at the facility for five days. She said she drove 250 miles from Eastern Oregon to Recovery Works because it's where she was able to get a bed. Her boyfriend also wanted her to come here so they could both get sober, she said. While we were talking, her boyfriend, Trey Rubin, who'd just completed residential treatment, walked up and stood outside one of the windows. "I wish I could come out," Aleah said, pressing her hand against the screen of an open window to meet his hand on the other side. "At least we can talk through a window," she said. "You look so good." Rubin recently moved into a sober house in Portland. "I want to be successful and do things in my life and that's definitely the first step," Rubin said. "You can't really do anything if you're not clean, you know." He said he's thinking about what he may do now that he's not using drugs. "I love dirt bikes and writing," he said. "I don't know exactly what I want to do yet. But maybe want to go to school to be an X-ray technician or something like that." Oregon has faced some criticism for how slow the expansion of treatment programs such as the one that helped Aleah and Rubin has been. But if anything, state lawmakers say they want to invest more in recovery programs, even if they're considering other changes. Oregon's 2024 legislative session got underway this week, where lawmakers are expected to debate Measure 110's future.  By early March, lawmakers could decide exactly what that future will be. Oregon Senate Majority Leader Kate Lieber – who co-chaired the legislature's addiction committee – told Oregon Public Broadcasting that she's not advocating for Measure 110 to be repealed. But she and other top lawmakers have said they support recriminalizing drug possession so long as there are ways for the criminal justice system to direct people into the treatment programs Measure 110 has helped to expand. "We knew that we didn't want to go backwards on what was happening with regard to the war on drugs, we can't go back to that – but people are dying of overdoses on the street," Lieber said. "The state of the drug crisis in Oregon is unacceptable."

The opioid crisis doesn’t get as many headlines as it used to before [Covid-19](https://www.vox.com/coronavirus-covid19), but the news remains stubbornly, shockingly bad. [Decades](https://www.cdc.gov/opioids/basics/epidemic.html) into the deadliest drug overdose epidemic in American history, people are dying at higher rates than ever. Between 2017 and 2021, the number of overdose deaths involving opioids [jumped](https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates) from 47,600 to 80,411 — many more Americans than are killed each year [by guns or cars](https://www.cdc.gov/nchs/fastats/injury.htm). The surge has been largely driven by powerful synthetics like fentanyl, an opioid [50 times](https://www.cdc.gov/stopoverdose/fentanyl/index.html) more potent than heroin. [Provisional data](https://blogs.cdc.gov/nchs/2023/05/18/7365/) from the Centers for Disease Control and Prevention show nearly as many opioid-involved overdose deaths in 2022, at 79,770. Overdoses in [Black](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10299749/), [American Indian](https://jamanetwork.com/journals/jama/article-abstract/2795517), and [Latinx](https://www.nbcnews.com/news/latino/drug-overdose-deaths-latinos-almost-tripled-decade-rcna76315) communities have been rising even faster, widening the mortality gap between white people and people of color. In 2020, Black men 65 and older died of overdoses at [seven times the rate](https://www.cdc.gov/media/releases/2022/s0719-overdose-rates-vs.html) of white men in the same age range. Meanwhile, the number of Americans struggling with opioid addiction remains staggering. In 2022, 6.1 million people 12 and older had an opioid use disorder, according to the Substance Abuse and Mental Health Services Administration’s [most recent annual survey](https://www.samhsa.gov/data/sites/default/files/reports/rpt42730/2022-nsduh-infographic-report.pdf), while 8.9 million reported misusing opioids within the past year. Looking at these statistics, I thought back to something that addiction specialist Sarah Wakeman told me when I was [reporting](https://www.harvardmagazine.com/2019/02/opioids-crisis-pain-suboxone) on the opioid crisis five years ago. “Most people get better,” [Wakeman](https://www.massgeneral.org/doctors/19383/sarah-wakeman), who is the senior medical director for substance use disorder at Mass General Brigham, said then. “That’s what we don’t ever talk about in the opioids conversation.” When she says “most people,” she means most people who get long-term [medication-assisted treatment](https://www.vox.com/science-and-health/2017/7/20/15937896/medication-assisted-treatment-methadone-buprenorphine-naltrexone) (MAT), widely considered the gold standard in addiction care. It [combines](https://www.fda.gov/drugs/information-drug-class/information-about-medication-assisted-treatment-mat) regular counseling and behavioral therapy with the medication methadone or buprenorphine (often prescribed under the brand name Suboxone). Both contain synthetic opioid compounds, which prevent withdrawal and cravings, and they can lower overdoses by as much as [76 percent](https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2760032). (A third medication, [less often used](https://www.vox.com/science-and-health/2017/11/15/16653718/study-buprenorphine-naltrexone-suboxone-vivitrol), is naltrexone, which blocks the high from opioids.) The philosophy of MAT — a departure from the moralizing, abstinence-based rehab and 12-step programs that [dominated addiction care](https://www.tandfonline.com/doi/abs/10.1300/J069v18n01_10) for most of the 20th century — began to take shape in the early 2000s, when the Food and Drug Administration approved buprenorphine and [a federal law](https://pubmed.ncbi.nlm.nih.gov/16118361/) authorized primary care physicians to prescribe it. MAT shifted the treatment paradigm dramatically. Now, every overdose death is a tragedy, Wakeman told me, not because opioid addiction is unsolvable but because, like so many other chronic illnesses, it’s now very treatable. So why have we failed to stop or even significantly slow the opioid crisis? Why do [nearly 90 percent](https://www.sciencedirect.com/science/article/pii/S0955395922002031?via%3Dihub) of those with opioid use disorder still lack access to evidence-based treatment like MAT? This fall, I got back in touch with Wakeman and posed this question. Is the problem us, I asked her, or is it the opioids? “Oh, it’s definitely us,” she said. The addiction crisis is as much an “ideological challenge” as it is a medical one. “We, as a society, have spent more than 100 years thinking of and building [policies](https://www.vox.com/policy) and systems and punishments to address addiction as if it were an issue of morality,” Wakeman said. “And so even though now we’re starting to talk about it as a [public health](https://www.vox.com/public-health) issue, our policies, our clinical approaches, our care models, our funding, really reflect this idea that we actually think people are doing something bad and so we should make it really hard on them.” This punitive mindset contributes to a disproportionate emphasis on detox, “which happens to be the most lucrative, least effective element of recovery,” as Walter Ling, a UCLA psychiatrist and neurologist whose research helped pave the way for FDA approval of buprenorphine and other opioid addiction medications, [put it](https://www.uclahealth.org/news/how-are-we-getting-opioid-crisis-so-wrong) in a recent op-ed. Even now, many drug rehab centers stress detoxification, meaning going off opioids rapidly, over MAT. A [2020 nationwide survey](https://jamanetwork.com/journals/jama/fullarticle/2769709) of inpatient programs found that only 29 percent offered a long-term MAT option; [only one in eight](https://jamanetwork.com/journals/jama/fullarticle/2805916) residential treatment facilities for adolescents offered buprenorphine for long-term treatment, according to [a study last June](https://apnews.com/article/opioids-addiction-teens-treatment-buprenorphine-overdose-9b994bd3ec27f6be7e2062861f1ad0a8). Nearly every clinician I spoke to offered some version of this same observation about how culture and ideology restrict addiction care. “The main thing that’s holding us back is stigma,” said Brown University epidemiologist [Josiah Rich](https://vivo.brown.edu/display/jrichmph), an adviser to the Rhode Island task force on overdoses, who has spent decades providing HIV and addiction care to people locked up in the state’s prisons. Physician and anthropologist [Kimberly Sue](https://medicine.yale.edu/profile/kimberly-sue/), a professor at Yale and the author of _Getting Wrecked: Women, Incarceration, and the American Opioid Crisis_, told me about treating young people jailed at Rikers Island whose families had cut them off or kicked them out for using drugs. “The US is extremely culturally punitive,” she said. “You know, ‘Pull yourself up by your own bootstraps.’ ‘You made your bed, you lie in it.’ … We’re told that you’re a loser, you don’t deserve to live because you use drugs. You don’t deserve to be healthy.” Our approach to treatment hasn’t caught up with the science of what works best. “Until the medications came around, our treatment for opioid addiction was mostly a failure,” Ling told me. “Yet we put our philosophy, our idea, ahead of science, ahead of what we know.” That trickles down into how people interact with the [health care](https://www.vox.com/health-care) system — and how structural barriers like racism and poverty compound the damage for those most susceptible to addiction. ### The war on drugs laid the foundation for dysfunctional addiction treatment The face of opioid addiction in America changed dramatically over the past two decades. As overdoses soared in white and rural communities and the crisis was no longer concentrated in cities or communities of color, public discourse around addiction shifted. Experts and policymakers began talking urgently about “[deaths of despair](https://press.princeton.edu/books/hardcover/9780691190785/deaths-of-despair-and-the-future-of-capitalism)” among working-class white people, and a surge of sympathetic media attention sought to understand the problem through this new wave of victims. Americans increasingly began to see addiction the same way [medical](https://nida.nih.gov/publications/drugs-brains-behavior-science-addiction/drug-misuse-addiction) [authorities](https://www.ncsbn.org/public-files/Understanding_the_Disease_of_Addiction.pdf) had for decades — as an illness. Even so, our treatment paradigm has not caught up. Perhaps the clearest example of how Americans’ cultural mindset limits access to treatment is the onerous regulation of [methadone](https://www.guernicamag.com/doctors-not-dealers/). Patients can receive the medication only at federally certified clinics, which tend to be located in impoverished or high-crime neighborhoods. Most patients must appear at the clinic daily for months or years before they’re allowed to take home even a small number of doses. This means waiting in line, often for hours, missing appointments and work, having to arrange for [child care](https://www.vox.com/child-care). For some patients, it also means long commutes, sometimes across state lines. In stark contrast, buprenorphine can be prescribed in doctors’ offices and dispensed by pharmacies. Although the overdose risk with methadone is slightly higher than for buprenorphine, it is stigma, not science, that guides methadone regulations. The medication was initially introduced in the US in 1947 as a pain reliever and cough suppressant; [researchers established](https://www.rockefeller.edu/news/12410-fifty-years-after-landmark-methadone-discovery-stigmas-and-misunderstandings-persist/) its effectiveness at treating opioid addiction during the 1960s, amid a spike in heroin use that devastated Black urban communities. Back then, even more than now, Americans viewed addiction through the lens of criminality and deviance rather than disease, so federal regulations put in place [in the early 1970s](https://www.ncbi.nlm.nih.gov/books/NBK232105/), just as Richard Nixon declared the “[war on drugs](https://www.vox.com/2016/3/22/11278760/war-on-drugs-racism-nixon),” [walled off methadone from mainstream medical settings](https://www.washingtonpost.com/made-by-history/2023/04/20/nixon-era-roots-todays-opioid-crisis/). That’s where it remains today, even though in countries like [Canada](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9271524/), the [UK](https://www.pewtrusts.org/en/research-and-analysis/fact-sheets/2023/05/uk-pharmacies-offer-sense-of-normalcy-for-methadone-patients), and [Australia](https://www.pewtrusts.org/en/research-and-analysis/fact-sheets/2023/05/in-australia-primary-care-and-pharmacies-deliver-methadone), where primary care doctors have been prescribing methadone for decades, it’s treated more like a normal medication. The long lines outside methadone clinics is one of the [main reasons](https://harmreductionjournal.biomedcentral.com/articles/10.1186/s12954-021-00535-y) people [drop out](https://www.sciencedirect.com/science/article/abs/pii/S2949875923001054) of or never begin treatment with the medication. Because of these restrictions, methadone is “legendarily hated” among drug users, New York University sociologist [David Frank](https://www.cduhr.org/profile/frank-david/), who is in recovery himself and has been taking methadone for 20 years, told me. In a recent study he published, one participant compared methadone treatment to “[liquid handcuffs](https://harmreductionjournal.biomedcentral.com/articles/10.1186/s12954-021-00535-y),” while another described the degrading experience of being told to keep waiting in line after her water broke. “Treatment is not set up to meet the actual needs of the population,” Frank said. “In fact, it’s a barrier to meeting those needs.” Most people come to treatment not because of a commitment to abstinence or even to cure a disease, but “to deal with the fact that the drug they’re dependent on is highly criminalized,” he said. “In my research, this comes up time and again. I ask people, why did you get on methadone? And they always tell the same story as mine: ‘I’m dope sick every day, it’s impossible. I get arrested, I’m scared, my life is falling apart.’ It’s a very pragmatic response. Methadone helps reduce those problems.” The punitive regulations flow largely from methadone’s history, providers say, from a time when heroin use was closely associated with [Black Americans](https://www.vox.com/race). When buprenorphine received FDA approval 40 years later, the opioid crisis was hitting white America, too. “People’s perceptions about methadone are really frozen in history,” said [Paul Joudrey](https://www.gim-crhc.pitt.edu/people/paul-j-joudrey-md-mph), a Pittsburgh-based addiction care doctor who, along with Frank, is on the board of the National Coalition to Liberate Methadone. Buprenorphine prescribers are far more common [in segregated white communities](https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2764663), while methadone clinics are more prevalent in Black and Hispanic neighborhoods. Patients who are white, wealthy, and well-educated [are more likely](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3818282/) than Black or Hispanic patients to receive buprenorphine. [Patients of color](https://www.nejm.org/doi/full/10.1056/NEJMsa2212412) are often directed instead to methadone clinics — and even when they do receive buprenorphine, [the average course of treatment is shorter](https://www.nytimes.com/2022/11/09/health/opioid-addiction-treatment-racial-disparities.html). Our very ideas of what it means to recover are still bound up with the stigmatized, criminalized history of addiction. A common [misconception](https://pcssnow.org/courses/myths-and-misconceptions-medications-for-opioid-use-disorder-moud/) among the [public](https://osf.io/uwhcn), experts told me, and even [some](https://www.jsatjournal.com/article/S0740-5472(20)30433-5/fulltext) [care](https://www.sciencedirect.com/science/article/pii/S0740547221002117) [providers](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10040326/) and [people who use drugs themselves](https://www.nytimes.com/2018/12/29/health/opioid-rehab-abstinence-medication.html), is that recovery with buprenorphine or methadone isn’t “real” recovery; that it just replaces one addiction with another. “We think of addiction, which is a lifetime-long problem, as being like pneumonia or some other kind of infection,” Ling said. “You come off \[the drugs\], and then people say, ‘Why can’t they just go back to their old self?’ But they can’t. Substance use has irreversible effects on the body and the brain.” Some people need to stay on MAT for years or decades — and that’s okay, Ling says. Some experts push this argument further, challenging the notion that being in recovery necessarily means getting off drugs altogether. “My goals for my patients are that they are alive, healthy, and able to have a connected, meaningful life,” said Sue of Yale, who is the former medical director of the National Harm Reduction Coalition. “I do not care how much or what they use in order to achieve that.” For some people, that means strict sobriety; for others, it might mean using drugs less often, or using certain drugs but not others. Sue never mandates abstinence. “The first thing I always ask my patients is, ‘What are your goals, in regards to your substance use?’” Sue told me. “Most people have never been asked that question.” Providers on the cutting edge of addiction treatment are increasingly moving toward this approach, with greater emphasis on harm reduction, an [evidence-based, albeit controversial, strategy](https://www.samhsa.gov/find-help/harm-reduction) that aims to minimize the damaging effects of drug use rather than fixating on forcing patients to get “clean.” In a society raised on the concept of total [abstinence](https://www.npr.org/2023/11/09/1211217460/fentanyl-drug-education-dare) from drugs, that can be a tough sell politically — but the idea is that opioid addiction is a serious illness, and breaking an addiction to opioids is extremely hard (as Ling said, patients can’t simply go back to their old selves). Harm reduction is in part about finding an approach that will actually work for people: reaching those who might not otherwise seek care, empowering them to make their own choices, and helping them work toward incremental changes. Harm reduction measures include safe consumption sites (where people use drugs under the supervision of trained medical professionals), syringe exchange programs (where users can obtain clean needles), distribution programs for naloxone (a medication that can reverse an overdose), and [fentanyl test strips](https://www.cdc.gov/stopoverdose/fentanyl/fentanyl-test-strips.html) (which can prevent overdoses by detecting whether someone’s drugs contain fentanyl). “Any positive change — that’s sort of the mantra of harm reduction,” said Sue. ### Cutting-edge treatments don’t mean much if patients can’t access them A visit last fall with one of Sarah Wakeman’s patients during a checkup in her Boston clinic gave me a glimpse of addiction treatment — and the barriers that work against it. Samuel (who’s being referred to by a pseudonym to protect his privacy) first encountered opioids in high school, when his doctor prescribed them (“pretty heavily,” he said) for a wrestling injury. “I found out that I liked it,” he said, and he became addicted in college, after experimenting with drugs with a roommate. Before long, he wound up on heroin. For several years, his life unraveled: debt, lost jobs, defaulted loans, an arrest, multiple trips to rehab and 12-step programs. Samuel found his way to Wakeman’s practice a few years ago. He’s stable now, taking buprenorphine — with a job and an apartment and a new puppy. But he told me he’d encountered judgment and distrust from many of the people he initially looked to for help, even those whose job it is to help him, like doctors and psychiatrists. Even now, pharmacists sometimes hesitate to refill his buprenorphine prescription, leading him to stash extra doses so he doesn’t run out, he said, which can be “dangerous behavior” for someone with an addiction. That stigma compounds the hurdles that are already a part of buprenorphine treatment. Although it’s intended to be a long-term therapy, as a controlled substance, it is prescribed in small increments that must be refilled every few days or weeks. If he’d been any less motivated to get better, he told me, he’s not sure he would have made it — or, he added, if he’d been any less privileged: Samuel is an educated white man in his mid-30s who grew up in a family of medical professionals. The logistical and ideological obstacles to treatment are, of course, tied to the kinds of people who bear the brunt of the epidemic — those who exist, in one way or another, on the margins of society. Addiction is one of a cluster of interconnected crises unfolding across the country: homelessness, poverty, mental illness, untreated trauma, an [epidemic of loneliness](https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(23)00957-1.pdf). Opioid overdoses [spiked](https://pubmed.ncbi.nlm.nih.gov/33856885/) in 2020 [during the onslaught of Covid-19](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8856931/#CR3), in part because people were isolated from each other as well as from treatment. [Racism](https://pubmed.ncbi.nlm.nih.gov/37163624/) [plays](https://www.scientificamerican.com/article/the-opioid-epidemic-now-kills-more-black-people-than-white-ones-because-of-unequal-access-to-treatment/) a major role in limiting access to treatment, too, as does [mass incarceration](https://www.vox.com/policy-and-politics/2018/3/13/17020002/prison-opioid-epidemic-medications-addiction). There’s a shortage of addiction care providers, particularly in rural America, where the scarcity of basic primary care for all types of patients is [increasingly](https://www.politico.com/news/2023/11/26/future-of-primary-care-family-medicine-00128547) [dire](https://www.statnews.com/2023/09/25/rural-health-doctor-shortage-physicians/#:~:text=In%202023%2C%2065%25%20of%20rural,Health%20Resources%20and%20Services%20Administration.). Until recently, nearly [60 percent](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8920951/#:~:text=While%20the%20addiction%20treatment%20workforce,acute%20with%20respect%20to%20physicians.) of rural people lived in counties without a single doctor authorized to prescribe buprenorphine. (That changed [last year](https://www.statnews.com/2023/02/14/x-waiver-buprenorphine-prescribing-gone-spread-the-word/), after a law requiring providers to obtain a special waiver to dispense the medication was eliminated.) In Madison, Wisconsin, where [Elizabeth Salisbury-Afshar](https://www.fammed.wisc.edu/directory/18926) practices addiction medicine, it’s not unusual for patients to travel one or two hours each way to her clinic “for an appointment that’s maybe 30 minutes long,” she says. “It’s a full-day endeavor. But folks don’t have another choice.” In rural areas, Salisbury-Ashfar said, many of the primary care doctors who would be the first line of addiction treatment are too overwhelmed to provide it. “The providers that we have, we’re just trying not to burn them out, because we are short-staffed on every front,” she said. “We would love to have enough primary care docs to be doing this, but primary care docs can’t keep up with primary care.” It’s not enough to have a breakthrough treatment like MAT if the people who need it can’t get it — or can’t stay in it. Among the “compounding mistakes and failures” that led to the current crisis is the fact that “our health care system is not set up well to accommodate people who are vulnerable or marginalized,” a group that includes most of those with addiction, said Joudrey, the Pittsburgh addiction doctor. “In the United States, we’ve become so focused on innovation and looking for technological solutions, we can end up neglecting the sociological and economic contributors of the overdose epidemic.” Joudrey told me about a patient he met years ago in a mobile treatment program. He started her on buprenorphine, which helped her stop using fentanyl, and every year afterward, she would send a thank-you email. “She was just thrilled,” he recalled. But she was also socially isolated and stuck in a dead-end job that didn’t quite pay the bills. This precarity left her at greater risk of falling back into drugs. “The medicine didn’t change her larger social circumstances,” Joudrey said. “As a clinician, as a researcher, it’s sort of grappling with what we can and can’t do, in terms of the limits of health care and medicine.” ### We have low-effort interventions that can make a difference These experiences hammer home the urgent need to build a different treatment architecture to lower overdose deaths. Research has outlined a number of promising approaches. Some have begun gaining traction already, including harm reduction. Although contentious for many years because many believed it enabled drug use, [harm reduction](https://www.samhsa.gov/find-help/harm-reduction) has been gaining mainstream acceptance among [providers](https://www.aamc.org/news/drug-overdoses-soar-more-providers-embrace-harm-reduction) and [policymakers](https://www.whitehouse.gov/briefing-room/statements-releases/2022/04/21/fact-sheet-white-house-releases-2022-national-drug-control-strategy-that-outlines-comprehensive-path-forward-to-address-addiction-and-the-overdose-epidemic/). [Decades](https://pubmed.ncbi.nlm.nih.gov/17132577/) of [research](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7021582/), in the [US](https://pubmed.ncbi.nlm.nih.gov/35273933/) as well as in countries [like Canada](https://www.npr.org/2022/09/15/1123108839/controversial-harm-reduction-strategies-appear-to-slow-drug-deaths) and [Ukraine](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4396789/), show that it saves both lives and money. Despite [halting and uneven progress](https://cchcs.ca.gov/wp-content/uploads/sites/60/MAT-in-United-States-Jails-and-Prisons-Final.pdf), a nationwide push to bring MAT into jails and prisons — driven in part by [ACLU lawsuits](https://www.aclu.org/press-releases/aclu-releases-report-treatment-incarcerated-people-opioid-use-disorder) in several states — is [picking up momentum](https://www.nytimes.com/2023/04/21/us/politics/prisons-opioid-addiction-treatment.html). The need for this is urgent: Overdose deaths from drugs or alcohol [rose by 600 percent](https://www.themarshallproject.org/2021/07/15/inside-the-nation-s-overdose-crisis-in-prisons-and-jails) in state prisons between 2001 and 2018, according to the Bureau of Justice Statistics — which [estimated](https://bjs.ojp.gov/content/pub/pdf/dudaspji0709_sum.pdf) in 2009 (the most recent year with national data) that almost two-thirds of incarcerated people have substance use disorders. A 2015 [study](https://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2018.304514?journalCode=ajph) in North Carolina found that the risk of overdose was as much as 40 times higher for those recently released from prison than for other state residents. In 2014, Massachusetts General Hospital in Boston, where Wakeman practices, opened [one of the first](https://www.wbur.org/news/2018/03/07/mgh-addiction-medication) “bridge clinics” in the country, intended to bridge the gap between a patient’s discharge from the emergency room (after, say, an overdose) and longer-term addiction treatment — a critical moment, Wakeman told me, when the risk of relapse or overdose is high. Patients can walk into the bridge clinic without an appointment — from the emergency department down the hall, or simply right off the street — and begin buprenorphine treatment that day. They can also receive psychiatric counseling services, recovery coaching, and nursing care, and the clinic keeps harm reduction supplies for patients still using. If they want to, Wakeman said, people can just have a cup of coffee and “hang out here if they need a place to be okay.” Bridge clinics have been opening up at other sites, too, including [dozens in California alone](https://www.annemergmed.com/article/S0196-0644(21)00434-0/fulltext), and early evidence shows they’ve led to [promising rates](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10101823/#CR22) of MAT treatment and [linked patients](https://pubmed.ncbi.nlm.nih.gov/36402631/) to longer-term addiction care. Those effects can ripple through other parts of the hospital. One [study](https://pubmed.ncbi.nlm.nih.gov/34118702/) by researchers in Syracuse, New York, found that emergency department visits dropped by 42 percent in the six months after a bridge clinic opened. Research also indicates that bridge clinics help fill a void in care for patients with [“clinically complex” cases](https://pubmed.ncbi.nlm.nih.gov/33270549/): patients with concurrent addictions to other substances, serious mental illness, homelessness, and infections like HIV or hepatitis. Where primary care doctors are stretched thin, nurses could fill gaps in access to care. Since 2016, federal regulations have allowed nurse practitioners and physician assistants (PAs) to prescribe buprenorphine, but [laws](https://www.healthaffairs.org/content/forefront/effects-comprehensive-addiction-and-recovery-act-2016-nurse-practitioner-and-physician) in [some states](https://www.sciencedirect.com/science/article/pii/S0740547221004414), including those hit hard by the overdose crisis, still block them from providing that care. Tennessee explicitly forbids nurses and PAs from prescribing buprenorphine. “So you can’t do everything you’re educated and certified to do,” said [Matthew Tierney](https://profiles.ucsf.edu/matt.tierney), a psychiatric nurse practitioner and clinical professor at the University of California San Francisco, who serves as medical director for inpatient substance use management for UCSF Health. Advanced practice nurses, he said, especially those in [mental health](https://www.vox.com/mental-health), “have the education and training to really treat substance related disorders.” When federal rules opened up prescribing to nurses and PAs, they began applying for licenses [in higher numbers](https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2022.00310) than physicians. Bringing methadone care into normal medical settings, like in other countries, would be a [huge step](https://academic.oup.com/healthaffairsscholar/article/1/5/qxad061/7378813?login=false) in opening up access. Early in the Covid pandemic, many methadone clinics [relaxed](https://apnews.com/article/science-health-pandemics-coronavirus-pandemic-c36442b3fe8f2074e2fe3907d11ca579) their rules, allowing more take-home doses and letting family members pick up medications for patients in quarantine — [offering a glimpse of](https://ajph.aphapublications.org/doi/full/10.2105/AJPH.2021.306654) what lasting change [might look like](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7834469/). A bill before [Congress](https://www.vox.com/congress), the Modernizing Opioid Treatment Access Act (MOTA), would effectively make that permanent, authorizing addiction medicine physicians and psychiatrists to prescribe methadone. Studies [indicate](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10256218/) that patients are no more likely to overdose or abuse the medication when they’re able to take home a longer supply. In fact, it seems to [help survival rates](https://pubmed.ncbi.nlm.nih.gov/26455554/). Among addiction specialists, opinions about MOTA are, admittedly, not uniform — some worry the bill [goes too far](https://www.medpagetoday.com/opinion/second-opinions/107435?xid=nl_secondopinion_2023-11-21&eun=g2234136d0r) and would put patients at risk of methadone overdose, while others [think](https://www.healthaffairs.org/content/forefront/save-lives-opioid-overdose-deaths-bring-methadone-into-mainstream-medicine) it doesn’t go [far enough](https://filtermag.org/whiteout-opioids-race-capitalism/) in expanding access. [Rachel Simon](https://www.nychealthandhospitals.org/doctors/simon-rachel-elizabeth/), a doctor who practices at the methadone clinic in New York’s Bellevue Hospital, sees MOTA as “a crucial first step” to lowering treatment barriers. “Methadone is a beautiful medicine,” she told me. “The time to make changes was yesterday.” ### What if we remove treatment from sterile medical settings? For some patients, it might help to disentangle addiction care from formal medical settings. Context matters, and making treatment more culturally authentic can succeed where other approaches fail. The Connecticut-based Imani Breakthrough Project, launched in 2017, brings addiction care into Black and [Latinx](https://www.vox.com/the-highlight/2019/10/15/20914347/latin-latina-latino-latinx-means) churches as a way to address racial disparities in treatment. Developed by Yale addiction psychiatrists [Ayana Jordan](https://medicine.yale.edu/profile/ayana-jordan/) and [Chyrell Bellamy](https://medicine.yale.edu/profile/chyrell-bellamy/), the program (“Imani” means “faith” in Swahili) consists of weekly mutual support and recovery education classes alongside individualized coaching and cognitive behavioral therapy, all held in churches. “This project was really born out of a dire need,” Jordan told me — at a time when Black and Hispanic overdose deaths were climbing, but the media was primarily focused on the epidemic’s white, rural victims. While they were developing the program, Jordan said, “overwhelmingly, what we found is that people didn’t want to come into traditional care. They didn’t feel safe.” (Black Americans in particular often [distrust the medical establishment](https://pubmed.ncbi.nlm.nih.gov/34244014/) — with [good](https://www.pbs.org/newshour/show/with-a-history-of-abuse-in-american-medicine-black-patients-struggle-for-equal-access) [historical](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4354806/) [reason](https://www.penguinrandomhouse.com/books/185986/medical-apartheid-by-harriet-a-washington/).) And for many patients, spirituality was important to recovery, Jordan told me, so the church itself represented a form of intervention: a sacred and familiar space where people in the community felt known. Originally located in eight churches across Connecticut, the program recently expanded into Rhode Island and [New Orleans](https://theneworleanstribune.com/2023/07/19/mhsd-faith-based-partners-yale-university-launch-program-to-fight-the-opioid-crisis-in-new-orleans/), with plans to open in Boston and New York City. In 2021, Jordan and her team launched a new version of the Imani program as a five-year NIH-funded project, in which participants can consult with Black or Latinx psychiatrists via telehealth to start MAT in their church. The eventual goal, she told me, is to implement the Imani model nationwide. According to a [study](https://pubmed.ncbi.nlm.nih.gov/37207836/) of Imani’s first three years, a striking 42 percent of participants remained in the program after 12 weeks. (There isn’t a perfect comparison to treatment in a standard medical setting, but [a 2016 analysis](https://www.sciencedirect.com/science/article/abs/pii/S0306460316300648?via%3Dihub) of addiction treatment data found that 20 percent of Black patients and 15 percent of Latinx patients completed their programs, compared to 60 percent of white patients.) Participants also improved their scores on tests measuring [wellness](https://www.vox.com/health) and community citizenship. “And we had great outcomes in terms of stopping substance use altogether, or decreasing their substance use,” Jordan told me. Recalling the early sessions, Jordan said, “We were seeing for the first time an environment that is really clear about the sovereignty of being Black or Latinx.” In a country where the dual identity of being a person of color with addiction means that “you’re totally thrown away,” she said, having a place where “church members alongside people who look like you, welcome you, and also integrate medical practices into the group is extremely powerful.”

Three years ago, when Oregon voters approved a pioneering plan to decriminalize hard drugs, advocates looking to halt the jailing of drug users believed they were on the edge of a revolution that would soon sweep across the country. But even as the state’s landmark law took effect in 2021, the scourge of fentanyl was taking hold. Overdoses soared as the state stumbled in its efforts to fund enhanced treatment programs. And while many other downtowns emerged from the dark days of the pandemic, Portland continued to struggle, with scenes of drugs and despair. Lately, even some of the liberal politicians who had embraced a new approach to drugs have supported an end to the experiment. On Friday, a bill that will reimpose criminal penalties for possession of some drugs won final passage in the State Legislature and was headed next to Gov. Tina Kotek, [who has expressed alarm about open drug use](https://www.nytimes.com/2023/12/11/us/portland-oregon-drug-laws.html) and helped broker a plan to ban such activity. “It’s clear that we must do something to try and adjust what’s going on out in our communities,” State Senator Chris Gorsek, a Democrat who had supported decriminalization, said in an interview. Soon after, senators took the floor, with some sharing stories of how addictions and overdoses had impacted their own loved ones. They passed the measure by a 21-8 margin. The abrupt rollback is a devastating turn for decriminalization proponents who say the large number of overdose deaths stems from a confluence of factors and failures largely unrelated to the law. They have warned against returning to a “war on drugs” strategy and have urged the Legislature to instead invest in affordable housing and drug treatment options. The Joint Interim Committee on Addiction and Community Safety Response discussing the effects of and changes to Measure 110 at the Oregon State Capitol in Salem last month.Credit...Jordan Gale for The New York Times Thank you for your patience while we verify access. If you are in Reader mode please exit and [log into](https://myaccount.nytimes.com/auth/login?response_type=cookie&client_id=vi&redirect_uri=https%3A%2F%2Fwww.nytimes.com%2F2024%2F03%2F01%2Fus%2Foregon-drug-decriminalization-rollback-measure-110.html&asset=opttrunc) your Times account, or [subscribe](https://www.nytimes.com/subscription?campaignId=89WYR&redirect_uri=https%3A%2F%2Fwww.nytimes.com%2F2024%2F03%2F01%2Fus%2Foregon-drug-decriminalization-rollback-measure-110.html) for all of The Times. Thank you for your patience while we verify access. Already a subscriber? [Log in](https://myaccount.nytimes.com/auth/login?response_type=cookie&client_id=vi&redirect_uri=https%3A%2F%2Fwww.nytimes.com%2F2024%2F03%2F01%2Fus%2Foregon-drug-decriminalization-rollback-measure-110.html&asset=opttrunc). Want all of The Times? [Subscribe](https://www.nytimes.com/subscription?campaignId=89WYR&redirect_uri=https%3A%2F%2Fwww.nytimes.com%2F2024%2F03%2F01%2Fus%2Foregon-drug-decriminalization-rollback-measure-110.html).

/cdn.vox-cdn.com/uploads/chorus_image/image/73211364/AP24062114153683.0.jpg) Oregon Gov. Tina Kotek speaks during a signing ceremony for HB4002, re-criminalizing personal possession of controlled substances, including psychedelics. Susan Walsh/AP In 2020, it looked as though the [war on drugs](https://www.vox.com/drug-war) would begin to end in Oregon. After [Measure 110](https://www.courts.oregon.gov/about/Documents/BM110Statistics.pdf) was passed that year, Oregon became the first state in the US to decriminalize personal possession of all drugs that had been outlawed by the [Controlled Substances Act](https://www.dea.gov/drug-information/csa#:~:text=The%20Controlled%20Substances%20Act%20(CSA,and%20safety%20or%20dependence%20liability.) in 1970, ranging from heroin and cocaine to LSD and psychedelic mushrooms. When it went into effect in early 2021, the move was [celebrated](https://drugpolicy.org/news/drug-decriminalization-oregon-one-year-later-thousands-lives-not-ruined/) by drug reform advocates who had long been calling for decriminalization in the wake of President Nixon’s [failed war on drugs.](https://www.npr.org/2021/06/17/1006495476/after-50-years-of-the-war-on-drugs-what-good-is-it-doing-for-us) Now, amid a spike in [public](https://www.nytimes.com/2023/07/31/health/portland-oregon-drugs.html) drug use and [overdoses](https://www.koin.com/news/oregon/fentanyl-deaths-highest-increase-in-country/), Oregon is in the process of reeling back its progressive drug laws, with a [new bill](https://olis.oregonlegislature.gov/liz/2024R1/Downloads/MeasureDocument/HB4002) that aims to reinstate lighter criminal penalties for personal drug possession. And while the target is deadly drugs like fentanyl, the law would also result in banning non-clinical use of psychedelics like MDMA, DMT, or psilocybin — drugs that are unconnected to the current overdose epidemic and the public displays of drug use. By treating all drugs as an undifferentiated category, Oregon is set to deliver a major blow to advocates of psychedelic use who don’t want to see expensive clinics and tightly controlled environments be the only legal point of access. While regulated and supervised models for using psychedelics are showing growing promise for [treating mental illness](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9553847/), decriminalized use allows for a much wider spectrum of user motivations — many of which have occurred [for millennia](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8412860/) — no less deserving of legal protection, from recreational and spiritual to the simple pleasure of spicing up a museum visit with a small handful of mushrooms. “The biggest threat to psychedelics is from people who would claim to be for them in extremely limited contexts and against them in all others,” said Jon Dennis, a lawyer at the Portland-based firm Sagebrush Law specializing in psychedelics. It would be one thing if arguments against the decriminalization of psychedelics were being made. But that’s not the case. Instead, the lumping together of psychedelics and opioids seems to have gone largely unnoticed, setting up personal use of psychedelics to become an unintended casualty of Oregon’s opioid crisis. ### How Oregon decriminalized drugs The idea behind drug decriminalization was that investing in health services and harm reduction are more effective and humane responses to substance abuse than incarceration. The hope was for Oregon to serve as inspiration for other states, and eventually the nation, to follow suit. But in the years that followed, Oregon fell deeper into an opioid and drug overdose crisis that has been [surging across the nation](https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)02252-2/abstract). In 2021, the US had [over 80,000](https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates) opioid-related overdose deaths. Beyond the death toll, critics — [fairly or unfairly](https://www.nytimes.com/2024/02/05/opinion/oregon-decriminalization-drugs-reversal.html) — connected decriminalization to the rising [visibility of drug use](https://www.pbs.org/newshour/politics/with-oregon-facing-rampant-public-drug-use-lawmakers-backpedal-on-pioneering-decriminalization-law) and [homelessness in Oregon towns and cities,](https://www.oregonlive.com/politics/2023/12/oregon-has-highest-rate-of-homeless-families-in-the-country.html#:~:text=The%20state%27s%20homeless%20population%20increased,the%20worst%20of%20it%20yet.) including open-air fentanyl markets [popping up](https://www.oregonlive.com/crime/2023/04/alarming-spate-of-overdoses-draws-scrutiny-to-open-air-fentanyl-market-in-downtown-portland.html) in downtown Portland. That put increasing pressure on Oregon legislators to do something to change the state’s drug policy. The new solution crafted by state Sen. Kate Lieber and state Rep. Jason Kropf — [House Bill 4002](https://olis.oregonlegislature.gov/liz/2024R1/Downloads/MeasureDocument/HB4002) — is intended as a compromise between the full decriminalization of Measure 110 and the status quo before that leaned heavily on incarceration for drug possession. While improving access to substance abuse treatments — like reducing barriers to receiving medication and encouraging counties to direct offenders to treatment programs rather than court — the bill recriminalizes personal possession of all controlled substances (except for cannabis), bringing back the possibility of jail time for possession of even relatively small amounts. Oregon Gov. Tina Kotek last week [announced](https://www.oregon.gov/newsroom/pages/newsdetail.aspx?newsid=215409) that she intends to sign the bill within 30 days of it clearing both state legislatures with bipartisan support. It’s been [widely](https://www.cnn.com/2024/03/08/politics/oregon-drug-laws-recriminalization/index.html) described as “this very precise [amendment](https://www.opb.org/article/2024/03/08/oregon-governor-tina-kotek-bill-ending-drug-decriminalization-expand-treatment/) that’s only going to address the problems with Measure 110, which were thought to be opioids and meth,” said Dennis. But the bill turns out to be much larger in scope than advertised. Instead of specifically targeting the opioids and methamphetamine that have been behind most overdose deaths, HB4002 also recriminalizes personal possession of psychedelic drugs like psilocybin mushrooms, MDMA, and LSD. Unlike the concern around [opioids](https://www.nytimes.com/2023/08/01/opinion/oregon-drug-failure.html) (including synthetic ones like fentanyl, which are responsible for the [majority of overdoses](https://www.cdc.gov/drugoverdose/deaths/index.html#:~:text=Drug%20Overdose%20Deaths%20Remained%20High%20in%202021&text=Opioids%E2%80%94mainly%20synthetic%20opioids%20(other,of%20all%20drug%20overdose%20deaths).)) or meth, neither the public nor experts have reported significant negative effects from the decriminalization of psychedelics. “All of the conversations around the legislature didn’t think to distinguish between these different classes of drugs,” Dennis said. “I think this was just a broad oversight on their part, rather than nuanced policy discussions.” There are no op-eds being written about tripping hippies filling public spaces in grand displays of love and cosmic beatitude. The streets are not littered with acid blotter paper or mushroom caps. Psychonauts aren’t seeking out [encounters with DMT entities](https://newrepublic.com/article/169525/psychonauts-training-psychedelics-dmt-extended-state) in public parks. No argument for recriminalizing psychedelics has been made, and yet, they’re being swept into a recriminalization bill by the debate around opioids. Psychedelics have [uncommon](https://www.sciencedirect.com/science/article/pii/S0165032723000915?via%3Dihub) but potentially serious [risks of their own](https://www.vox.com/future-perfect/23954347/psychedelics-bad-trips-ketamine-mdma-psilocybin-lsd-risks), including short-term encounters with intense anxiety and [long-term battles](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10597511/) with destabilizing [experiences](https://bulletin.hds.harvard.edu/a-theological-reckoning-with-bad-trips/). Access to safety information and [support](https://challengingpsychedelicexperiences.com/help-for-difficult-trips) is crucial for their use. On the whole, psychedelics are [far safer](https://www.vice.com/en/article/43gey3/mushrooms-are-the-safest-drug-you-can-take) than many other legally accessible substances, and the list of therapeutic, spiritual, and creative benefits seems to grow each month, from alleviating [depression](https://www.vox.com/future-perfect/2020/10/9/21506664/psychedelics-mental-health-depression-ptsd-psilocybin-mdma) and addiction to combating [eating disorders](https://www.nature.com/articles/s41591-023-02455-9) and helping [find meaning in life](https://www.vox.com/future-perfect/23972716/psychedelics-meaning-science-psychedelic-mushrooms-ketamine-psilocybin-mysticism). Expanding access through decriminalization (together with public education and clinical resources for those in need) could help make the most of these benefits. ### What HB 4002 will do Before Measure 110, possession of a controlled substance like LSD or heroin in Oregon could be charged as a Class A misdemeanor, carrying a maximum of one year in jail and fines up to [$6,250](https://oregon.public.law/statutes/ors_161.635). Measure 110, which passed November 2020 with [58 percent](https://ballotpedia.org/Oregon_Measure_110,_Drug_Decriminalization_and_Addiction_Treatment_Initiative_(2020)) of the vote, was intended to treat substance abuse as a [public health](https://www.vox.com/public-health) issue, rather than a criminal one. It created a new category for possession of small amounts of controlled substances — Class E violations — that came with no jail time and a maximum of a $100 fine that could be waived if the individual chose to complete a health assessment. Effectively, it meant that getting caught with illegal drugs could, at worst, get you the equivalent of a traffic ticket. The new bill, HB 4002, scraps the Class E category altogether. If it goes into effect on September 1, possession of small amounts of controlled substances will once again be punishable with criminal offenses, though less severe than the way things worked prior to Measure 110. Instead of Class E violations, personal possession of controlled substances will be considered a “drug enforcement misdemeanor,” which carries a maximum of 180 days in jail, though with a series of intervening steps designed to “deflect” individuals toward treatment rather than incarceration. Even after HB4002 goes into effect, “Oregon will be in a better position than it was prior to Measure 110,” said [Kellen Russoniello](https://drugpolicy.org/person/kellen-russoniello/), senior policy counsel at the [Drug Policy Alliance](https://drugpolicy.org/). The new criminal penalties are designed to try to get people into treatment, rather than prison. “But it’s still a step backward from decriminalization.” Sen. Lieber’s office provided me with a diagram Thursday to show all the steps meant to reduce the odds that someone charged with a drug enforcement misdemeanor will wind up in jail: :no_upscale()/cdn.vox-cdn.com/uploads/chorus_asset/file/25338553/Oregon_Drug_Intervention_Plan_PCS_U_Flow_Chart.png) Courtesy of Sen. Kate Lieber’s office The bill does not affect [Measure 109](https://www.oregonlegislature.gov/bills_laws/ors/ors475A.html), which implemented Oregon’s [regulated access to psilocybin mushrooms](https://www.nytimes.com/2023/01/03/health/psychedelic-drugs-mushrooms-oregon.html). Under that model, adults can sign up for a supervised psilocybin session at a licensed facility, which can cost anywhere from about $1,000 to $3,000. Regulated [ketamine clinics](https://www.npr.org/sections/health-shots/2024/01/30/1227630630/ketamine-infusion-clinic-mental-health-depression-anxiety-fda-off-label), where people can receive ketamine under supervision to treat conditions like depression or anxiety, are also unaffected. But it does ensure that regulated access is the only way to legally use psychedelics, walking back the decriminalization that allowed for more affordable and unconstrained personal consumption on one’s own terms. ### The opioid crisis created support for quickly passing HB-4002 While decriminalization has become a focal point in the debate over drugs, Oregon’s opioid crisis was escalating before 2020. From 2019 to 2020, unintentional opioid deaths in Oregon rose by [about 70 percent](https://www.oregon.gov/oha/PH/PREVENTIONWELLNESS/SUBSTANCEUSE/OPIOIDS/Documents/quarterly_opioid_overdose_related_data_report.pdf). After Measure 110 took effect in February 2021, the surge continued. In 2021, deaths rose another 56 percent, and another 30 percent in 2022. Despite the trends predating decriminalization, critics [felt](https://www.nytimes.com/2023/08/01/opinion/oregon-drug-failure.html) that the rise in overdose deaths, public displays of drug use, and crime were attributable to Measure 110. That provided a strong base of support for HB-4002. An [April 2023 survey](https://www.dhmresearch.com/wp-content/uploads/2023/05/DHM-Panel-Oregon_Measure110_May-2023.pdf) of 500 Oregon voters found that 63 percent supported bringing back criminal penalties for drug possession while continuing to use cannabis tax revenue for drug treatment programs. The bill was sold as a compromise that would stem the chaos that Measure 110 had allegedly unleashed. But during the post-decriminalization years that saw Oregon’s opioid crisis continue to worsen, the same trends were taking place [across the country](https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates), including in [neighboring states](https://s3.amazonaws.com/assets.cfsecosystem.com/m110/Presentations/Panel1_Kral_Final.pdf) that hadn’t decriminalized opioids, like California and Nevada. A [study](https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2809867) led by the New York University Grossman School of Medicine and published in _JAMA Psychiatry_ found that in Oregon and Washington, both states that had drug decriminalization policies in 2021, there was no evidence for an association between decriminalization and drug overdose rates. A [second study](https://s3.amazonaws.com/assets.cfsecosystem.com/m110/Presentations/Panel+1_Del+Pozo.pdf), led by public health researcher [Brandon del Pozo](https://vivo.brown.edu/display/bdelpozo) of Brown University and funded by the National Institute on Drug Abuse, replicated the findings for Oregon: no link between decriminalization and drug overdoses. Instead, most of the spike was attributed to the introduction of fentanyl into the general drug supply. Fentanyl is up to [50 times stronger](https://www.cdc.gov/stopoverdose/fentanyl/index.html) than heroin, and is often laced into unregulated drugs like heroin or cocaine, making it far more likely than other drugs to lead to fatal overdoses. Much of the public sentiment’s [swing](https://www.dhmresearch.com/wp-content/uploads/2023/05/DHM-Panel-Oregon_Measure110_May-2023.pdf) against decriminalization centers around the visibility of drug use, rather than the numerical impact on overdose deaths. So it’s worth noting that the same year that decriminalization was passed, Covid-era eviction protections also expired. After plummeting in 2020 and 2021, the eviction rate shot back up in 2022 [by nearly 25 percent](https://drugpolicy.org/wp-content/uploads/2024/02/DPA-WhatReallyHappenedM110.pdf). Between 2022 and 2023, the state’s homeless population rose by 12 percent. None of this is to definitively say that Oregon’s decriminalization did nothing to worsen the opioid crisis, but their [less-than-ideal](https://www.propublica.org/article/oregon-leaders-hampered-drug-decriminalization-effort#:~:text=This%20is%20the%20day%2Dto,for%20law%20enforcement%20in%20Oregon.) implementation certainly seemed to amplify the visibility and social disorder associated with it. By failing to fund programs that would have trained law enforcement (who were [generally skeptical of decriminalization](https://www.rollingstone.com/politics/politics-features/oregon-drug-war-decriminalization-1234982783/) to begin with) on how to direct drug users toward rehabilitation or designing a ticketing system that emphasized treatment information, even advocates of Measure 110 were dismayed with the form it took through implementation. “Certainly, there’s a sense among Oregon voters that what’s going on isn’t working,” said Russoniello. But blaming Measure 110 has been called political [fearmongering](https://www.nytimes.com/2024/02/05/opinion/oregon-decriminalization-drugs-reversal.html), rather than evidence-based policy. “The opposition was able to take the frustration with all of these social issues that Oregonians are facing and direct people’s frustration and anger at the big red herring of Measure 110, even though it isn’t backed by any sort of evidence.” And wherever the debate falls on what’s fueling the opioid crisis, psychedelics are another matter entirely. ### Why are we punishing psychedelics for an ongoing debate about opioids? There’s reasonable and urgent debate to be had over the best way to regulate opioids and support users. [Advocates maintain](https://drugpolicy.org/wp-content/uploads/2024/02/DPA-WhatReallyHappenedM110.pdf) that a well-implemented decriminalization approach is both more effective and equitable (minority groups are [significantly overrepresented](https://www.oregon.gov/cjc/CJC%20Document%20Library/AdultCJSystemRacialandEthnicStatementBackground.pdf) in Oregon’s [criminal justice](https://www.vox.com/criminal-justice) system) than returning to criminal penalties, even if recriminalization comes with “[deflection](https://www.oregonlive.com/politics/2024/02/multnomah-county-signs-on-to-measure-110-diversion-approach-seeks-25-million-for-deflection-center.html)” programs in place designed to make incarceration the sanction of last resort. And yet, when it comes to psychedelics, the same questions, concerns, and sense of urgency present in the opioid crisis are notably absent. The therapeutic value of psychedelics in regulated settings is well on its way to federal recognition, with the FDA [expected](https://theintercept.com/2022/07/26/mdma-psilocybin-fda-ptsd/) to approve MDMA for treating PTSD as soon as [this August](https://www.psychiatrictimes.com/view/fda-accepts-grants-priority-review-of-nda-for-mdma-assisted-therapy-for-ptsd), and psilocybin for depression to follow suit. But decriminalization can serve as a [complement to the shortcomings](https://eujournalfuturesresearch.springeropen.com/articles/10.1186/s40309-022-00199-2) of [medicalized psychedelics](https://akjournals.com/view/journals/2054/4/1/article-p34.xml), helping to mitigate concerns around access, affordability, and preserving the [diversity of purposes](https://www.vox.com/future-perfect/23721486/ketamine-dmt-lsd-psychedelics-magic-mushrooms-legalization-recreation-psilocybin) for which psychedelics have long been used. Critics of what has been called “[psychedelic exceptionalism](https://psychedelicstoday.com/2020/02/18/psychedelic-exceptionalism-and-reframing-drug-narratives-an-interview-with-dr-carl-hart/)” argue that the law should not encode moral judgments that label some drugs as better or worse than others. The logic of decriminalization applies to all drugs, not only those that are more politically or culturally palatable. In fact, “The impact of decriminalization of heroin, methamphetamine, and cocaine will be greater than for psychedelics,” said Russoniello, “because more people are incarcerated for those drugs than for psychedelics.” Even so, that shouldn’t mean that progress on decriminalizing psychedelics should get stymied by the ongoing debate over opioids. So far, experts I spoke with who were concerned about criminalizing psychedelics despite the lack of evidence or argument for it could point to no public efforts to change the bill or clarify its effects. “I don’t think most legislators even really knew that this \[HB4002\] was recriminalizing all drugs,” said Dennis. HB-4002 now awaits Gov. Kotek’s signature.

Media caption, Watch: A recovered addict's view on decriminalisation **Last year, British Columbia (BC) became the first province in Canada to decriminalise the use of hard drugs as part of its efforts to tackle a deadly opioids crisis. But the policy is facing pushback, leaving its future uncertain.** Every Monday, former Vancouver Mayor Kennedy Stewart would receive an email listing all the people who had died in the city from a drug overdose the previous week. One day, three years ago, that list included the name of a relative - his brother-in-law's sister, Susan Havelock. "She died out here on the street at two o'clock in the morning," Mr Stewart told the BBC at his office in Downtown Vancouver, pointing out the window. "When it gets in your family, you begin to see how desperate this whole situation is." North America is in the midst of a toxic drug crisis. Fatal overdoses peaked above 112,000 in the US for the first time last year. In Canada, nowhere is this issue felt more acutely than in BC, where the crisis was first declared a public health emergency in 2016. Last year, the province saw a record of more than 2,500 overdose deaths. About 225,000 people are estimated to use illegal drugs in BC, and experts say a toxic street drug supply - laced with fentanyl and other products - places each of them at risk of death. In an attempt to address the crisis in January 2023, BC became the first - and only - province in Canada to decriminalise the possession of a small amount of hard drugs, to "reduce the barriers and stigma" that bar those with severe drug addiction from life-saving help or treatment. The BC programme, which runs on a pilot basis until 2026, allows adults to possess up to 2.5 grams of heroin, fentanyl, cocaine or methamphetamine without being arrested, charged or having their drugs seized, except around schools and airports. But just over a year into the project, it has come under increasing pressure from some residents and political opponents, who [have called it a "harmful experiment"](https://www.bcunitedcaucus.ca/2024/01/one-year-later-david-ebys-decriminalization-experiment-a-complete-failure/) implemented without safeguards for the public, one that has "utterly failed" to reduce drug overdose deaths. BC has since introduced a bill that would expand places where drug use is prohibited to include not just schools and airports but playgrounds and near homes and businesses - a move blocked, for now, by the BC Supreme Court over concerns it would cause "irreparable harm" to people who use drugs. Image caption, In 2023, British Columbia hit a grim milestone of more than 2,500 drug overdose deaths Now supporters of decriminalisation fear that public buy-in for the policy is eroding. "It's really unfortunate," said Deputy Chief Fiona Wilson of the Vancouver Police Department, who also serves as the president of the BC Association of Chiefs of Police. "At the end of the day we're all rowing in the same direction with respect to the fact that we don't want to criminalise people by virtue of their drug use, which should be treated as a health matter." It is a debate felt not just in the bigger cities like Vancouver, but in places like Port Coquitlam, a suburb of 60,000 people east of Vancouver rich in walking trails, public parks and single-family homes. There, it was an altercation during a child's birthday party that was "the last straw" for Mayor Brad West. Mr West told the BBC he had heard from a family who had spotted a person using drugs near the party, held in a local park. Confronted, the person refused to leave, he said. "That to me is unacceptable," he said, adding that police had the right to intervene in that situation. Stories emerged elsewhere of drug paraphernalia found in parks, and of dogs accidentally ingesting opioids found on the ground. In June, Port Coquitlam unanimously passed its own bylaws to restrict some public drug consumption. Other jurisdictions have followed suit. Image caption, Drug harm reduction advocates like Guy Felicella say decriminalisation can help save lives Decriminalisation is based on the argument that the war on drugs has failed - that arresting people with severe addiction and seizing their drugs could increase their likelihood of overdose by forcing them to find other drugs that may be lethal. A criminal record may also bar them from finding a stable job, reducing the chance of recovery. "I got thrown in jail for nine months for a half a gram of cocaine," said Guy Felicella, a Vancouver-based advocate for drug harm reduction and recovery, who recovered from drug addiction after overdosing six times in 2013. Decriminalisation, he said, would have helped reduce his fear of being legally punished - a fear that forced him and others to use in private, out of view from someone who could call for help if they overdosed. Portugal, where drugs were decriminalised in 2001, has drug death rates [that are significantly lower than other countries.](https://www.commonwealthfund.org/sites/default/files/2023-06/Gumas_intl_overdose_blog_post_APPENDIX_v2.pdf) Its success inspired efforts in both BC and in the US state of Oregon, which decriminalised drugs in 2020. But in all three places, the policy has faced pushback, and in Oregon, lawmakers voted in March to reverse it altogether after it was blamed for a rise in public disorder and drug use. In BC, which has a history of harm reduction advocacy, the government's push to revise its decriminalisation policy was challenged in court over concerns it would lead to an "increased risk of overdose fatality". So far, the courts have sided with that argument - an outcome that has elicited a mixed reaction. For Mayor West, the courts are "out of touch with where the public is". "This focus on 'irreparable harm' to a certain group ignores the harm that occurs to others by allowing rampant public drug use," he said. But these sentiments have been countered by supporters of decriminalisation, like the province's outgoing chief coroner, who has said there is no evidence that suggests the general public is at risk from public drug use. "It's not comfortable seeing people use drugs in public," Lisa Lapointe said in an interview with local news outlet CityNews in January. "But who's most uncomfortable? Is it those of us who get to return to our warm homes… or is it those living unhoused, who are trying to cope the best way they know?" In Vancouver's Downtown Eastside, a historic neighbourhood that has long grappled with social issues like poverty and drug use, advocates have accused politicians of sowing "moral panic". "Scapegoating and vilifying people who use drugs has \[historically\] been a real good vote-getter," said Garth Mullins, a member of the Vancouver Area Network of Drug Users. There is no data on how much public consumption in BC has increased post-decriminalisation, but there has been a 76% drop in drug possession charges in the first year of the policy. Image caption, Former Vancouver Mayor Kennedy Stewart was behind the push to bring decriminalisation to his city Data also shows that the use of drug checking services - where people can test their drugs for fentanyl and other substances - and overdose prevention sites - where people can use drugs under supervision - has increased. The death rate, however, has continued to rise. Since decriminalisation, reported opioid-related toxicity deaths increased by nearly 5%. Ms Lapointe, the province's outgoing chief coroner, has dismissed any link between decriminalising drugs and that rise, saying "illicit fentanyl is responsible" for the fatalities. She and other public health officials maintain that decriminalisation is only one tool of many to address the crisis. Mr Stewart, mayor of Vancouver from 2018 to 2022, was a driving force behind the initial push to decriminalise drugs in BC. He lost his re-election bid by 23,000 votes to Ken Sim, a centre-right mayoral candidate who campaigned on a promise to hire more police officers and clear homeless encampments in Vancouver's Downtown Eastside. Mr Sim also supports the province's push to restrict some public drug use - signalling a political shift in the major metropolis. In a statement to the BBC, Mr Sim says the drug crisis is "devastating" and "deeply personal for many Vancouverites and British Columbians". But he believes a "delicate balance" needs to be struck between supporting people with severe addiction and "keeping areas safe for children and families". Mr Stewart believes Vancouverites have changed in recent years - with skyrocketing real estate values and rising costs due to inflation, he argues some people have become more insular. One thing that has not changed, he notes, is the severity of the drug crisis. "Those emails are still rolling into this new mayor's inbox every Monday," Mr Stewart said. * _If you have been affected by any of the issues raised in this story you can visit_ [BBC Action Line](https://www.bbc.co.uk/actionline). * [Drug use](/news/topics/clm1wxp5nplt) * [Vancouver](/news/topics/cp3mvndldd0t) * [British Columbia](/news/topics/cx250jvg4jvt) * [Canada](/news/topics/cywd23g0q41t)

An estimated 107,543 people died of drug overdoses in the US in 2023, a shocking figure that obscures a glimmer of hope – this is the first annual decline in drug overdose deaths since 2018. The grim toll represents Americans’ struggle with powerful synthetic drugs, in particular the synthetic opioid fentanyl, known to be up to 100 times stronger than morphine. More than 1 million people have died of a drug overdose [since 2001](https://www.cdc.gov/drugoverdose/deaths/index.html#:~:text=Drug%20Overdose%20Deaths%20Remained%20High,1999%20from%20a%20drug%20overdose.&text=In%202021%2C%20106%2C699%20drug%20overdose,2021%20(32.4%20per%20100%2C000).), according to the Centers for Disease Control and Prevention. The National Center for Health Statistics (NCHS), which [tracks overdose deaths](https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm), attributed more than 74,000 deaths to fentanyl, followed by more than 36,000 deaths from methamphetamine. Often, overdose deaths involve more than one drug. Drug overdoses declined 3% in 2023. “We are encouraged to see the preliminary data that shows a decrease in the overdose death rate for the first time in five years, especially following the period of rapid double-digit increases from 2019-2021,” said the White House Drug Control Policy director, Dr Rahul Gupta. The west was hit particularly hard by drug overdoses, according to the data from the NCHS. Alaska, Oregon and Washington all saw increases in drug overdose deaths of more than 27%. The increases may reflect how illicit drugs have moved across the US, after primarily emerging in states east of the Mississippi in the early 2010s. Other states saw notable declines: Nebraska, Kansas, Indiana and Maine all saw declines of 15% or more. Recent reports by the Drug Enforcement Agency (DEA) and a study supported by the National Institutes of [Health](https://www.theguardian.com/society/health), both released this week, paint an increasingly complex picture of the US’s illicit drug supply, with fentanyl-laced pills appearing to make up an increasing proportion of the illicit drug market. “Pills are flooding the market,” said Joseph J Palamar, associate professor in the department of population health at New York University, and the lead author of the NIH-supported study released this week in the International Journal of Drug Policy. According to Palamar’s study, law enforcement seized more than 115m fentanyl pills in 2023, compared with about 49,000 in 2017, a 2,300% increase, while new synthetic drugs such as xylazine have posed new threats. Palamar also said he believes the arc of drug use has changed over time. In the early 2000s, a person might have developed substance use disorder by starting with a prescription opioid, such as Oxycontin, and moving to heroin. By the early 2010s, it was common for heroin to be laced with fentanyl. Today, fentanyl may be preferred by some people and appears as an adulterant in many different types of illicit drugs. It is also pressed to look like prescription benzodiazepines or opioids, raising the possibilities that people believe they are taking prescription drugs, or may begin using with fentanyl. “The most serious thing is you get these young people who think they’re going to take a Xanax or a Adderall or an Oxycontin and then they find out there’s fentanyl in it,” said Palamar. “You have some kid who thinks he’s getting an Adderall from Snapchat or whatever – that kid could overdose and die.” [skip past newsletter promotion](https://www.theguardian.com/us-news/article/2024/may/15/drug-overdose-deaths-2023#EmailSignup-skip-link-12) Sign up to First Thing Our US morning briefing breaks down the key stories of the day, telling you what’s happening and why it matters **Privacy Notice:** Newsletters may contain info about charities, online ads, and content funded by outside parties. For more information see our [Privacy Policy](https://www.theguardian.com/help/privacy-policy). We use Google reCaptcha to protect our website and the Google [Privacy Policy](https://policies.google.com/privacy) and [Terms of Service](https://policies.google.com/terms) apply. after newsletter promotion The illicit drug supply is primarily controlled by Mexican cartels, according to the DEA’s [National Drug Threat Assessment](https://www.dea.gov/sites/default/files/2024-05/NDTA_2024.pdf). Cartels ship fentanyl, methamphetamine and synthetic drugs into the US through expansive networks, often with the backing of illicit Chinese chemical suppliers, pill presses and bankers. The toll also reflects broader struggles within American society. An estimated [2.5 million people](https://nida.nih.gov/news-events/news-releases/2023/08/only-1-in-5-us-adults-with-opioid-use-disorder-received-medications-to-treat-it-in-2021) suffer with opioid use disorder, but only one in five are in treatment, even though the disease has increasingly come into [public view](https://www.theguardian.com/us-news/2024/feb/21/oregon-drug-law-measure-110-backlash) because of a [housing affordability crisis](https://www.theguardian.com/us-news/2024/feb/22/los-angeles-unhoused-deaths-increase-housing-crisis-fentanyl-overdoses). Experts attribute the low number of Americans in treatment to [systemic barriers](https://www.statnews.com/2024/03/05/opioid-addiction-treatment-methadone-buprenorphine-restrictions/#:~:text=The%20evidence%20supporting%20the%20use,to%20those%20not%20receiving%20medication.), including a focus on abstinence, [insurance company policies](https://www.theguardian.com/us-news/2024/feb/03/opioid-treatment-prior-authorization-health-insurance-edited-) and laws out of step with science and those of peer western nations. At the same time, addiction and the overdose crisis have become a new front in the culture war. Republicans have criticized Joe Biden for failing to focus on [interdiction of illicit fentanyl](https://www.presidency.ucsb.edu/documents/op-ed-nikki-haley-ending-the-fentanyl-crisis-starts-securing-the-border) at the border, even as many [Republican policies](https://www.theguardian.com/us-news/2024/feb/03/opioid-treatment-prior-authorization-health-insurance-edited-#:~:text=In%20her%20analysis%2C%20Andrews%20said,harmful%20in%20one%20program%3A%20Medicaid.) make treatment harder to access.

Dave Yeager didn’t join the US army to become a pathological gambler. But after re-enlisting as a food inspection specialist in the wake of 9/11, Yeager arrived at his base hotel in Seoul, Korea, feeling overwhelmed and restless. “I’m walking around and find a casino-style slot machine room,” says the 57-year-old former sergeant. “As soon as I sat down, the first thing I noticed was that my shoulders started to relax. Then I won, and it was like a dopamine hit. In that moment, all of the fear and anger and stress that I was feeling just went away.” Suddenly and without warning, a night of gambling here and there became a seven-day-a-week addiction – one that had him phoning home for more money, pawning personal effects and stealing from his unit. When a demotion in rank failed to curb Yeager’s reckless behavior, his bosses threw up their hands. “My commander, a colonel I really respect, basically said in few words, ‘We have no idea what to do with you because you’re such a stellar performer,” he recalls of the come-to-Jesus meeting that preceded his transfer to a US duty station. “Nobody ever used the word _gambling_. It was ‘this problem you have’.” While the boom unleashed by the 2018 legalization of sports betting [raised fears of an emerging addiction crisis](https://www.theguardian.com/us-news/2023/dec/01/sports-betting-regulation-gambling-addiction), this institutional problem – at the heart of the US military – can be traced back decades, to the rooms like the one Yeager ventured into in Korea. In 1951, Congress banned slot machines from military bases in the US. In the 70s, the army and air force pulled them from foreign bases only to slowly bring them back in the 80s – with the idea that it would keep the troops from running into off-base trouble. Currently, the [US military](https://www.theguardian.com/us-news/us-military) operates more than 3,000 slot machines on bases in 12 countries – down from 8,000 slots in 94 countries in 1999, according to the Pentagon. That’s besides the other chance games the military sponsors on bases, with service members as young as 18 able to participate. The remaining slot machines alone rake in more than $100m annually, money that each branch steers into groups supporting “morale, welfare and recreation” initiatives on all bases such as movie theaters and golf courses. None of that money, Yeager notes, goes toward education, screening or prevention. “When you fall into a gambling problem,” he says, “it’s not treated as a mental health issue and an addiction. It’s treated as a money problem and a disciplinary issue.” All the while, service members spiral deeper down the hole. A [2003 patient chart analysis](https://www.psychiatrist.com/wp-content/uploads/2021/02/17991_suicide-attempts-among-veterans-seeking-treatment.pdf) at one Veterans Affairs (VA) medical center found that, of the patient population that had attempted suicide, 64% blamed gambling-related harms for pushing them to the brink. Three years later, the suicide death of a decorated army helicopter pilot forced the general public to [somewhat reckon with](https://www.cnn.com/2007/US/05/22/military.gambling/index.html) the military’s gambling problem. A [2016 survey of Iraq war veterans](https://pubmed.ncbi.nlm.nih.gov/27156377/) concluded that 4.2% had become at-risk gamblers subsequent to being deployed. According to the National Council on Problem Gambling, an estimated 56,000 active duty service members may meet the criteria for gambling disorder – which more generally affects [an estimated 1% of Americans](https://www.yalemedicine.org/conditions/gambling-disorder#:~:text=Gambling%20disorder%20affects%20about%201,includes%20daily%20fantasy%20sports%20leagues.) – roughly the same percentage of the adult population currently in active duty service. Both demographics skew heavily male. > You’re taught from day one, leave your problems at the door; you have a mission to do Dave Yeager In a 2021 Rutgers University study of gambling in the military, the researcher Mark van der Maas deduced that active and retired military service members were more than twice as likely to become problem gamblers than the general population – and even that may be underestimating the actual figures by quite a margin. “People tend not to think of the different things they’re doing as capital-G gambling because that’s such a morally loaded term,” van der Maas says. “A sports bettor, for example, might not think they’re gambling because they put so much time and research into it.” Van der Maas’s research suggests a connection between military service and poor mental outcomes for women, a less-studied gambling cohort relative to men. “Generally speaking, there are fewer women with gambling disorder compared with men,” he says. “But when we talk about the reasons why people gamble, women are more likely to say that they gamble to help deal with negative emotional state. “In both the US and Canada, women in military service or on police forces are exposed to sexual harassment and assault on the job. Understanding how being in that emotionally stressful environment potentially leads to gambling disorder for women is an area we need to pay more attention to.” Even though gambling has been recognized in the Diagnostic and Statistical Manual of Medical Disorders since 1980, the military is no better at confronting the problem than other American institutions that don’t see gambling on a par with drugs or alcohol addiction. (Some insurance carriers have only just begun covering problem gambling treatments.) It’s only since 2019 that the Department of Defense has mandated annual screenings for gambling disorder as part of service members’ general health assessment in addition to conducting random spot surveys of active duty soldiers. “Early detection and treatment of gambling disorder and other health-related behavioral issues is critical to maintaining the overall wellbeing and operational effectiveness of our forces,” a defense department spokesperson said. Before this statement, neither the defense department nor the VA had publicly commented on efforts to curb problem gambling within their ranks. > It’s only a matter of time before stories come out about the sergeant who committed treason because of their gambling addiction Dave Yeager Still, the military’s periodic checkups for gambling aren’t as rigorous as the ones used for substance abuse, or physical fitness. “It really would just take three quick questions to at least flag if someone needed more follow-up,” van der Maas says. This relaxed attitude makes military members especially vulnerable to gambling addiction. “When you think about military people, they’re very bonded,” says Heather Chapman, a psychologist who directs the gambling program at the Louis Stokes Cleveland VA, one of the few residential facilities in the country that focuses on the disorder. “It almost becomes like a family, and what you see is that behavior becomes integrated within the family structure, something to do when they have downtime – whether it’s slots or a Texas hold ’em tournament. It doesn’t have the immediate problematic issues that drugs and alcohol can have. There’s no obvious screen for gambling other than financial issues, which can affect a person’s clearance if they have considerable debt or declare bankruptcy.” Gambling can seem like an especially attractive escape in a high-stress environment that conditions workers to accept risk, bottle individual issues and finish the jobs they start. “You’re taught from day one, leave your problems at the door; you have a mission to do,” Yeager says. “The problem is that, even when they fall into addiction, the mentality is ‘I _have_ to fix this on my own. I _have_ to keep this to myself. I can’t leave until I _win._’ “One of the tenets of gambling addiction is chasing losses. You add the warrior mentality to that, and you’ve basically got gambling addiction on steroids.” Yeager’s addiction resulted in the breakup of his young family, the end of his military career and a debt in the high five figures. (“The only thing I didn’t do was borrow from my subordinates,” he says.) After a decade-long nosedive that included a two-week stay at a civilian psychiatric hospital, Yeager remembers the stumped counselor at his local VA handing him a packet for the VA gambling program in Cleveland. It was only after making that pilgrimage and communing with veterans in his same foxhole that Yeager turned his life around. Now remarried, reconciled with his family and out of debt, he raises awareness about problem gambling in the military, touring the country and promoting a book about his recovery all the while. He hopes to be a light to service members. In some ways, as gambling becomes more ubiquitous and accessible, they are even more vulnerable to addiction. “Just having gambling in your pocket now changes everything,” Chapman says. “We won’t really know what the true impact will be for another five or six years down the road when things really start to boil over.” Some federal lawmakers have shown a willingness to cooperate in the interest of heading off disaster. In 2017, the senators Elizabeth Warren and Steve Daines introduced a bipartisan bill that would force the Department of Defense to track gambling disorders in its health assessments and develop policies and programs around treatment and prevention. Earlier this year the congresswoman Andrea Salinas teamed up with the senator Richard Blumenthal on a bill that, among other things, would [funnel half of the federal taxes on gambling operators into national treatment and research programs](https://www.theguardian.com/us-news/2024/jan/27/gambling-addiction-bill-treatment-online-sport-betting-andrea-salinas). But both measures have struggled for traction within a divided Congress. The inaction just deepens the sense of dread within the precincts of the military on the frontlines of the gambling addiction problem – not least Yeager, who shudders to think of the potential risks to national security if the military’s gambling problem continues unchecked. “I’m telling you right now: it’s only a matter of time before you start seeing stories come out about the major who lost their commission, or the sergeant who committed treason because of their gambling addiction,” he says. “There’s so much more we need to do. And that’s why I don’t shut up.” * _In the US, call the National Council on Problem Gambling at 800-GAMBLER or text 800GAM. In the UK, support for problem gambling can be found via the NHS National Problem Gambling Clinic on 020 7381 7722, or GamCare on 0808 8020 133. In Australia, Gambling Help Online is available on 1800 858 858 and the National Debt Helpline is at 1800 007 007._

**2 Scrappy weapons startups are changing the face of war in Ukraine** They’re leaving the more established players in the dust. ([FT](https://www.ft.com/content/cf6ded0f-f595-4359-b8f7-273799f1149c) $) \+ _Inside the messy ethics of making war with machines._ ([MIT Technology Review](https://www.technologyreview.com/2023/08/16/1077386/war-machines/?truid=*%7CLINKID%7C*&utm_source=the_download&utm_medium=email&utm_campaign=the_download.unpaid.engagement&utm_term=*%7CSUBCLASS%7C*&utm_content=*%7CDATE:m-d-Y%7C*)) **3 How to scam a scammer** AI bots are the first line of defense against crooks on the phone. ([The Guardian](https://www.theguardian.com/technology/article/2024/jul/07/ai-chatbots-phone-scams)) \+ _Crypto hacking thefts are on the rise._ ([Reuters](https://www.reuters.com/technology/crypto-hacking-thefts-double-14-bln-first-half-researchers-say-2024-07-05/)) \+ _Watch out for card skimmers, too._ ([Insider](https://www.businessinsider.com/how-to-spot-card-skimmers-ebt-scam-2024-7) $) **4 Saudi Arabia is using esports to launder its reputation **It’s been accused of attempting to sportswash its human rights record. ([CNN](https://edition.cnn.com/2024/07/06/sport/esports-world-cup-saudi-arabia-spt-intl/)) **5 Here’s what would happen if Russia detonated a nuclear bomb in space **It would cause indiscriminate damage all over the world. ([WP](https://www.washingtonpost.com/technology/interactive/2024/nukes-space-explosion-nuclear-weapon-russia/?itid=sf_technology_article_list) $) \+ _How to fight a war in space (and get away with it)_ ([MIT Technology Review](https://www.technologyreview.com/2019/06/26/725/satellite-space-wars/?truid=*%7CLINKID%7C*&utm_source=the_download&utm_medium=email&utm_campaign=the_download.unpaid.engagement&utm_term=*%7CSUBCLASS%7C*&utm_content=*%7CDATE:m-d-Y%7C*)) **6 Ferrari is working on its first fully electric vehicle **Though other luxury automakers have struggled to make the switch. ([NYT](https://www.nytimes.com/2024/07/06/business/ferrari-electric-vehicles.html) $) \+ _Why the world’s biggest EV maker is getting into shipping._ ([MIT Technology Review](https://www.technologyreview.com/2024/01/30/1087393/byd-shipping-electric-cars-china/?truid=*%7CLINKID%7C*&utm_source=the_download&utm_medium=email&utm_campaign=the_download.unpaid.engagement&utm_term=*%7CSUBCLASS%7C*&utm_content=*%7CDATE:m-d-Y%7C*)) **7 How an Australian couple persuaded regulators to greenlight MDMA therapy **Despite lacking a medical or scientific background. ([Bloomberg](https://www.bloomberg.com/news/features/2024-07-08/australia-clears-medical-mdma-mushrooms-after-couple-s-drugs-campaign?srnd=phx-businessweek&sref=E9Urfma4) $) \+ _A person may have died after eating microdosing candies._ ([Ars Technica](https://arstechnica.com/science/2024/07/authorities-investigating-death-possibly-linked-to-toxic-microdosing-candies/)) \+ _US FDA advisors just said no to the use of MDMA as a therapy._ ([MIT Technology Review](https://www.technologyreview.com/2024/06/06/1093327/fda-advisors-just-said-no-to-the-use-of-mdma-as-a-therapy/?truid=*%7CLINKID%7C*&utm_source=the_download&utm_medium=email&utm_campaign=the_download.unpaid.engagement&utm_term=*%7CSUBCLASS%7C*&utm_content=*%7CDATE:m-d-Y%7C*)) **8 Google’s repairs policy is busted **Good luck trying to get that Pixelbook Go working again. ([Wired](https://www.wired.com/story/google-repair-policy-broken/) $) **9 This pill can help to treat alcoholism** But doctors appear reluctant to prescribe it. ([Slate](https://slate.com/technology/2024/07/alcoholism-pill-naltrexone-prescription-addiction-treatment.html) $)

 (Chantal Jahchan for The Washington Post) Save **KOM AL-RAF, JORDAN** On clear days, the Syrian villages along the border here look deceptively empty. The Jordanian soldiers peering north across no man’s land see only dusty ghost towns where nothing moves except feral dogs and an occasional farmer working fields that have seen too little rain and too much war. But on nights when the fog rolls in over the hills, the frontier takes on a sinister, alternate existence. Dozens of men — in trucks, on dirt bikes and on foot — emerge from the mist to form heavily armed columns for a race across the border. They carry assault rifles, rocket-propelled grenades, even machine guns. Concealed in their vehicles and backpacks are hundreds of packages containing many tens of thousands of small white pills. The drugs, a synthetic stimulant called Captagon, are fresh from factories in the Syrian heartland that churn out an estimated $10 billion worth of illicit drugs each year. Story continues below advertisement In a country where traditional industry has all but ceased to exist, the pills are the fabulously profitable core of a zombie economy that has helped Syria’s political and military elite cling to power after 13 years of civil war and a decade of crushing sanctions. Having swollen to a massive scale with tacit government approval, according to U.S. and Middle Eastern officials, the trade increasingly threatens Syria’s neighbors, flooding the region with cheap drugs. “If visibility is bad, they are coming — every single time,” said Col. Essam Dweikat, commander of a Jordanian Armed Forces unit responsible for defending the western sector of the country’s 200-mile border with Syria. “The problem is, the people who come across now are armed, and they are ready to fight.” The U.S. government is putting more sanctions on foreign governments, companies and people than ever. But these powerful tools of economic warfare can have unintended consequences, hurting civilian populations and undermining U.S. foreign policy interests. The Money War investigates the proliferation of U.S. financial sanctions and the dangers of overuse. Jordan has twice dispatched fighter jets into Syrian airspace to carry out strikes against smugglers and their safe houses, according to intelligence officials in the region — operations the government in Amman has not acknowledged publicly. Yet, despite extraordinary efforts to stem the tide, billions of Captagon pills from dozens of manufacturing centers continue to pour across Syria’s borders and through its seaports. The trade’s ripple effects are expanding ever outward, to include rising levels of addiction in wealthy Persian Gulf countries and the appearance of drugmaking labs in neighboring Iraq and as far away as Germany, according to Iraqi and German officials. Huge profits from the pills — which cost less than a dollar to make but fetch up to $20 each on the street — have attracted a host of dangerous accomplices, from organized crime networks to Iranian-backed militias in Lebanon, Iraq and Syria, according to U.S. and Middle Eastern intelligence officials. In recent months, smugglers began moving weapons as well as drugs, the officials said. Jordanian raids on smuggling convoys have netted rockets, mines and explosives apparently intended for Islamist extremists in Jordan or possibly for Palestinian fighters in Gaza and the West Bank.  Fighters affiliated with Syria's Hayat Tahrir al-Sham rebel group display drugs previously seized at a checkpoint they control in Daret Ezza, Syria, in 2022. (Omar Haj Kadour/AFP/Getty Images) Most profoundly, the drugs have provided a lifeline for the government of Syrian President Bashar al-Assad, who has seized on Captagon as a way to stay in power, current and former U.S. officials said. As the United States and other Western countries ramped up pressure with sanctions — to hold Syrian officials accountable for war crimes or to pressure Assad to negotiate an end to the conflict — Syria’s ruling class found salvation in a small white pill, one that conferred massive profits and partial insulation from the punishment U.S. policymakers were serving up. “This is the stream of revenue on which they are relying in the face of sanctions pressure from us and from the European Union,” said Joel Rayburn, the U.S. special envoy to Syria from 2018 to 2021. “The Assad regime could not withstand robust sanctions enforcement, except for Captagon. There is no other source of revenue that could make up for what they lost due to sanctions enforcement.” The Syrian mission to the United Nations did not respond to a request for comment. The Assad government has repeatedly denied having any involvement with illicit drugs, and in the past year, it announced arrests of several low-level traffickers and the seizure of small quantities of the white pills. Yet Treasury Department documents have identified close relatives of Assad — including his brother Maher al-Assad, commander of the Syrian army’s 4th Armored Division — as key participants in Captagon trafficking. Most of the pills are produced in regime-held areas and moved through borders and port facilities under government control. A [2023 study](https://storage.googleapis.com/karam_viz/karam_online_publications/Sky%20High-The%20Ensuing%20Narcotics%20Crisis%20in%20Arab%20Asia%20and%20the%20Role%20of%20the%20Assad%20Regime%2013%20June%202023.pdf?itid=lk_inline_enhanced-template) extrapolating from known seizures of drugs since 2020 estimated that Captagon generates about $2.4 billion a year for the Assad regime, “well above any other single licit or illicit source of revenue,” wrote the authors at the Observatory of Political and Economic Networks, a nonprofit that conducts research on organized crime and corruption in Syria. How Captagon makes its way through Syria  How Captagon makes its way through Syria Ingredients for the drug, such as amphetamine, are purchased legally and imported into Syria through Latakia. The precursor chemicals are mixed in factories and machine-pressed into tablets primarily in this area along the Lebanese border. Armed smugglers predominantly use the Jordanian border to distribute it out of the country, but some also leaves via the ports of Latakia and Tartus, and into Iraq near Bukamal.  How Captagon makes its way through Syria Ingredients for the drug, such as amphetamine, are purchased legally and imported into Syria through Latakia. The precursor chemicals are mixed in factories and machine-pressed into tablets mostly in this area along the Lebanese border. Armed smugglers use the Jordanian border to distribute it out of the country, but some also leaves via the ports of Latakia and Tartus.  How Captagon makes its way through Syria Ingredients for the drug, such as amphetamine, are purchased legally and imported into Syria through Latakia. The precursor chemicals are mixed in factories and machine-pressed into tablets mostly in this area along the Lebanese border. Armed smugglers use the Jordanian border to distribute it out of the country, but some also leaves via the ports of Latakia and Tartus.  How Captagon makes its way through Syria Ingredients for the drug, such as amphetamine, are purchased legally and imported into Syria through Latakia. The precursor chemicals are mixed in factories and machine-pressed into tablets primarily in this area along the Lebanese border. Armed smugglers predominantly use the Jordanian border to distribute it out of the country, but some also leaves via the ports of Latakia and Tartus, and into Iraq near Bukamal.  How Captagon makes its way through Syria Ingredients for the drug, such as amphetamine, are purchased legally and imported into Syria through Latakia. The precursor chemicals are mixed in factories and machine-pressed into tablets primarily in this area along the Lebanese border. Armed smugglers predominantly use the Jordanian border to distribute it out of the country, but some also leaves via the ports of Latakia and Tartus, and into Iraq near Bukamal. The industry’s rise illustrates the complexities of trying to change a foreign power’s violent repression by ratcheting up economic pressure on its leadership and business elites. U.S. officials and experts say sanctions remain the most powerful tool, short of war, for punishing a government that has been accused of numerous war crimes since Assad began brutally crushing a pro-democracy uprising in 2011. The long list of offenses includes the systematic torture and executions of civilians, the deliberate targeting of hospitals and food distribution centers, and the killings of hundreds of women and children with outlawed sarin nerve gas, according to U.S. officials, U.N. investigations, and human rights and exile groups. Syria is officially listed by the United States as a sponsor of international terrorism and is regarded as an increasingly vital ally and strategic partner to Russia and Iran. Assad has defied [calls for his ouster](https://www.washingtonpost.com/politics/assad-must-go-obama-says/2011/08/18/gIQAelheOJ_story.html?itid=lk_inline_enhanced-template) while presiding over the destruction of this once moderately prosperous country of 22 million. At least 12 million Syrians are now refugees or internally displaced, and 90 percent of the country’s citizens live in poverty. The country’s GDP fell from a prewar high of $252 billion to just $9 billion in 2021, according to [World Bank estimates](https://data.worldbank.org/country/syrian-arab-republic?itid=lk_inline_enhanced-template). The economy continues to shrink, as does the life expectancy for young Syrians. Story continues below advertisement The emergence of industrial-scale Captagon production beginning around 2019 prompted U.S. officials and Congress to shift the focus of sanctions to specifically target the drug trade and its sponsors. In April, Congress approved [legislation targeting Syria’s drug kingpins](https://hill.house.gov/news/documentsingle.aspx?DocumentID=9294&itid=lk_inline_enhanced-template#:~:text=4681%2C%20the%20Illicit%20Captagon%20Trafficking,illicitly%20produce%20and%20traffic%20captagon.) as part of the $95 billion bipartisan foreign aid package [signed into law](https://www.govtrack.us/congress/bills/118/hr4681?itid=lk_inline_enhanced-template) by President Biden. That followed a Treasury Department [announcement of new sanctions](https://home.treasury.gov/news/press-releases/jy2210?itid=lk_inline_enhanced-template) against Syrian business executives with alleged ties to Captagon smuggling. Yet Captagon production continues to soar, and Assad is unshaken and apparently wealthier than ever, U.S. officials acknowledge. While the sanctions imposed against his government enjoy broad support among Syrian opposition leaders and human rights advocacy groups, the experience of the past decade underscores a perplexing reality: While sanctions remain a vital tool for punishing criminal behavior by governments, the targets of sanctions inevitably find ways to blunt their impact, often with painful consequences for ordinary citizens. “The most profound point is that sanctions strengthen the bad actor relative to the rest of the population,” said Ben Rhodes, the former deputy national security adviser for the Obama administration who worked on Syria policy in the early years of the civil war. “The people who are most able to withstand this are the people with guns and power.”  A sack of confiscated Captagon pills in 2022 at the judicial police headquarters in Kafarshima, south of Lebanon's capital, Beirut. (Joseph Eid/AFP/Getty Images) Syria’s Captagon crisis came on fast and hard. A few well-connected Syrians and Lebanese nationals built the foundations for a vast drug empire amid the chaos of the country’s fragmentation. Before the start of the conflict in 2011, Captagon was regarded as a niche product for a small number of crime groups in Lebanon and Turkey. These manufacturers developed a knockoff version of the drug that was first developed in the 1960s by a German pharmaceutical company and marketed under the Captagon brand. The original version combined amphetamine with a second drug that stimulates the central nervous system. It was used by German physicians to treat hyperactivity and depression until the 1980s, when U.S. regulators and the World Health Organization recommended outlawing it because of the high risk for abuse. Beginning around 2018, U.S. and Middle Eastern officials said, cottage-scale manufacturing of the drug in Lebanon expanded to a handful of Syrian towns in a border region north of Damascus. A key figure, according to Treasury Department [sanctions documents](https://home.treasury.gov/news/press-releases/jy1369?itid=lk_inline_enhanced-template), was Hassan Daqqou, a dual Syrian-Lebanese national and onetime car dealer who began buying up properties on both sides of the border for production centers and warehouses. Daqqou — dubbed the “King of Captagon” by the Lebanese news media — succeeded in building his empire through alliances with powerful friends within government and security circles in Syria and Lebanon. Among his collaborators, U.S. and Middle Eastern officials said, were operatives with the Lebanese militia group Hezbollah as well top Syrian political and military leaders — not only Maher al-Assad, but also several Assad cousins and business executives close to the Syrian leader. “The most profound point is that sanctions strengthen the bad actor relative to the rest of the population. The people who are most able to withstand this are the people with guns and power.” former deputy national security adviser for the Obama administration Two Biden administration officials, citing U.S. intelligence assessments, confirmed in interviews that Maher’s 4th Division has been an active participant in the Captagon trade since at least 2020, controlling distribution and transportation hubs, including port facilities in Latakia on the Syrian coast. Syrian control of operations increased after Daqqou was imprisoned in Lebanon for drug trafficking in 2021. Biden administration officials say they have no evidence that Assad is personally directing the Captagon trade. But by naming his brother and cousins as key facilitators, U.S. officials made clear their view that drug manufacturing in Syria is now a state enterprise. “Syria’s security forces now provide protection for drug traffickers,” said one Biden administration official, speaking on the condition of anonymity to discuss intelligence assessments. White House officials believe Assad is now using Captagon as leverage with Arab states, offering to selectively restrict the flow of drugs as a reward to governments that normalize ties with Syria. “It is clear that he could shut this down if he wanted to,” the administration official said. Also clear is the massive scale of drug manufacturing in Syria, which U.S. officials say now produces most of the world’s Captagon supply. Administration officials say ingredients for the drug, such as amphetamine, are purchased legally from several countries, including Iran and India, and imported through Latakia. The precursor chemicals are mixed in factories and machine-pressed into tablets bearing a distinctive double-C logo. Since the start of the decade, law enforcement agencies intercepted huge shipments of Syrian-made drugs in busts at ports in Italy, Saudi Arabia, the United Arab Emirates and Malaysia. In 2021, the Malaysian authorities discovered more than 95 million Captagon tablets hidden inside a cargo ship — a record haul with a street value of $1.2 billion that was routed through Malaysia to hide its ultimate destination: Saudi Arabia. Story continues below advertisement The biggest maritime busts showed smugglers going to extraordinary lengths to conceal their cargo. The 84 million tablets seized by customs officials in the Italian seaport of Salerno in 2020 had been hidden inside industrial-size spools of paper. Saudi police found millions of the white pills stashed inside containers of pomegranates and flour in separate incidents in August 2022 and April 2023. In one of the most recent attempts, uncovered by Dubai investigators this past September, drug traffickers hid 86 million pills inside prefabricated wooden panels and doors labeled for delivery to construction companies. Nearly all the pills were traced back to ports in Syria. While it’s not technically accurate to call Syria a narco-state — Captagon is a stimulant, not a narcotic — the country has become so dependent on drug income that Assad would be hard-pressed to shut down the drug factories if he decided to, said Caroline Rose, a researcher who oversees the [Special Project on the Captagon Trade](https://newlinesinstitute.org/state-resilience-fragility/from-2015-2023-the-captagon-trades-trends-trajectory-and-policy-implications/?itid=lk_inline_enhanced-template) at the New Lines Institute, a Washington nonprofit. “They’ve taken Captagon to such a level that the industry can sustain itself,” Rose said. “It’s no longer mobile facilities, but permanent factories that can accommodate industrial-scale production. And on top of that, there’s an active security apparatus that provides guards, protection and support and even facilitates the movement of the drugs. “It’s a perfect system,” she said.  Jordanian soldiers patrol along the border with Syria in 2022. (Khalil Mazraawi/AFP/Getty Images) For Syria’s neighbors, it’s a disaster. Captagon has now become a drug of choice — and a public health crisis — among young people across the Middle East, making deep inroads in countries such as Saudi Arabia and the United Arab Emirates where alcohol is banned or, for locals, proscribed. Habitual use brings addiction and a wide array of health problems, from insomnia and depression to hallucinations and heart problems, [according to medical researchers](https://www.cureus.com/articles/227465-the-emergence-of-the-old-drug-captagon-as-a-new-illicit-drug-a-narrative-review?itid=lk_inline_enhanced-template#!/). The drug is also a tool for Islamist groups, including Islamic State militants, because it provides users with a burst of euphoric energy and a feeling of invincibility and emotional detachment on the battlefield. Some fighters call it “Captain Courage.” Surging drug trafficking has forced Jordan to deploy hundreds of soldiers on its northern border. In the past year, Jordanian forces have waged running battles with groups of up to 100 traffickers that left multiple people dead and wounded on both sides. On a recent late-winter afternoon near Kom al-Raf, a dozen soldiers in full combat gear traced the southern edge of no man’s land, checking for signs of breaches in the barrier system of berms and coiled concertina wire. As they walked, other soldiers stood guard from atop armored vehicles and watchtowers that have been erected at half-mile intervals along the perimeter road. In recent months, officers said, the smugglers had begun using drones to conduct surveillance or, in some cases, to ferry small parcels to confederates across the border. But vastly more drugs are hauled overland. Near Kom al-Raf, a firefight in 2022 killed a Jordanian soldier when his patrol surprised a large column of smugglers — at least 68 gunmen on foot, according to the after-action report — as they attempted to cross in dense fog. A map of the Syria-Jordan border where smugglers transport Captagon.  A major storage location for Captagon and the launch point for shipments heading toward Jordan. Targeted by Jordanian airstrikes in April 2022. Border area where armed clashes with smugglers have occurred. Sources: Human Rights Watch and Northwestern University’s Knight Lab  A major storage location for Captagon and the launch point for shipments heading toward Jordan. Targeted by Jordanian airstrikes in April 2022. Border area where armed clashes with smugglers have occurred. Sources: Human Rights Watch and Northwestern University’s Knight Lab  A major storage location for Captagon and the launch point for shipments heading toward Jordan. Targeted by Jordanian airstrikes in April 2022. Border area where armed clashes with smugglers have occurred. Sources: Human Rights Watch and Northwestern University’s Knight Lab  A major storage location for Captagon and the launch point for shipments heading toward Jordan. Targeted by Jordanian airstrikes in April 2022. Border area where armed clashes with smugglers have occurred. Sources: Human Rights Watch and Northwestern University’s Knight Lab After a brief firefight, the smugglers fled back into Syria, leaving behind 100-pound packs filled with Captagon tablets as well as bolt-cutters and weapons, Jordanian officials said. The convoy’s large size and willingness to engage a military patrol startled the Jordanians and prompted army commanders to adopt more aggressive measures. “We’ve had to change our rules of engagement multiple times because their methods have changed,” Brig. Gen. Mustafa al-Hiyari said in an interview at the headquarters of the Jordanian Armed Forces, perched on a heavily fortified hilltop just outside Amman. “Smugglers generally don’t want to fight, but these are armed.” Since 2020, the border region has seen at least a dozen armed clashes that resulted in deaths, injuries or arrests. One encounter in January resulted in the capture of 15 alleged traffickers, according to photos shown to The Washington Post. Jordanian officials said the men acknowledged during interrogations that they had undergone professional military training to qualify for the job of courier. At the time of the arrests, several were high on Captagon, the officials said.  Seized drugs, including Captagon, in Marea, Syria, in 2022. (AFP/Getty Images) In one of the most recent cases, Jordanian authorities tracked a suspected drug shipment last month as it traversed more than 100 miles of open highway before police swooped in at a border crossing with Saudi Arabia. Millions of pills were found hidden inside construction equipment bound for the gulf kingdom, officials said. Based on interrogations and other evidence, Jordanian intelligence officials said they have concluded that the most recent bands of smugglers are linked to Iranian-backed Syrian militias, including some of the same groups that have fired rockets at U.S. forces based in eastern Syria. There is no evidence of direct involvement in drug trafficking by Tehran, but Iranian officials have provided weapons, money and intelligence to the groups. U.S. and Jordanian officials say the militias may be responsible for the increasingly sophisticated weapons carried by traffickers. In several instances, smugglers have left caches of weapons inside Jordanian territory, possibly with the intention of providing them to other Iranian-backed militants in the West Bank or the Gaza Strip. The Post was shown photos of some of the hidden weapons, which included Claymore-type anti-personnel mines. “The Iranian proxy groups operate like warlords,” constantly competing for fighters, better weapons and cash, said Charles Lister, director of counterterrorism programs at the Washington-based nonprofit Middle East Institute. “Drugs are just an easy way to make money and become more powerful than your neighbors.”  Displaced Syrians in Idlib. At least 12 million Syrians are now refugees or internally displaced, and 90 percent of the country’s citizens live in poverty. (Bilal Alhammoud/AFP/Getty Images) The U.S. policy of maintaining harsh sanctions enjoys broad bipartisan support. The toughest measures to date came in 2020, nine years after the start of the war and the same year that the first massive seizures of Captagon drugs were being recorded. The congressionally approved [Caesar Act](https://2017-2021.state.gov/caesar-syria-civilian-protection-act/?itid=lk_inline_enhanced-template) was named in honor of a Syrian military photographer and defector — known publicly only as “Caesar” — who [used his camera to document](https://www.cnn.com/2019/12/17/politics/defense-caesar-syria-bill/index.html?itid=lk_inline_enhanced-template) the Assad regime’s torture and murder of more than 11,000 Syrian prisoners. The sanctions targeted the country’s largest remaining industrial sectors, including energy production and construction, and are explicitly intended to discourage international business agreements that could help Assad repair the country’s battered infrastructure. As a means of inflicting well-deserved punishment on Syria’s leader, the sanctions are widely regarded as a triumph. Supporters of the measures warn that the world cannot “normalize” Assad or allow his regime to enrich itself through construction contracts to rebuild cities that Assad helped to depopulate and destroy. Story continues below advertisement The Caesar Act, together with this year’s Captagon sanctions, sends an important signal to the Assad regime and its allies that the United States is standing with ordinary Syrians, said Mouaz Moustafa, executive director of the Syrian Emergency Task Force, a Washington-based nonprofit that advocates for victims of Syrian war crimes. “There are strict humanitarian exceptions to ensure that no Syrian civilians, regardless of their political outlook, are harmed by these sanctions,” Moustafa said. “The sanctions are focused on the people who are harming ordinary Syrians with chemical weapons, torture and indiscriminate bombardment. The drugs were part of a deliberate strategy by these same people to ensure that they have a revenue source, and that they have complete control over it.” Yet even the most ardent supporters acknowledge that no “victory” in Syria is completely clean. While there may be few viable alternatives to sanctions, the measures always come with unwanted side effects — including the inevitable certainty that the elites of society will find ways to survive and even profit, said Peter Andreas, professor of international studies at Brown University and the author of a study on how sanctions increase illicit trade. “The targets of sanctions, because their survival depends on it, are willing to go through all kinds of alliances to succeed,” Andreas said. Sanctions can eventually “put the whole economy in an underworld,” he said. “It’s an unintended but very real and long-lasting consequence.”

NEW YORK -- It was a landmark moment for the [psychedelic movement](https://apnews.com/article/aaron-rodgers-psychedelics-conference-bae8c5ae3f221770fb84b123a92cf2d2): The Department of Veteran Affairs’ top doctor stood on stage, praising advocates who have spent decades promoting the [healing potential of mind-altering drugs](https://apnews.com/article/af93ce6f3daf4a8b97f21b9cde196cda). In an unannounced appearance at a New York psychedelic conference, the VA’s Dr. Shereef Elnahal said his agency was ready to start rolling out [MDMA-assisted therapy for post-traumatic stress disorder](https://apnews.com/article/mdma-fda-psychedelic-therapy-ptsd-treatment-drug-bc2d7495035a9532876c3dcaf52a9761) as soon as regulators approved it. “The VA has to be first, as we have been, with the mental health needs of our veterans,” Elnahal told attendees at the May meeting. He also highlighted the “awesome, groundbreaking” research on the drug by MAPS, or the Multidisciplinary Association for Psychedelic Studies, the leading nonprofit advocating for the medical and [legal use of hallucinogenic drugs](https://apnews.com/article/psychedelic-churches-ayahuasca-5101fe47fe9a6e28de686272ed96ff46). But expectations for MDMA’s first-of-a-kind approval unraveled a few weeks later when Food and Drug Administration advisers [voted overwhelmingly against the drug](https://apnews.com/article/mdma-psychedelics-fda-ptsd-ecstasy-molly-1f3753324fa7f91821c9ee6246fa18e1), citing flawed data, questionable research conduct, and potential safety and addiction risks. The panel's recommendation isn't binding, but the FDA is widely expected to delay or decline approval when it makes its decision by mid-August. The potential rejection has sent shockwaves through the psychedelic community, including [combat veterans](https://apnews.com/article/magic-mushrooms-therapy-conservative-states-3384fd864634204deba9fa8c21d4dcf8) who have spent years lobbying for the drug, which is also known as ecstasy or molly. The advocacy effort has long been intertwined with MAPS, which has funded or supported some of the most vocal veterans supporting psychedelic therapy. Dr. Harold Kudler of Duke University met with veterans and MAPS leaders while serving as the VA’s top consultant on mental health services. He believes FDA's experts are justifiably skeptical of the science behind the drug, which he says has been drowned out by messaging from MAPS and its leader, Rick Doblin, who began pursuing MDMA's approval in the mid-1980s. “Rick is the most persuasive advocate within the scientific community that I’ve ever seen. You want to believe him because he's offering you something you sorely need — an effective treatment for PTSD,” Kudler said. “But I think the FDA committee caught a glimpse of how much of this is Rick’s zeal and how much is real.” MAPS declined to make Doblin available for an interview. Instead the group pointed to a recent [statement](https://www.scientiststatementonptsd.com/) by two dozen scientists and pharmaceutical executives — many with backgrounds in psychedelic research — supporting MDMA's approval. Earlier this year, MAPS changed the name of its drug development arm to Lykos Therapeutics, allowing the new company to [raise funds from outside investors](https://apnews.com/article/psychedelic-drugs-mushrooms-startups-psilocybin-fda-e3f629f817781b096d72535e022d8b2f). In addition to shortcomings in Lykos' studies, FDA panelists voiced concern about separate allegations that some MAPS-affiliated researchers suppressed negative study results or coached patients to inflate positive results. The FDA says it's investigating those claims. Casey Tylek, an Army veteran, says he didn't experience any of that while [participating in the study](https://apnews.com/article/mdma-ecstasy-ptsd-study-molly-fda-1155a374305027567d5f41910022022d). When he asked researchers for guidance in evaluating the effect of the drug, Tylek says he was repeatedly rebuffed and told he had to rate the treatment without any outside influence. Tylek says he was “pessimistic” going into the trial, but credits MDMA-assisted therapy with resolving anger, anxiety and trauma stemming from a rocket attack in Iraq. “It basically rewrote that memory in my mind and how it functioned,” Tylek said. “I was able to just kind of let go of it and not be hung up on it.” Kudler and other researchers say they want to see the MDMA results confirmed in larger studies that have no links to the psychedelic community. That work would take years. Veterans who support the treatment say it would jeopardize patients suffering from PTSD who haven’t been helped by antidepressants and other existing therapies. The suicide rate among veterans is 70% higher than the general population, according to government figures, with 18 veteran suicides per day in 2021. Jon Lubecky, who served in both the Marines and the Army, says he tried to kill himself five times after returning from deployment to Iraq in 2006. After years of struggling with PTSD he enrolled in a MAPS trial in 2014. He credits MDMA-assisted therapy with curing his condition. Since then, Lubecky has told his story hundreds of times in media interviews, congressional hearings and private meetings with military officials and federal lawmakers, including conservatives like Sen. Rand Paul and Rep. Dan Crenshaw. Lubecky worked as a consultant for MAPS for more than five years. But he rejects the idea that he was merely advancing the agenda of psychedelic boosters who want to see the drugs outright legalized. “I’m not in this for ending the drug war or any of those other things," he said. "I’m in it for my friends.” Lubecky’s work helped secure $20 million in funding for the VA to conduct its own studies of psychedelics, including MDMA and ketamine. Part of the rationale for that research: Many veterans now leave the U.S. to undergo psychedelic therapy at clinics in Mexico, Peru and other countries where it is more accessible. A nonprofit group, Heroic Hearts Project, currently has a waiting list of over 1,000 veterans seeking financial and logistical support to travel abroad. A former Army Ranger, Jesse Gould, founded the group after returning from a weeklong retreat in Peru using ayahuasca, the psychedelic brew associated with indigenous cultures of the Amazon. After the experience, he said he was able to overcome anxiety, anger and depression that had burdened him after three deployments to Afghanistan. Gould says MAPS deserves credit for kickstarting research that could eventually help thousands of veterans. “I think MAPS has done more for the veteran community in this area than most politicians have done in the last 20 years,” said Gould, whose group has no financial ties to MAPS. “Time and time again our needs either go unheard or go to the back of the line.” Heroic Hearts hosted an event on Capitol Hill earlier this month where several House lawmakers and veterans called for MDMA's approval. Gould doesn’t expect the FDA to flatly reject MDMA. Instead he and others say the agency may ask Lykos to perform additional studies. Even if the company is unable to quickly conduct that research, experts say others could benefit by avoiding the pitfalls in Lykos' MDMA application, including a small patient population with little diversity and a high potential for bias. [Dozens of other drugmakers](https://apnews.com/article/filament-health-natural-psychedelics-psilocybin-aadee1fa4e84692d614888fa5ff66d18) are studying [psilocybin](https://apnews.com/article/mushroom-psychedelic-alcoholism-study-a3b6692ae7590de9fd09a7cac271a199), LSD and other psychedelics for depression, anxiety and addiction. Dr. John Krystal, a Yale University psychiatry professor, said Lykos' setback "will hopefully ensure that future studies are conducted in ways that give reviewers greater confidence about the effectiveness and the safety of these drugs.” \_\_\_ The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Science and Educational Media Group. The AP is solely responsible for all content.

 How do you fight HIV infections in the midst of a war? That’s a question that’s been bedeviling Ukraine since the Russian invasion of February 2022. It’s a critical issue for a country that, with an estimated [245,000 people living with HIV](https://www.thelancet.com/journals/lanhiv/article/PIIS2352-3018(22)00257-0/abstract), has the second highest incidence of the infectious disease in Europe after Russia, with the virus typically spreading through contaminated blood, sexual contact and shared needle usage. “After the fall of the Soviet Union, injectable drug use was very, very high across all former USSR countries,” says Dr. Ksenia Voronova, an infectious diseases doctor who works for [AIDS Healthcare Foundation Ukraine.](https://www.aidshealth.org/category/global/ukraine/) “There were a lot of cheap, high purity drugs, and people would gather together and share needles. It was one of the main reasons for the fast spread of HIV. “ ### A threat to past progress Ukraine turned the corner in its battle to control HIV in 2012, when the annual rates of new infections [declined](https://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2013/november/20131120report) for the very first time, from 17,300 people being newly infected with the virus in 2011 to 16,847 the following year. This reduction followed the implementation of contact tracing to rapidly identify newly infected individuals and provide them with access to antiretroviral drugs that suppress the virus. Injectable drug users were offered opioid substitution therapy such as methadone or buprenorphine, which provided them with a pathway to stabilize and eventually tackle their addiction. “Ukraine has always been, I believe, at the forefront of HIV prevention,” says [Tetyana Vasylyeva](https://publichealth.uci.edu/faculty/vasylyeva-tetyana/), a Ukrainian epidemiologist now based at UC Irvine. “These initiatives, which helped find undiagnosed people and link them to care, were tested in Ukraine and have since been adopted by many countries in Southeast Asia and Africa.” “Things were on a good trajectory,” she says. But when war came to Ukraine in early 2022, Vasylyeva was immediately concerned that much of this progress would be undone. By early 2024, the fighting had already displaced an estimated 3.7 million people within Ukraine and another 6.3 million fled the country. So far, Russian bombardments have completely destroyed 214 medical facilities and damaged more than 1,600, with the biggest losses in eastern Ukraine. National health-care spending declined from 12% of the budget to just 5% while defense expenditure soared from 9% to 55%. ### Coming up with solutions But despite limited resources, the groups leading the effort to address HIV have improvised solutions, from organizing medical missions in war-torn regions close to the front line, to rolling out new preventative medications that can protect people from the virus for weeks at a time. [The Alliance for Public Health](https://aph.org.ua/en/home/), a Ukrainian advocacy group working to fight HIV/AIDS, tuberculosis and other infectious diseases in the country, was able to procure emergency antiretroviral supplies through U.S. donors such the Global Fund and PEPFAR — treatments previously purchased in large quantities by the Ukrainian government. But the Alliance still faced challenges in administering care, as many trained health-care professionals with expertise in managing HIV left the country. “At the time, I was trying to establish a research project in Ukraine, and the lack of skilled professionals with experience of working in HIV services was pretty dramatic,” says Vasylyeva. “Of course some people stayed, but their workload tripled.” At the same time, Ukraine was experiencing a dramatic population displacement as millions fled from the east to the relative safety of western cities like Lviv. Andriy Klepikov, the Alliance’s executive director, says that as a result of this population movement, demands soared for so-called Pre-Exposure Prophylaxis (PrEP) drugs, which are 99% effective at preventing HIV transmission through sex and 74% efficient at preventing HIV infections through drug use.  But even as the Alliance and other organizations attempted to help the influx of people fleeing to the west, they worried about the health of those still in war-torn eastern Ukraine. Studies showed that the stresses of war were driving a sharp rise in the [use of injectable opioids](https://www.nyu.edu/about/news-publications/news/2024/february/war-opioid-crisis-ukraine.html). And with hundreds of hospitals and clinics razed, access to health care was extremely limited. Within a few months, the Alliance estimated that without intervention, this could ultimately lead to hundreds of new infections. ### Bringing help to the 'Red Zone' In December 2022, a small team of doctors, nurses and lab technicians embarked on their first mission into what the Ukrainian government calls the Red Zone, an area of roughly 6,000 square miles. It encompasses the rural towns and villages of eastern and central Ukraine which lie between five and 50 kilometers from the front line. This mission represented the first step in an ongoing project launched by the Alliance to restore some form of health care to Ukraine’s most vulnerable citizens. Pavlo Smyrnov, deputy executive director of the Alliance, recalls that the initial journey took them on icy roads winding through fields on the outskirts of Kupiansk, a city that had been captured by Russian forces in late February, and liberated seven months later in early September 2022. The crew travelled in vans equipped with a small lab, capable of analyzing rapid HIV tests, and stocks of vital medications. Smyrnov says the team could hear the rattle of gunfire just three or four miles away, but were still able to provide general medical care to around 70 people**.** Since then, similar missions have been undertaken to 230 towns across the Red Zone, administering just over 1,000 HIV tests and uncovering 12 previously undetected cases in the process. The team also carried out tests for tuberculosis, hepatitis C and syphilis. With battlefield lines continuously being redrawn, these missions come with their own risks. Phones must be switched off to avoid detection from the Russian army and low-flying military planes occasionally whizz through the treetops, just 30 feet or so from the ground, to avoid radar. Smyrnov says that at times the fighting has been so close that the van’s windows have been shaken by the rumble of incoming artillery. “Our team protocol is that when that happens, we pack up and leave immediately,” he says. “Because there is a possibility that the next shot will be on your position. It’s quite hair-raising.” Still, these mobile clinics may become more widespread. The Alliance says that Russia has continued to bombard Ukraine’s energy facilities to an extent that electricity blackouts last for much of the day, but the mobile clinics are powered by their own independent generators and can work through the disruptions. UC Irvine’s Vasylyeva recently traveled to Ukraine to help set up mobile testing across major cities. “It’s really hard to run HIV tests in a traditional laboratory when there’s no electricity for up to eight hours a day,” she says. “But with these mobile labs, we can still get testing done, even if the electricity goes down for a really long time.” Her project is in partnership with the [L.V. Gromashevsky Institute of Epidemiology and Infectious Diseases](https://ror.org/01t7qjd50), one of Ukraine’s leading scientific institutions studying HIV and other infections within the country. ### Reaching out to refugees Other efforts are working to help displaced Ukrainian refugees get HIV support in their new countries. The Alliance for Public Health says it has had success with telemedicine. MISSING TEXT? Over the last two years, the group introduced a digital service called the HelpNowHub, which runs on encrypted social media channels like WhatsApp and Telegram. It has addressed more than 50,000 requests from Ukrainians living with or affected by HIV, helping them access antiretrovirals and HIV prevention medications in their new country as well offering translation support to help them navigate their local health care services. ### A new generation of preventive drugs There is also hope in the form of a new generation of pharmaceuticals, which were the focus of considerable optimism at the AIDS 2024 conference in Munich last month. A longer-acting form of the preventative drugs taken before HIV exposure (PrEP) called cabotegravir is drawing particular attention. It prevents HIV from entering cells and could make it far easier to stop chains of new infections. While previous forms of PrEP had to be taken daily, cabotegravir only has to be injected once every two months. Clinical trials conducted in the U.S., Latin America and sub-Saharan Africa found that cabotegravir reduces the risk of contracting HIV by anywhere between 66 and 89%, and this month, a new trial of the drug has begun in 100 homosexual men in Kiev and Lviv. “Cabotegravir is the talk of the town everywhere right now, but particularly in a country like Ukraine where the situation is so volatile, you don’t know whether your health-care facility will still be standing next month, it can be crucial,” says Vasylyeva of UC Irvine. “So the longer you can go without needing contact with your care provider, the better.” But while Vasylyeva is optimistic about Ukraine’s ability to continue driving down infection rates, the situation in the Russian-occupied cities of eastern Ukraine remains uncertain. Here, the Ukrainian HIV charity, [100%Life](https://network.org.ua/en/), fears that the epidemic is being silently fueled by forced sex work. Vasylyeva admits that there is no data on HIV rates among these regions as testing has all but stopped, but she and others strongly suspect that rates are rising. “I’m scared to think about what’s happening in these territories and what’s going to happen when the war ends,” she says. “All of us are very hopeful it will end in Ukraine’s favor, but even then, there will need to be a lot of adjustment to make sure that HIV cases in these areas don’t seed outbreaks in the rest of the country when Ukraine is unified.” _David Cox is a freelance health journalist who has written for publications around the world including NPR,_ The New York Times, Wired _and_ The Guardian. _He has a Ph.D. in neuroscience._

 It should be easier to get the methadone today than it has been in decades. In April, 2024, the federal government relaxed some of the rules around the treatment for opioid addiction. But many patients are still not benefitting from those changes. Kellyann Kaiser, 30, is among those in recovery who had been waiting eagerly for greater access to methadone. She said she was addicted to opioids from the age of 13 into her late 20s. She tried several different addiction medications, including buprenorphine and naltrexone. “I think just methadone is what got me sober,” she said. “Without that, I think I would still be using.” But it hasn’t always been easy for her to get the sticky pink liquid — taken daily — that relieves her opioid cravings and withdrawal symptoms. At first, she had to drive an hour from her western Massachusetts home to a methadone clinic. “And I have three little children, so I would have to find a babysitter for them. Go out there and come back,” she said. “I used to have to go every single day.” Now, there’s a clinic closer to her home and Kaiser only has to go once a month. That’s because new federal rules allow her to take methadone bottles home, instead of taking each dose at the clinic. “(Under) the old rules you had to be in clinic for 90 days and you had to never miss a day to get one bottle. So that's a lot of perfection,” to expect from patients, says Dr. Ruth Potee who oversees Kaiser’s treatment at the nonprofit Behavioral Health Network, based in Springfield, Mass. Potee is also a national advocate for better addiction treatment. In contrast, newer anti-addiction drugs like buprenorphine and Vivitrol can be prescribed in a primary care office and picked up at a pharmacy. Since they have a different chemistry, those medications can’t be abused in the same way as methadone. But for many people, Potee said, methadone works better against the potent new street drugs like Fentanyl and Xylazine. She calls methadone a “miracle drug.” “It doesn't take any length of time to get on to it,” she said. “You get to a stable dose and then you stay there. You don't really develop tolerance to it.” ### A COVID-era experiment with methadone rules proves successful Methadone, which locks up opiate receptors in the brain, was first introduced to treat addiction in the 1960s, just as the Nixon administration’s War on Drugs was doubling down on a law-enforcement approach to drug abuse. At the time, methadone’s high street value and potential for abuse led the federal government to set up strict rules around how to get it, including daily visits to a high security methadone clinic and mandatory counseling. “They just built the rules in this one way that made it incredibly restrictive,” Potee said, “And they never went back to change it, despite decades of increasing addiction.” But this past spring, the federal agency that oversees substance abuse and mental health services — called SAMHSA — changed the methadone rules for the first time in decades. Under the new rules, patients still have to get methadone at clinics, but if they meet the criteria, they can take weeks’ worth of bottles home and get counseling via telehealth, and providers have more leeway in prescribing individual doses. Dr. Yngvild Olsen, who directs substance abuse treatment for SAMHSA, said regulators first tried out the new rules as a COVID measure and, as she put it, the sky didn’t fall. “This did not increase the rate of methadone-related mortality, for example, which had been one of the concerns prior to this kind of natural experiment,” she said. The agency also put in guardrails to limit abuse and black-market sales. For instance, Kellyann Kaiser said she had to earn the right to take methadone at home. “I had to pass so many drug tests to get it,” she said. “And then you have to take a class, like a safety class, on what you do with your methadone, how you keep it safe in your home.” Kaiser lost custody of her son when she was using illegal opioids. She credits methadone with getting him back and the new rules with helping her stick to treatment. ### Adoption of the new rules slow and patchy, leaving many out Kaiser lives in Massachusetts, a state that embraced the new flexibility around methadone. Not all places have. The federal standards are voluntary. Olsen says states can choose to keep their rules more strict, including daily check-ins. “There are some states that are still really looking at and figuring out what's going to work best for their state and to what extent they will align \[with the federal rules.\]” Olsen said her staff is encouraging states to fully implement the federal guidelines by the official (albeit voluntary) compliance date in October, but many advocates say adoption has been frustratingly slow. “Substance use treatment programs love rules,” said Brian Hurley, who heads the American Society for Addiction Medicine. “It takes time both for state regs to change and, frankly, for business operations and clinical practices to evolve.” He says the general culture of methadone clinics — also called Opioid Treatment Programs or OTPs — is mired in the way things have always been done. So starting in Los Angeles where he’s based, he’s trying to help local clinics set up new protocols, “shifting the approach from a rules-based to a patient-centered approach.” But there are reasons some providers are going slowly. “When you look at a whole system of 2000-plus treatment programs, it's like watching an aircraft carrier change course in the middle of the ocean,” said Mark Parrino, head of the American Association for the Treatment of Opioid Dependence, a trade group for methadone clinics. “It does so, but it does so carefully.” Parrino said his group approves of the new flexibility but that members worry about liability when patients are not closely supervised. He pointed out that patients can overdose on methadone, which is itself an opioid. “Methadone is a very therapeutic medication when it's used wisely,” Parrino said. “But if it's used unwisely, it's unforgiving.” Parrino also brought up a financial concern. He said clinics —many of them for-profit and run by private equity firms — are waiting to see if Medicaid changes how it pays for methadone treatment when patients come in less frequently. Otherwise, he said, “the programs absolutely lose money. Some would not be able to continue.” But even if the federal rules are put into wide practice, many addiction doctors and advocates say they don’t go far enough. “They won't be enough until methadone is freed from methadone clinics generally,” said Massachusetts U.S. Senator Ed Markey, who is sponsoring legislation he says would break the clinics’ monopoly on methadone. Markey’s legislation, known as the Modernizing Opioid Treatment Access Act (MOTAA), would allow methadone to be prescribed by any board-certified addiction doctor and picked up at a regular pharmacy. The American Society of Addiction Medicine supports the proposed legislation. The clinic trade association opposes it.

Micheal Ray Richardson was a brilliant player: a four-time NBA All-Star guard. He was also the first player banned for life by the league for drug use, something which was far more common during his playing days. Back in the 1980s, substances like cocaine were not only part of professional sports but also [society and](https://www.yahoo.com/news/casual-cocaine-ads-show-lit-034207924.html?guce_referrer=aHR0cHM6Ly93d3cuZ29vZ2xlLmNvbS8&guce_referrer_sig=AQAAAHMFIIC0I8gRIjyL5Ph-tiwdxeSMiSc1V0Fv4xwrr9QNyjpRhZ4mLAej3B3Y4sfhnjBFzxcfzMnY9IEOPlR4V-CQpIEt3kViJFKF_2-_lXbrkS5m0nJZph6h3XPuM7wwtnmWFhCsFStqxjzNIeIDu3IfXdSJzRH7eabvm1XZuj65) [entertainment at large](https://faroutmagazine.co.uk/this-bill-murray-movie-was-a-permanent-cocaine-party/), and Richardson says talk about drugs was routine during what some still call the NBA’s cocaine era. “During warmups,” Richardson says, “guys on different teams would say, ‘Yo, man, I got what you’re looking for. Let’s get together when \[the game\] is over.’ And _boom_ that’s how it got going.” At the time, drugs were “everywhere – it was like a fad,” says Richardson, who also goes by the nickname Sugar. But in the NBA, it alienated many fans. So much so that to correct the problem, the NBA instituted a three-strike system, which led to Richardson’s 1986 banishment (all of which he discusses in his [forthcoming memoir](https://www.amazon.com/Banned-Squandered-All-Star-Finding-Redemption/dp/1683584902), [Banned](https://hoopshype.com/2024/09/19/banned-how-i-squandered-an-all-star-nba-career-before-finding-my-redemption/)). Today, aside from the 10ft basket and the five-on-five competition, the [NBA](https://www.theguardian.com/sport/nba) does not resemble the league in the late 1970s and early 1980s. But when it comes to drugs, that change took time. For Richardson, who grew up modestly in the midwest and only got into drugs after succumbing to peer pressure while living in New York City and playing for the Knicks, drugs were not a part of his early life. Then they overtook him and led to a debilitating years-long addiction. But his story is far from unique. When David Stern took over as commissioner of the NBA in 1984, one of his top priorities, along with promoting the Magic Johnson-Larry Bird rivalry, was cleaning up the game. That meant suspensions and lifetime bans (Richardson was also the first player reinstated to the NBA, in 1988, but he never returned to the league). Still, pro basketball in those days was littered with addiction and lost potential. Marvin “Bad News” Barnes is perhaps the poster child for drug issues. His biography, [Bad News](https://www.amazon.com/Bad-News-Turbulent-Basketballs-Original/dp/1683582675/ref=sr_1_1?crid=2X7JD0W75AM82&dib=eyJ2IjoiMSJ9.9xcKMDEHBV6wMLdwH0w53RPhkgZE3PSZcn4ALMVySrOdjBLSGLfRv9XbdZeZsg4oP4cQT3uthlPIYg0G0_RdwYMP1k9zYkmNVFGz60Hkau54EJCmip34_rmQL41K14EvOvNmpnWWsltbaiC-PEWqPg9H5taZs-kqmVChnBNtHJSM866lIYyD5FIfxjVeiYprlVdBAGTmf1IuCtHRn6QG-7IVyTBMY5ssdyrynXqaYlo.bfoB_qbjJ5JgbBpGfjJNqInB6rbwUtUR81QQ1CCNC3A&dib_tag=se&keywords=bad+news+barnes+book&qid=1728504234&sprefix=bad+news+barnes+boo%2Caps%2C153&sr=8-1), details a life of [drug abuse](https://www.chicagotribune.com/1990/03/04/bad-news-is-back-behind-bars/), which included hanging out with drug kingpins, derailing what could have been a Hall of Fame career. He went from averaging 24.1 points and 10.8 rebounds per game in 1975-76 in the ABA to 9.6 and 4.8 a season later in the NBA. Barnes was out of pro hoops by 1980 and, despite trying many times, never kicked his habit before passing away in 2014. But Barnes, too, is not an isolated case. In 1986, the same year Richardson was banned for life, Boston Celtics rookie Len Bias, died from a drug overdose at the age of 22 [mere hours after being drafted](https://www.bbc.com/sport/basketball/65953921). “He got ahold of some bad stuff,” Richardson says. “That was a sad moment. A wakeup call for everybody.” [](https://www.theguardian.com/sport/2024/oct/23/drugs-were-everywhere-the-rise-and-fall-of-the-nbas-cocaine-era#img-2) Len Bias died shortly after being drafted by the Boston Celtics. Photograph: AP Also in 1986, All-Star John Drew was banned for life for violating the league’s substance abuse policy. That same year, Rockets guard John Lucas was waived by the team because his drug issues [had become so bad](https://www.latimes.com/archives/la-xpm-1986-11-23-sp-12376-story.html). (Lucas later turned his life around, became an NBA coach, [founded a rehabilitation center](https://johnlucasenterprises.com/athlete-aftercare), which has helped save the lives of many athletes and even headed up a professional tennis team [featuring Steffi Graf](https://en.wikipedia.org/wiki/Houston_Wranglers).) In 1987, All-Star “Fast” Eddie Johnson was banned for drugs. Chris Washburn, a former No 3 pick, was banned in 1989. In 1991, former Sixth Man of the Year, Roy Tarpley, and promising rookie Richard Dumas were both sent packing. The list goes on. But it wasn’t just players. Coaches and executives were affected by substance abuse. Usually in the form of alcohol. “When I was in the \[Continental Basketball Association\],” says Richardson, “my coach [Bill Musselman](https://www.basketball-reference.com/coaches/mussebi99c.html) – he used to get at that bar when the game was over and he would be red as a beat. He would be so damn drunk. But there were a lot of coaches who drunk their alcohol. Back then it was more accepted.” In the NBA, drug abuse was so rampant in the 1980s ([even Michael Jordan has talked about it](https://www.nbcsports.com/nba/news/the-time-michael-jordan-walked-in-on-bulls-teammates-doing-cocaine)) that teams were said to have hired [private investigators](https://thehub.news/savoir-faire-norm-nixons-lakers/) to spy on their players, from Los Angeles Lakers All-Star Norm Nixon to Richardson when he was with the Golden State Warriors. Richardson believes his lifetime ban, along with Bias’s death and the other suspensions, finally forced players to confront their drug use. They knew real repercussions were around the corner, that the league was demanding better behavior. Still, the NBA, like all walks of life, has since had to deal with other examples, [from alcohol abuse](https://www.jsonline.com/story/news/health/2024/03/12/vin-baker-recovery-opens-tuesday-offering-mix-of-addiction-treatments/72894757007/) to [prescription drug dependence](https://www.cnn.com/2024/02/20/sport/rex-chapman-autobiography-drug-gambling-addiction-spt-intl/index.html). Other leagues [like the NFL](https://www.youtube.com/watch?v=bC6dRUz76B4) and MLB have also had to deal with serious drug issues, [from opioids](https://www.washingtonpost.com/sports/2022/02/22/mlb-opioid-epidemic-eric-kay-trial/) [to painkillers](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3095672/) [to steroids](https://www.nbclosangeles.com/news/sports/mlb/mlb-biggest-scandals-steroids-gambling-sign-stealing/3369188/) [to cannabis](https://www.cbssports.com/nfl/news/chiefs-travis-kelce-estimates-up-to-80-percent-of-nfl-players-use-cannabis/) use, which is legal in many US states now and which the NBA stopped [testing for in 2021](https://www.forbes.com/sites/ariannajohnson/2023/04/03/nba-will-no-longer-penalize-marijuana-use-report-says-heres-how-other-leagues-measure-up/) (a fact that irks Richardson, who has been drug-free now for decades). And all sports are facing [problems with gambling](https://www.theguardian.com/sport/2024/apr/15/its-an-addiction-nbas-ties-to-gambling-trouble-players-past-and-present) and [gambling addictions](https://www.cnn.com/2024/06/15/sport/sports-betting-gambling-professional-athletes-dg/index.html). When it comes to the NBA, Richardson says, there were issues with heroin (Kareem Abdul-Jabbar even [admitted to trying it once](https://www.upi.com/Archives/1983/11/05/Kareem-Abdul-Jabbar-expects-negative-reactions-to-revelations-he-used/6543436856400/)) and then crack. The only remedy was distance. “You’ve got to keep yourself out of those place,” Richardson says. “Where it won’t give you opportunities to do it. Keep yourself out of those environments.” [skip past newsletter promotion](https://www.theguardian.com/sport/2024/oct/23/drugs-were-everywhere-the-rise-and-fall-of-the-nbas-cocaine-era#EmailSignup-skip-link-11) Sign up to Soccer with Jonathan Wilson Jonathan Wilson brings expert analysis on the biggest stories from European soccer **Privacy Notice:** Newsletters may contain info about charities, online ads, and content funded by outside parties. For more information see our [Privacy Policy](https://www.theguardian.com/help/privacy-policy). We use Google reCaptcha to protect our website and the Google [Privacy Policy](https://policies.google.com/privacy) and [Terms of Service](https://policies.google.com/terms) apply. after newsletter promotion [ How Len Bias’s death helped launch the US’s unjust war on drugs ](https://www.theguardian.com/sport/2021/jun/29/len-bias-death-basketball-war-on-drugs) Today, the NBA looks at substance abuse and drug addiction as part of a bigger picture, offering its players a multi-pronged attack that focuses on mental health. At a time when the US is suffering from [fentanyl](https://www.economist.com/graphic-detail/2024/03/14/americas-fentanyl-epidemic-explained-in-six-charts) [and opioid epidemics](https://www.theguardian.com/us-news/2024/jan/28/us-opioids-crisis-fentanyl-appalachia) and [other debilitating social](https://health.ucdavis.edu/blog/cultivating-health/social-medias-impact-our-mental-health-and-tips-to-use-it-safely/2024/05) issues, the NBA is working to educate its workforce about the perils of drug use and addiction as well as focusing on others issues that can [affect one’s mental](https://www.theguardian.com/sport/2023/sep/05/money-social-media-and-trust-issues-why-loneliness-stalks-the-nba) state. With annual salaries rising to as much as $60m-plus, there is a lot to be protected. Indeed, the league has come a long way over the years. From players like DeMar DeRozan, who just wrote [a book on his mental health journey](https://www.amazon.com/Above-Noise-Story-Chasing-Calm/dp/0593581261), to Hall of Famer Spencer Haywood speaking openly about his [issues with substances](https://clutchpoints.com/lakers-news-spencer-haywood-gets-brutally-honest-on-deep-denial-of-drug-problems-affecting-game-with-la). “Even now,” says Richardson, “it’s not like it was back in the 80s when I was \[playing\]. Because now there’s the fentanyl. Now what they’re doing is mixing all the drugs with fentanyl and it only takes a little – because fentanyl will kill you.” And if fans wish to take a quick glance at a list of [recent NBA suspensions](https://pr.nba.com/tag/nba-suspensions/), they will not find many of the kind that the league suffered from decades ago. Rather, they will largely see the more garden variety on court fighting or run-ins with refs (though there are still some recent instances [of substance abuse](https://www.si.com/nba/2017/08/20/oj-mayo-drug-ban-comeback-milwaukee-bucks-travelle-gaines)). Two people charged with continuing the improvement of the NBA from a social perspective [include Jamila Wideman](https://sps.columbia.edu/person/jamila-wideman), a former WNBA player and current senior vice-president of player development in the NBA, and [Dr Kensa Gunter](https://www.linkedin.com/in/kensa-gunter-psyd-cmpc-4a722631/), a psychologist and director of NBA and WNBA mind health. Both, especially compared to Richardson’s era, [are doing an excellent job](https://eightypercentmental.com/category/the-podcast/series-3/), given the outside factors and demands on players’ lives today, from social media to gambling pressures. “One thing about alcohol and drugs,” says Richardson, “they do not discriminate.”

Singapore Prison Service A guard monitors CCTV in the Drug Rehabilitation Centre (DRC) control room Kim\* is a young professional who started using cannabis when family life became messy. Things improved, but her drug habit stuck - and by then, her social circle was primarily made up of people who also used. With a reliable local supplier of weed, Kim’s friends asked her if she would get some for them. “That’s what I did,” Kim says. “I never marked up the price in any way, because this was friendship... It’s like, I’m helping you to purchase something we both use anyway.” Singapore, where Kim lives, has some of the harshest drugs laws in the world. If you sell, give, deliver, administer, transport or distribute narcotics, that’s drug trafficking. And the law also presumes you’re a trafficker if you possess drugs in quantities that cross certain weight thresholds. Kim’s life unravelled very fast when one of the friends she sourced cannabis for was caught by the state’s Central Narcotics Bureau. Kim was named as the supplier of the marijuana, and picked up too. After the authorities trawled through her phone, another friend was arrested - and Kim was charged with drug trafficking. “I was wracked with horror,” she says. “To have charges of trafficking levelled at me? That was just overwhelming. I felt complete and utter fear of what was going to pan out for me.” Cannabis for recreational use has been decriminalised in many places around the world. In the US, 24 states have legalised it. While cannabis is illegal In the UK, punishments for its possession have plummeted in recent years. In Singapore, if you’re found with 15g you’re assumed to be trafficking - and with 500g or more, the death penalty is mandatory. It’s a controversial policy and there have been [several recent cases](https://www.bbc.co.uk/news/world-asia-65395390). The most recent execution - of a 64-year-old on a heroin charge - took place on 16 October. The Singaporean government won’t tell the BBC how many people are currently on death row. **Singapore’s death penalty becomes mandatory in drug cases involving** * 15g diamorphine (heroin) * 30g cocaine * 500g cannabis * 250g methamphetamine Kim’s not facing execution, but she could be looking at a lengthy prison term. “The minimum sentence would be five years,” she says. “The worst-case could be up to 20 years.” While Kim awaits judgement on trafficking charges, her friends have already been dealt with. But they weren’t prosecuted. Classed as drug consumers - not traffickers - they faced very different treatment. They were sent to the state-run Drug Rehabilitation Centre for six months each. When anyone’s caught using an illicit substance in Singapore, they’re assessed as low, medium or high risk. Only those deemed at low risk of reoffending are allowed to stay at home, where they are monitored in the community. Everyone else - even a first-time offender - is sent for compulsory rehabilitation. Singapore Prison Service The BBC was given rare access inside Singapore's austere Drug Rehabilitation Centre There’s no private, residential rehab in Singapore - no mooching around in fluffy bathrobes and then retreating to your own en-suite room. The Drug Rehabilitation Centre (DRC) is a vast complex run by Singapore’s Prison Service, which makes sense because this is incarceration by any other name. There’s barbed wire, a control room, and CCTV everywhere. Guards patrol the walkways. In December 2023, 3,981 Singaporeans were inmates - about 1 in 8 of them women. Institution S1 houses around 500 identically-dressed male inmates, most first or second-time drug offenders. A cell accommodates seven or eight men. There are two toilets, and a shower behind a waist-high wall. There are no beds. The men sleep on thin, rush mats on the concrete floor. And a detainee will spend at least six months here - even if they’re a casual, rather than addicted, drug user. “While it is rehabilitation, it’s still a very deterrent regime,” says Supt Ravin Singh. “We don’t want to make your stay too comfortable.” Singapore Prison Service Inmates are given items including a T-shirt and socks, and a rush mat on which to sleep The men spend up to six hours a day in a classroom on psychology-based courses. “The aim is to motivate inmates to want to stay away from drugs, to renew their lives without them, and to address negative thinking regarding drugs,” says Lau Kuan Mei, Deputy Director for the Correctional Rehabilitation Service. Singapore Prison Service Inmates take part in sessions including on mindfulness, during which they are taught how to control runaway thoughts “They teach us a lot about how to manage our triggers for using drugs,” says Jon\*, who’s in his late 20s and close to the end of a six-month stay. Jon has a history of using methamphetamine and is one of the inmates prison authorities have selected to talk to the BBC. Meth (also known as crystal or ice) is a powerful, highly addictive stimulant, and the most commonly abused drug in Singapore and the region. Earlier this year, on a weekday afternoon, Central Narcotics Bureau officers arrived at Jon's house where he lives with his parents. Before they took him away, he spoke to his shocked mother. “She said, ‘learn your lesson, pay your dues, and come back clean,” Jon remembers. And that’s what he’s aiming to do - but he knows it won’t be easy. “It’s exciting leaving,” he says. “But I’m also nervous... In here you’re locked up and not faced with drugs.” Jon’s worried he might be tempted to take meth again. His rehab programme has been obligatory, not voluntary as it might have been if he lived in North America or Europe. Even so, it might not impact his chances of staying drug-free. "If you look at evidence-based policies in drug addiction... it doesn’t really matter whether the treatment offered is voluntary or non-voluntary,” says Dr Muni Winslow, an addiction psychiatrist who worked in Singapore’s government institutions. He believes the treatment offered to drug users has improved. “It’s much better now because the whole criminal justice system has a lot of psychologists and counsellors who are trained in addictions.” Historically, drugs have been viewed as a criminal justice issue, rather than a health issue in Singapore. While the state execution of traffickers still sets the tone for how the government and most Singaporeans view narcotics, it hasn’t prevented changes to how drug users are treated. For example, no-one who spends time in the rehab centre gets a criminal record. “We talked to psychologists and addiction specialists and our thinking evolved,” explains Minister for Home Affairs and Law, K Shanmugam. “If they’re not a threat to society, we don’t need to treat them as criminals.”  Home Affairs and Law Minister K Shanmugam suggests thinking on how to treat drug users has shifted in Singapore Singapore commits huge resources to enabling people to stay clean once they leave the DRC. Most importantly, they’re helped to find work. But although authorities say the system has changed, critics believe it's still humane. The Transformative Justice Collective, a group which campaigns against the death penalty, describes the DRC as a form of mandatory detention where prisoners face "humiliation" and "loss of liberties". The group says programmes in the centre are superficial and focused on "shame" - failing to tackle the root causes of drug dependence. "We've seen a lot of lives disrupted and a lot of trauma inflicted from being arrested, from being thrown into prison, from having to share a cell," says Kirsten Han. "It causes a lot of stress and instability. And these are not harms caused by drugs. These are harms caused by the war on drugs." Singapore Prison Service Urine testing cubicles are the first of their kind in the world Surveillance remains a critical part of the country's mission to keep former inmates clean. At a supervision centre, a neat-looking man in his 50s arrives. He’s been in and out of the Drug Rehabilitation Centre six times, struggling with heroin. But for the last 26 months he’s been drug-free, living at home, monitored by an electronic tag. Now his sentence is over. When the tag’s snipped off, he’s delighted, and leaves quickly after exchanging a few words with Karen Lee, the director of the Community Corrections Command. “He looks healthy,” she says. “And that’s what we hope for all our supervisees… While three out of 10 do come back as repeat drug abusers, we shouldn’t forget there are seven supervisees out there, successfully living their lives as reintegrated citizens of Singapore.” While tagged, the ex-heroin user had another incentive to stay clean: regular urine analysis. Singapore’s state-of-the-art Urine Supervision Cubicles are the first of their kind in the world. Once a supervisee enters a cubicle, the door locks behind him. After he pees into the urinal the technology tests for drugs including cannabis, cocaine, ecstasy and heroin. It takes about seven minutes. “It’s not so boring - we’ve also prepared videos for him to watch, like Mr Bean!” says Karen Lee. If the test is negative, a green light goes on, and the man’s free to go. A red light indicates a positive test result - and the supervisee will be re-arrested. Singapore’s zero-tolerance policy doesn’t distinguish between casual drug users and those with an addiction. And although punishment is no longer front and centre of the system, Singapore retains draconian practices - including a legal requirement for doctors to report patients to the authorities if they disclose use of narcotics. This may well deter people from getting help with problematic drug dependency. But the harshest treatment is reserved for those convicted of trafficking. Kim - who sourced cannabis for her friends - is trying to keep busy while she waits for the court’s decision about the charges against her. “Once I heard there was very little possibility of me not serving a sentence, I took some time,” Kim says, “to mourn almost, for the period of my life I would lose. I think I've accepted prison on a deeper level. It just never gets easier as the day draws nearer.” If Kim’s incarcerated - as she expects - she won’t be unusual. In December 2023, around half of the country’s convicted prison population - 2,299 people - were serving time for drug offences. _\* All names have been changed._  [Singapore: Drugs, rehab, execution](https://www.bbc.co.uk/sounds/play/w3ct5mtb) The laws against illegal narcotics are notoriously severe in Singapore. Penalties for trafficking include the death penalty, but the government argues its zero-tolerance policy is effective. If you are caught using any illicit narcotic, including cannabis, you may find yourself in compulsory rehab. The BBC's Linda Pressly approached Singapore's authorities and was granted access to the state’s austere Drug Rehabilitation Centre. She speaks to drug users who have to spend months at the facility before being released back into the community under surveillance.

The father of the victim was first to testify. He wore a gray quilted vest, a blue-gray shirt and an expression trying but failing to show nothing. He refused for now even to look at the thickset man charged in the torture and murder of his son. “Thomas Rath,” he said, when asked to identify himself. The same name as his son. The same as an [upstate New York murder case](https://www.nytimes.com/2024/05/19/nyregion/ithaca-homeless-encampment-thomas-rath.html) that reflected the struggles of communities to meet the commingled challenges of addiction, mental illness and homelessness. Drug abuse transformed the younger Thomas Rath from an attentive father with a good job to struggling with addiction, living under a tarp in an Ithaca homeless encampment so firmly established that it had a name: the Jungle. There, in May 2023, he was handcuffed and beaten, then taken away to be brutalized, shot to death and left in a makeshift grave. Thirteen people, many of them Jungle denizens, were charged in the case, with the man on trial, Joseph Howell, 38, accused of orchestrating the nightmare. Prosecutors depicted him as a malevolent manipulator who used threats and drugs to get vulnerable people to do bad things. The Ithaca, N.Y., homeless encampment known as the Jungle. The trial took place two weeks ago in Owego, in the brick-and-limestone Tioga County courthouse built just after the Civil War. Its only courtroom features a balcony and two slowly spinning fans hanging from the high ceiling. Think “To Kill a Mockingbird.” Thank you for your patience while we verify access. If you are in Reader mode please exit and [log into](https://myaccount.nytimes.com/auth/login?response_type=cookie&client_id=vi&redirect_uri=https%3A%2F%2Fwww.nytimes.com%2F2024%2F11%2F01%2Fnyregion%2Fthomas-rath-father-murder-trial-ithaca.html&asset=opttrunc) your Times account, or [subscribe](https://www.nytimes.com/subscription?campaignId=89WYR&redirect_uri=https%3A%2F%2Fwww.nytimes.com%2F2024%2F11%2F01%2Fnyregion%2Fthomas-rath-father-murder-trial-ithaca.html) for all of The Times. Thank you for your patience while we verify access. Already a subscriber? [Log in](https://myaccount.nytimes.com/auth/login?response_type=cookie&client_id=vi&redirect_uri=https%3A%2F%2Fwww.nytimes.com%2F2024%2F11%2F01%2Fnyregion%2Fthomas-rath-father-murder-trial-ithaca.html&asset=opttrunc). Want all of The Times? [Subscribe](https://www.nytimes.com/subscription?campaignId=89WYR&redirect_uri=https%3A%2F%2Fwww.nytimes.com%2F2024%2F11%2F01%2Fnyregion%2Fthomas-rath-father-murder-trial-ithaca.html).

Getty Images There has been an 80% increase in women reporting problematic crack cocaine use Dublin is in the midst of a crack cocaine crisis, according to the city's drug counsellors. The number of people seeking treatment for the use of the drug in the Republic of Ireland increased by 594% from 173 cases in 2017 to 1,201 in 2023, [statistics from the Health Research Board (HRB) show](https://www.hrb.ie/press-releases/addiction-treatment-ndtrs-press-releases/hrb-reports-sustained-rise-in-demand-for-cocaine-treatment/). One user said he came to the city in his 20s where he became an addict. "I kind of slipped from maybe taking a few beers, to taking a couple of ecstasy, to taking some other stuff, and then I ended up on heroin and crack cocaine," said Ferghal Connolly. 'Communities on their knees' ----------------------------  Daithi Doolan said the current crack cocaine problem is a crisis Crack is the street name given to a solid form of cocaine that is usually smoked. Daithi Doolan, from the South Inner City Drug and Alcohol Partnership, said many homes in Dublin had some form of addiction. "It's actually a crisis," he added. "It's happening at the school gate in the playground." Doolan, who is also a Sinn Féin councillor, said communities cannot cope with the scale of drug use. "The drug-related intimidation is affecting individuals, families and whole communities are being held to ransom by the drug dealers." 'Drugs are all around' ----------------------  In previous decades, Dublin had been battling heroin in inner city communities. Those at the frontline of addiction say a heroin shortage, due to geopolitical changes in Afghanistan, has sparked an increase of crack cocaine use. * [Poppy crops slashed in the Taliban's war on drugs](https://www.bbc.co.uk/news/world-asia-65787391) In 2023, 4,923 people sought drug treatment with cocaine, in its powder or crack form, as the main problem.  Cheryl Kelly said women need separate services because of their complex needs Cheryl Kelly, an addiction counsellor in the Donore Community Drug and Alcohol Team, said women need separate services from men for their "complex" needs. "Women would find themselves in situations where they may be engaging in forced sex work, or they might be afraid of social services, and the women face an awful lot of shame and stigma in and around their drug use," she said. The HRB statistics showed an increase in females seeking treatment for cocaine use from 284 cases in 2017 to 1,387 in 2023. Where crack cocaine was the main problem, nearly half were female, just over one in 20 were employed and the median age was 39. 'A need for female-only spaces' ------------------------------- Ms Kelly said setting up a dedicated scheme for women was important. "They face an awful lot of shame and stigma because they're nurturing and minding their children, their family or whoever it may be. "It was very important for me to engage or to help in our community drugs and alcohol team to set up the pilot programme for women. "Women won't engage in services if they feel like the man that's been intimidating them down at a shop on Friday is also going to be in the same service seeking support, so there is definitely a need for female-only spaces where women can feel safe." 'No border that defines addiction' ----------------------------------  Alan Kinsella said his programme has had consistent full numbers Alan Kinsella, a case worker in the city centre's Coolmine Therapeutic community, said: "We have a specific programme which is aimed to work with people who are using cocaine, both powder cocaine and crack cocaine; it has consistently had full numbers," he said. "When a programme which is so specific to a drug which is busy and full, it kind of tells the story of the scope of what cocaine is like, particularly in Dublin city centre." Alan said there is no social border that defines cocaine addiction. "We see people presented with cocaine as an issue from all walks of life, and people who have jobs - there is no kind of differentiation between the people that we see and the drug that they're using."

[Claudia Sheinbaum](https://www.theguardian.com/world/claudia-sheinbaum) has said her “very kind” phone conversation with [Donald Trump](https://www.theguardian.com/us-news/donaldtrump), in which they discussed immigration and fentanyl, means “there will not be a potential tariff war” between the US and [Mexico](https://www.theguardian.com/world/mexico). The president of Mexico spoke to reporters on Thursday following Trump’s threat earlier in the week to apply a [25% tariff against Mexico and Canada](https://www.theguardian.com/us-news/2024/nov/25/trump-mexico-canada-tariffs-border), and an additional 10% tariff against China, when he takes office in January if the countries did not stop all illegal immigration and fentanyl smuggling into the US. Trump, in a [post](https://truthsocial.com/@realDonaldTrump/posts/113557687421746022) on Truth Social on Wednesday, claimed that during the phone call with Sheinbaum she had “agreed to stop Migration through Mexico, and into the United States, effectively closing our Southern Border”. During her [Thursday address](https://www.youtube.com/watch?v=InKlbqma_f4) Sheinbaum clarified she did not agree to shut down the border. “Each person has their own way of communicating,” Sheinbaum said. “But I can assure you, I guarantee you, that we never – additionally, we would be incapable of doing so – proposed that we would close the border in the north \[of Mexico\], or in the south of the United States. It has never been our idea and, of course, we are not in agreement with that.” She added that the two did not discuss tariffs, but that the conversation with Trump had reassured her that no tit-for-tat tariff battle would be needed in future. On Monday this week, Trump threatened to impose a 25% percent tariff on Mexico until drugs, including fentanyl, and undocumented immigrants “stop this Invasion of our Country”. He declared that Mexico and Canada should use their power to address drug trafficking and migration and, until they do, “it is time for them to pay a very big price!” The following day, Sheinbaum [suggested](https://www.theguardian.com/world/2024/nov/26/mexico-trump-tariffs) Mexico could retaliate with tariffs of its own. On Wednesday, however, the conversation between Sheinbaum and Trump was “very kind”, the Mexican president said. She said she told Trump of the various migration initiatives her government has undertaken, including providing resources and support to central American countries and to migrants arriving in Mexico. Potential immigrants “will not reach the northern border, because Mexico has a strategy”, Sheinbaum said. Trump “recognized this effort” by the Mexican government, Sheinbaum added. She also said Trump expressed interest in the government-driven programs to address fentanyl addiction and overdoses in Mexico. And she raised the problem of American-made weapons entering Mexico from the US to be used by drug cartels. Sheinbaum further added that she encouraged Trump to stop the blockades against Cuba and Venezuela, since “people suffer and it leads to the phenomenon of migration”. Asked by a reporter from Rolling Stone magazine that quoted anonymous Trump-aligned sources discussing a “soft invasion” of Mexico by deploying the US military inside the country against drug trafficking groups, Sheinbaum dismissed the idea, calling it “entirely a movie”. “What I base myself on is the conversation – the two conversations – that I had with President Trump, and then, at the moment, the communication we will have with his work team and when he takes office,” Sheinbaum said. “We will always defend our sovereignty. Mexico is a free, independent, sovereign country – and that is above everything else.”

On October 16, Liam Payne, a former member of One Direction, [fell from his third-floor hotel room](https://www.theguardian.com/music/2024/oct/16/liam-payne-former-one-direction-singer-dies-aged-31) and died. Within days, headlines in [TMZ](https://www.tmz.com/2024/10/21/liam-payne-pink-cocaine-in-system-autopsy-reveals/), [ABC News](https://abcnews.go.com/GMA/Culture/liam-payne-partial-autopsy-report-multiple-substances/story?id=114985701), and [the Guardian](https://www.theguardian.com/music/2024/oct/22/liam-payne-cause-of-death-toxicology-reports-cocaine-methamphetamine) announced that he had “pink cocaine” in his system. On August 10, 24-year-old Instagram model [Maecee Marie Lathers](https://www.instagram.com/maecee_marie/?utm_source=ig_embed&ig_rid=6a13609b-2bea-400b-ad6b-75d46e161e2e) killed two people in a car crash in Miami. Topless, vomiting, and screaming, Lathers told police officers that [she was under the influence of a drug called “tusi,”](https://www.usatoday.com/story/news/nation/2024/09/13/instagram-model-marie-lathers-pink-cocaine-miami/75213417007/) a pink powder that’s gaining popularity in the US. A toxicology report later found that while she hadn’t been drinking, there were several other drugs in her system — but nothing called tusi. [“Tucibi”](https://energycontrol.org/sustancias/tusi/) — also called tusi or pink cocaine — is a Spanish phonetic play on 2C-B, a California-born synthetic psychedelic originally popular amongst Gen X psychonauts and ravers seeking a euphoric, trippy high. However, despite either of its names, pink cocaine rarely contains 2C-B or cocaine at all. In the 2000s, 2C-B made its way from European nightclubs to Colombia, where it devolved into something else entirely: a pink powdered cocktail of every type of party drug you might find at Coachella. It’s essentially a Gen Z [speedball](https://www.addictioncenter.com/drugs/heroin/speedball/): Rather than blending cocaine and heroin, pink cocaine mixes [ketamine](https://www.vox.com/first-person/2018/7/24/17603616/depression-treatment-severe-ketamine-special-k) with stimulants [like MDMA](https://www.vox.com/future-perfect/365820/mdma-therapy-lykos-therapeutics-maps-psychedelics-ecstasy) and even caffeine. It can also include [a chaotic sprinkling](https://doi.org/10.1080/00952990.2023.2207716) of methamphetamine, DMT, and oxycodone, among other substances. Largely through artful [cartel marketing](https://www.youtube.com/watch?v=VOjAlLoXOhQ) portraying tusi as pretty, fun, and accessible, this blend of cheap drug leftovers has become the substance of choice for Colombian DJs and Mexican rappers, a wolf in sheep’s clothing for European ravers, and a source of confusion for everyone else. Tusi is making its way across the world, and it’s increasingly important that potential users know what it is. The global war on drugs was originally organized around the [production and trafficking of plant-based drugs](https://www.vice.com/en/article/synthetic-drugs-could-change-the-global-drug-trade-forever-v26n3/) like cocaine, heroin, and marijuana. But in recent years, drug manufacturers have turned to synthetic drugs like MDMA, ketamine, and fentanyl, which are easier to mass produce and smuggle across borders. Pink cocaine is everything new all at once — easy money for producers, a cheap Instagrammable high for users, and a massive headache for law enforcement. The biggest problem: like playing a game of Russian roulette, only luck decides whether you’ll have fun — or die. 2,5-dimethoxy-4-bromophenethylamine, or 2C-B, was first synthesized in the 1970s by Californian biochemist and psychonaut [Alexander Shulgin](https://www.theguardian.com/science/2014/jun/03/alexander-shulgin), who is best known for introducing [MDMA](https://www.vox.com/today-explained-podcast/363903/mdma-medicine-ptsd-fda) to the world of psychotherapy. Of the [over 100](https://www.theguardian.com/science/from-the-archive-blog/2014/jun/03/shulgin-alexander-drugs-ecstasy-mdma) psychedelics Shulgin created, [2C-B was his favorite](https://www.vice.com/en/article/sihkal-shulgins-i-have-known-and-loved/) — in [his words](https://www.cognitiveliberty.org/ccle1/shulgin/adsarchive/2cb.htm), “one of the most graceful, erotic, sensual, introspective compounds I have ever invented.” The effects of 2C-B are [often described](https://www.erowid.org/experiences/subs/exp_2CB_Glowing_Experiences.shtml) as an MDMA-LSD hybrid, giving users both a heightened, vibrant sensory experience and a feeling of euphoria and openness. In many ways, Shulgin viewed 2C-B as a counterpart to MDMA, which has been touted for its therapeutic potential [for 40 years](https://www.vox.com/today-explained-podcast/363903/mdma-medicine-ptsd-fda), well before it became popular as a club drug. Not only are the two drugs chemically similar, but their psychoactive effects complement each other. “Once the MDMA has shown you where your problems are,” [Shulgin wrote](https://www.cognitiveliberty.org/ccle1/shulgin/adsarchive/2cb.htm), “the 2C-B opens up the emotional, intuitive, and archetypal area of your psyche to help you solve them.” Anecdotally, [many people report](https://www.erowid.org/experiences/exp.cgi?A=Search&S1=52&Sub1=&DoseMethodID=-1&S2=-3&Sub2=&S3=-1&Sub3=&Str=&Title=&AuthorSearch=&A1=-1&GenderSelect=-1&Intensity=&I2=&C1=1&Context=-1&Lang=1&Group=-1&S4=-1&SP=1) that 2C-B’s psychedelic effects are relatively mild and short-lived. Trips last a few hours, unlike the full-day trip provided by LSD. Like other hallucinogens, 2C-B generally doesn’t [cause a next-day hangover](https://www.vice.com/en/article/what-is-2cb-and-its-effects/), according to users [interviewed by Vice](https://www.vice.com/en/article/what-is-2cb-and-its-effects/). It can also have [less fun side effects](https://adf.org.au/drug-facts/2c-b/) like anxiety, nausea, headaches, or elevated heart rate, any of which can get dangerous in situations where users are dancing — and likely not drinking enough water — in crowded, hot spaces. In the 1980s and early 1990s, 2C-B was legally manufactured and sold in adult bookstores and dance clubs [as a libido-enhancing drug](https://www.justice.gov/archive/ndic/pubs0/665/665p.pdf). That changed when the Drug Enforcement Administration (DEA) [listed 2C-B as a Schedule I drug](https://www.justice.gov/archive/ndic/pubs0/665/index.htm) in 1995, pushing it underground, where it remained a [relatively niche drug for rave-goers](https://psychedelichealth.co.uk/2023/06/23/2c-b-lsd-mdma-baby/). But over the past decade, it’s become an [increasingly popular party drug](https://www.vice.com/en/article/what-is-2cb-and-its-effects/) in Latin America, Europe, and the US. The [2019 Global Drug Survey](https://www.drugsandalcohol.ie/30537/1/Exec-Summary.pdf) of over 120,000 people from more than 30 countries reported that darknet purchases of 2C-B and other drugs have been on the rise since 2014. In the early 2000s, wealthy young people [smuggled small amounts of 2C-B](https://insightcrime.org/es/noticias/tusi-coctel-sicodelico-rosa-engano-latinoamerica/) from Europe to Colombia, where it quickly became popular in [Colombia’s elite club scene](https://insightcrime.org/news/analysis/2c-b-now-drug-of-choice-for-colombia-elite/). By 2012, models, politicians, and actors were [shelling out 130,000 pesos](https://insightcrime.org/news/analysis/2c-b-now-drug-of-choice-for-colombia-elite/) (about $71 at the time) for a gram of 2C-B — over 10 times the price of cocaine. “The media positioned it as an elite drug,” said [Julian Quintero](https://www.linkedin.com/in/juli%C3%A1n-andr%C3%A9s-quintero-l%C3%B3pez-a5b28421/?originalSubdomain=co), a sociologist, drug researcher, and director of the [Technical Social Action Corporation](https://www.acciontecnicasocial.com/que-es-ats/) (ATS), a Colombian drug policy nonprofit. “Very few could access it.” While 2C-B was considered high-class, it wasn’t much to look at. It was usually sold as a plain-looking pill or an [off-white, bitter powder](https://commons.wikimedia.org/wiki/File:4-bromo-2,5-dimethoxyphenethylamine.jpg#/media/File:4-bromo-2,5-dimethoxyphenethylamine.jpg) that [hurts to snort](https://www.bdp.org.uk/get-information/drugs-information/2c-b/). To make the drug more appealing, narcos started mixing the powder with sweet pink food coloring. Soon, demand outpaced the supply of 2C-B available in Latin America, so Colombian dealers [cut the powder](https://insightcrime.org/es/noticias/tusi-coctel-sicodelico-rosa-engano-latinoamerica/) with cheaper, longer-lasting, and more abundant European imports like MDMA and ketamine. People began calling the pink powder “[tusi,](https://energycontrol.org/sustancias/tusi/)” a Spanish spelling of the English pronunciation of “2C.” In the early 2010s, Quintero said, tusi still reliably contained about 10 percent 2C-B, mixed in with the MDMA and ketamine. But by the mid-2010s, the 2C-B component disappeared. Removing the priciest ingredient, Quintero told me, was the “magic formula.” Today, a gram of tusi costs $10, not $100, making it accessible to just about anyone who can afford a night out. [Joseph Palamar](https://med.nyu.edu/faculty/joseph-j-palamar), a drug use epidemiologist at New York University and deputy director of the [National Drug Early Warning System](https://ndews.org/), said that the homophones — “tusi” and “2C-B” — initially confused old school ’90s ravers, who only knew of the original 2C-B and likely thought that’s what they were taking. But, he said, “new school people probably don’t know the difference.” Despite the flurry of headlines announcing that, according to an anonymous tip, Liam Payne’s autopsy found pink cocaine in his system, there’s no chemical test for pink cocaine. You can only test for its common ingredients, like ketamine and MDMA. If both of those substances are found at once, it _might_ be pink cocaine — but there’s no way to know for sure. Calling the powder “pink cocaine,” or polvo rosa_,_ has even less to do with the drug’s contents. “The name ‘pink cocaine’ is one of many fantasies invented by the police to name things they don’t understand,” Quintero said. Much of polvo rosa’s rise in the club scene can be attributed to its Instagram-ready aesthetic. “The fact that it’s a pretty color draws a lot of people in,” Palamar said. It’s a brilliant marketing strategy: transform a bland-looking, expensive, exclusive synthetic drug into an Instagram-worthy accessory that almost any partygoer can afford — simply by changing just about everything in it. If tusi had a standard recipe — something potential users could make informed decisions about — this wouldn’t be as big a deal. But as tusi became more popular, the color told users increasingly little about what they were ingesting. “The thing is,” Palamar said, “anyone could dye any powder pink.” The initial rise of tusi in Latin America was part of a broader trend: Coca and opium production [declined between 2007 and 2012](https://insightcrime.org/news/analysis/un-world-drug-report-new-drugs-new-users) for a number of factors, including [increased seizures of heroin](https://www.unodc.org/documents/data-and-analysis/WDR2012/WDR_2012_web_small.pdf) exported to the US and evolving drug preferences. At the same time, the production and trafficking of synthetic drugs like 2C-B, MDMA, and ketamine grew. La Empreza, a street gang claiming to be the first to make and sell tusi in Colombia, [told Vice](https://www.youtube.com/watch?v=VOjAlLoXOhQ) in 2022 that in addition to MDMA, ketamine, and caffeine, their recipe for the drug includes synthetic methamphetamines, LSD, and fentanyl, among other chemicals. A batch of tusi is essentially made by tossing assorted drugs into a pan, adding a dash of pink food coloring, and stirring the mixture by hand. This isn’t even a great way to make a salad — the dressing won’t be evenly distributed across the greens, and some bites will wind up with more toppings than others. When mixing a powder and liquid drug salad, it’s nearly impossible to ensure that each dose of the final product will contain the same ratio of ingredients. When preparing non-toxic food, perfectly even distribution isn’t usually a concern, but a gram of powder that may contain a mystery dose of a powerful sedative like ketamine — or even the far deadlier fentanyl — is dangerous. The fact that tusi is so easy to make doesn’t just make it risky — it’s making it more popular. Because tusi is synthetic, lacks a standard recipe, and doesn’t require special equipment beyond kitchenware to make, nearly anyone can prepare it themselves. “Tusi not only emerged as a new drug for a new generation, but also popularized the idea that you can make your own drugs at home,” Quintero said. As of a couple years ago, tusi was the fifth most popular drug in Colombia. Pink cocaine has become synonymous with [Colombian guaracha](https://www.youtube.com/watch?v=0D5mC8fXHgQ), a style of electronic house music often referencing the drug in the lyrics. In the song “[Magia Rosa](https://www.youtube.com/watch?v=0D5mC8fXHgQ)” by DJ Goozo, Massianello, and NesBunny, featured vocalist Paulette sings: “Quiero magia rosas que me ponga poderosa.” In English, this roughly translates to “I want pink magic to become powerful.” Quintero told me that the rise of tusi paralleled the rise of reggaeton, guaracha, small-scale drug dealers, and sexual tourism to Colombia, lending the drug a distinct cultural ethos for a younger generation. “Those who use cocaine represent the old,” he said. “Those who use tusi represent the new.” Perhaps nowhere outside Colombia is tusi more celebrated in pop culture than Mexico. While tusi isn’t often mentioned by the Mexican government or mainstream news media, it frequently appears in corridos tumbados — a genre of Mexican regional music blending the vibrant accordions, plucky bass lines, and quintessential trumpets of traditional corridos with hip-hop and reggaeton. Peso Pluma, a 25-year-old Mexican rapper, [skyrocketed to global stardom](https://www.nytimes.com/2023/06/22/arts/music/peso-pluma-regional-mexican-music.html) last year with the love song “[Ella Baila Sola](https://www.youtube.com/watch?v=lZiaYpD9ZrI),” a collaboration with regional group Eslabon Armado. But a large swath of corridos tumbados are considered [narcocorridos](https://www.latimes.com/entertainment-arts/music/story/2023-05-22/peso-pluma-regional-mexican-ella-baila-sola), or songs centered around the plight of cartels or drugs. Three of his songs — “[Lady Gaga](https://www.youtube.com/watch?v=3Wnso2A4PZE),” “[Rosa Pastel,](https://www.youtube.com/watch?v=W9If4-IhzM0)” and “[Las Morras](https://www.youtube.com/watch?v=4jvO-GCO_Tk)” — mention using pink cocaine as part of a glamorous lifestyle, and music videos for those three songs alone have racked up over 500 million views combined. (Sometimes, the glamorous lifestyle isn’t so glamorous: Peso Pluma had to cancel and reschedule concerts last year because of [death threats from a cartel](https://www.nytimes.com/2023/09/15/arts/music/peso-pluma-postpone-concerts-threats.html).) Europe, home to hard-partying tourist destinations like Ibiza, isn’t a stranger to trippy, risky drugs. Combinations of ketamine and MDMA have been [trending among festivalgoers](https://www.vice.com/en/article/new-drug-queensland-festival-pill-testing/) across the world lately, [priming the club scene](https://www.vice.com/en/article/the-five-big-drug-trends-defining-summer-2024/) for tusi’s arrival. The drug first arrived in Europe sometime [within the last decade or so](https://www.vice.com/en/article/pink-cocaine-tusi-colombia-drug/). Claudio Vidal, a director at [Energy Control](https://energycontrol.org/), a drug harm reduction nonprofit in Spain, told me that while the first big pink cocaine drug bust happened in 2016, Energy Control first analyzed samples of pink powder in 2011. In 2022, the [United Nations Office on Drugs and Crime reported](https://www.unodc.org/documents/scientific/Global_SMART_Update_2022_Vol.27.pdf) tusi popping up at music festivals in Austria, Switzerland, and the UK, in addition to party scenes in Spain and Italy. That same year, a [survey of nearly 1,500 recreational drug users](https://energycontrol.org/wp-content/uploads/2023/01/OEC2022_INFORME_DEF.pdf) at European EDM festivals found that about 20 percent had tried tusi in the last 12 months. And this summer, pink cocaine started to gain traction in US states like [New York](https://www.marca.com/en/lifestyle/celebrities/2024/07/04/6686f9c9e2704e75298b45ec.html) and [California](https://www.newsweek.com/pink-cocaine-drugs-narcotics-tusi-dea-coastguard-1923902) for many of the same reasons it blew up in Colombia: it’s relatively affordable, theoretically fun, and pink. But, Vidal said, we don’t know enough yet to tell exactly where tusi is most popular, or who exactly is using it. The biggest challenge in studying pink cocaine is that, despite its rising prevalence in pop culture, it’s hard to rigorously study a drug that’s largely defined by what it isn’t. “We do not have enough data,” Vidal said. Given the lack of research examining pink cocaine specifically, no one knows how many people are having bad reactions to it yet. Drugs like ketamine and MDMA are unlikely to cause physical dependence — people aren’t generally using these substances to relieve withdrawal symptoms, like one might if they were addicted to opiates. That doesn’t mean they can’t create a kind of psychological dependence — as Palamar said, “A lot of people become accustomed to their world on ketamine,” which can make it hard to stop using it. Vidal hasn’t seen a tusi-related spike in demand for treatment at addiction treatment centers in Spain — at least not yet. More research will be necessary to see whether tusi users aren’t checking into treatment centers because they don’t have a substance use disorder, or because they’re avoiding treatment out of fear, stigma, or something else. But that may change as tusi itself changes. In [its 2023 report](https://www.echelecabeza.com/informe-2023-servicio-de-analisis-de-sustancias-sas-echele-cabeza/), Energy Control found that Colombian manufacturers were starting to add addictive substances like benzodiazepines to batches of tusi. Quintero suspects they are also adding opioids like heroin, morphine, and oxycodone “with the aim of creating dependency.” Cases of pink cocaine being contaminated with fentanyl have yet to be reported in the US, but that hasn’t stopped Palamar from worrying about it. Over the past several years, potentially fatal doses of fentanyl have been found in samples of [fake prescription pills](https://www.dea.gov/alert/dea-laboratory-testing-reveals-6-out-10-fentanyl-laced-fake-prescription-pills-now-contain), [methamphetamine, and cocaine](https://www.sciencedirect.com/science/article/pii/S0376871623012231). Given its rising popularity, it’s reasonable to think that pink cocaine could be next. But, at least for now, the biggest risks with pink cocaine don’t seem to be addiction or fatal overdose. Taking a mystery drug cocktail — especially if it’s mixed with alcohol on a night out — can get someone far more intoxicated than they planned for.

In 2022, the US reached [a grim peak](https://nida.nih.gov/sites/default/files/images/fig1-2024.jpg) in drug overdose deaths: Nearly 108,000 people died that year, more than twice the number who died in 2015, and more than four times the number in 2002. Now, in what experts hope is more than a blip, the overdose epidemic that has affected every state in the nation might be showing some signs of abating. The Centers for Disease Control and Prevention’s preliminary data on the [12-month period ending in June](https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm) showed that [overdoses dropped about 15 percentage points](https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm) from the previous period. There were still roughly 94,000 overdose deaths, signaling that the public health crisis is far from over, though a positive change could be on the horizon. Understand the world with a daily explainer plus the most compelling stories of the day. Sign up [here](https://www.vox.com/pages/today-explained-newsletter-signup). America’s overdose crisis was exacerbated decades ago by the increasing use of and addiction to synthetic opioids, such as fentanyl, that have proliferated through the nation’s drug supply. Fentanyl was first produced in the 1960s and prescribed by doctors to people seeking relief from severe pain, such as cancer patients. A cheaper, more potent cousin of heroin, the drug soon became a favored commodity of traffickers, who began cutting other drugs with fentanyl and drawing people addicted to prescription painkillers such as oxycodone that have become increasingly more difficult to access. [As my colleague German Lopez wrote in 2017](https://www.vox.com/science-and-health/2017/5/8/15454832/fentanyl-carfentanil-opioid-epidemic-overdose), fentanyl made America’s opioid crisis — already the deadliest drug crisis in US history — even deadlier. So what might have turned the trend around? In the latest episode of Vox’s _Today, Explained_ podcast, we asked Lev Facher, a reporter covering addiction at STAT News. “There’s no one event that happened about a year and a half ago that would explain this sudden significant decrease in drug overdose deaths,” says Facher. “While there’s a lot of optimism in the harm reduction and addiction medicine and recovery world, it’s cautious optimism because people don’t really know what’s happening.” Despite that, Facher says, experts and advocates do have a few potential explanations: The simplest explanation for the drop in overdoses could be the nature of the drugs themselves; they simply may have become less toxic and less potent. Last month, DEA administrator Anne Milgram suggested [that the agency’s crackdowns](https://www.dea.gov/press-releases/2024/11/15/deas-third-annual-national-family-summit-fentanyl-highlights-progress) were having a direct impact on the drug supply. “The cartels have reduced the amount of fentanyl they put into pills because of the pressure we are putting on them,” she said at the National Family Summit on Fentanyl, which gathers people who’ve had loved ones die from drug use. Customs and Border Protection (CBP) data can’t give us the full picture of the effectiveness of cartel crackdowns, but it shows that the [rate of fentanyl confiscation at the border](https://www.cbp.gov/newsroom/stats/cbp-drugs-dosage-value-and-weight) is hardly consistent. In January, CBP confiscated 1.3 million doses of the drug. The number of confiscations dropped significantly in June before rising back to about 1.3 million doses again in August. And data on the potency of illicit drugs is limited, given that drug-tracking systems vary from one community to another, Facher told Vox. “The places that do have really good drug checking, there have been some changes detected in terms of the drugs people are using, but nothing that would explain this sudden drop,” he said. Another explanation could be that harm-reduction efforts are working. Access to [naloxone](https://www.vox.com/even-better/353129/you-can-help-reverse-the-overdose-epidemic), the lifesaving, overdose-reversing drug, expanded significantly in cities across the United States in the last few years. Local governments such as [Los Angeles County](https://laist.com/news/health/los-angeles-naloxone-overdose-deaths) made the drug available at schools, churches, libraries, and jails, and [everyday](https://health.ucdavis.edu/blog/cultivating-health/why-you-should-carry-naloxone-narcan-to-combat-opioid-overdoses/2023/08) Americans are increasingly encouraged to carry naloxone. Harm-reduction campaigns may have also had an impact on those who use recreational “party” drugs, who might favor stimulants but could find themselves unknowingly ingesting fentanyl if a dealer has mixed it into cocaine or MDMA. [Drug testing kits like Overdrive](https://www.amazon.com/Fentanyl-Overdrive-Substances-Detection-Sensitive/dp/B0D936KTKM) are available for less than $15 from retailers like Amazon and provide people with step-by-step directions on testing drugs for fentanyl. Data also suggests that the way people consume drugs might reduce the likelihood of death by overdose. Smoking fentanyl is becoming increasingly more popular than injecting it, and the former is linked to [fewer fatal overdoses and blood-borne infections](https://www.sciencedirect.com/science/article/abs/pii/S0376871623012917?via%3Dihub). The third explanation, floated by some epidemiologists, is the most bleak, and suggests that after hundreds of thousands of people were killed by drug overdoses in a relatively short time span, the [epidemic is essentially burning itself out](https://www.nejm.org/doi/full/10.1056/NEJMe2406359). “It’s a concept called the ‘depletion of susceptibles,’” Facher said. “And that’s just to say that so many people have already died of drug overdoses that there aren’t as many drug users left to die. That’s not necessarily a mainstream theory. And even if it were accepted, it probably wouldn’t explain the full significant sudden decrease in drug deaths.” The staggering number of deaths from the opioid epidemic, however, could be a contributing factor to declining youth drug misuse. [An analysis from KFF](https://www.kff.org/mental-health/issue-brief/teens-drugs-and-overdose-contrasting-pre-pandemic-and-current-trends/#:~:text=In%202023%2C%2010%25%20of%20high,alcohol%20use%20(30%25%20vs.) showed a small drop in opioid misuse among high school students from 2017 to 2023. As [Maia Szalavitz writes for the New York Times](https://www.nytimes.com/2024/12/02/opinion/drug-overdose-deaths-decline.html), “Drug epidemics are often cyclical. Younger generations witness the harm specific drugs have caused their older siblings or parents, leading them to avoid those substances.” The latest data on overdose deaths comes amid a pivotal presidential transition. While the addiction crisis is a marquee issue for both Republicans and Democrats, the incoming Trump administration includes high-level officials who’ve been intimately impacted by it. The vice president-elect, JD Vance, has spoken extensively about how opioid addiction affected his mother and his community of Middletown, Ohio. Trump’s nominee for secretary of the Department of Health and Human Services, Robert F. Kennedy Jr., is in addiction recovery himself and his policy proposals include a network of “[wellness farms](https://www.youtube.com/watch?v=liZq31HLnyA&t=1778s)” to serve [as treatment facilities.](https://www.statnews.com/2024/12/11/rfk-jr-opioid-epidemic-addiction-policy-tough-love/) It remains to be seen whether the administration will focus its efforts on addiction recovery or if it will devote more attention [to law enforcement](https://www.youtube.com/watch?v=NUClE1P8ApI) and [the US-Mexico border](https://www.npr.org/2024/11/18/nx-s1-5187973/fentanyl-trump-cartels-addiction). “There is trepidation about a potential shift toward law enforcement and away from treatment,” Facher said. “Most of my sources talk about harm reduction, treatment prevention, and really just keeping people alive \[by\] meeting them where they are and getting them the services they need to live healthier lives as the cornerstone of ending this drug crisis.” You’ve read 1 article in the last month Here at Vox, we're unwavering in our commitment to covering the issues that matter most to you — threats to democracy, immigration, reproductive rights, the environment, and the rising polarization across this country. Our mission is to provide clear, accessible journalism that empowers you to stay informed and engaged in shaping our world. By becoming a Vox Member, you directly strengthen our ability to deliver in-depth, independent reporting that drives meaningful change. We rely on readers like you — join us.  Swati Sharma Vox Editor-in-Chief See More: * [Criminal Justice](https://www.vox.com/criminal-justice) * [Health](https://www.vox.com/health) * [Policy](https://www.vox.com/policy) * [War on Drugs](https://www.vox.com/drug-war)