Prisoners of the Opioid Crisis
America is failing some of its most vulnerable. Here's a better approach to dealing with addiction.
At a little after 11 o’clock on a Wednesday morning last spring, I watched cartoons with three small children while their mother talked to her parole agent in the next room. Community supervision can be an intimate process, and over the course of several months of field research I sat in many similar living rooms listening to many similar conversations. Rain made marshes out of the plowed fields across the highway while the children stared ahead at the screen, apparently unperturbed by the presence of armed strangers in their house. “You been using?” the agent asked in a tone that was almost confessional, as if they shared a secret. The woman looked down, said nothing, and cried quietly. She had just tested positive for fentanyl, a substance that has upended the landscape of drug abuse in the United States.
The opioid epidemic was kindled by the oversupply of prescription pain relievers in the late 1990s and fanned by new sources of heroin in the early 2010s. Today, however, fentanyl is king. The drug, which is primarily produced from Chinese chemicals by Mexican cartels and trafficked through major U.S. cities, is everywhere. It’s easy to see why. Fentanyl is about fifty times as potent as heroin, and is attractive for smugglers looking to minimize their profile and for distributors eager to stretch their inventory. An innocuous white powder, it can be easily mixed with other substances or pressed into counterfeit pills, making it a versatile (and dangerous) ingredient in multi-drug cocktails.
The boys’ mother, like most fentanyl users, was formerly a prescription pill and heroin user who barely noticed the gradual change in the drugs she was buying. But fentanyl is uniquely dangerous to her: the chemical is quickly metabolized by the human body, which makes for an intense but relatively short high that leaves users wanting more. Its potency means that getting the dosage right is difficult, and the line between satisfaction and fatality is vanishingly thin. Between 2016 and 2020, fentanyl deaths increased in all but seven states, a trend that contributed to the first national drop in average life expectancy in more than a century. More than half of the nearly 108,000 drug overdose deaths in the United States in 2021 were caused by synthetic opioids like fentanyl.
For parole agents and other frontline public safety workers, making sure clients aren’t on drugs used to be about keeping them out of jail. These days, it’s about keeping them alive. Fentanyl has made that job incredibly difficult: markets for the drug are remarkably resilient to disruption, and experts suggest that even after a major bust, supply can rebound in under three weeks. What’s more, the criminal justice system doesn’t have the capacity to adequately deter drug abuse among problem users. The rate of drug dependence may be as high as 65 percent among people in prison and around 40 percent among people on probation or parole. One parole agent told me that drug use is so prevalent that “the assumption is that they’re fucked up. We’re basically social workers with a gun these days.”
Without the ability to disrupt markets or deter users, policymakers have largely failed to contain the opioid epidemic as it enters its third and deadliest decade. There’s a growing understanding that if the drugs are here to stay, we need to focus resources on attacking addiction itself.
But addiction is a complex problem, and considerable disagreement exists about the best way to fight it. Two attitudes have dominated policy and practice throughout the epidemic, which might be called the “spiritual approach” and the “medical approach.” Each has its strengths; but their limitations mean they are unlikely to abate the death toll on their own.
The spiritual approach is grounded in the belief that addiction is a moral failure that can be remedied through spiritual development. This belief forms the basis of modern Twelve-Step Facilitation (TSF) programs such as Alcoholics Anonymous and Narcotics Anonymous. These programs, which have long been part of criminal justice responses to drug use, frame addiction as a condition that can only be mitigated through an appeal to a higher power, coupled with group-based abstinence and contrition.
According to psychologists, these programs can work at least as well as other forms of treatment. The problem is that their effects are concentrated among perhaps a third of participants who derive significant benefits, while the rest experience no changes. There is little data about how these programs impact opioid use, specifically. But TSFs improve behaviors by replacing unhealthy social networks with healthy ones—and this can be expected to work better for the users of social drugs, like alcohol, rather than opioids, which are most often consumed alone.
The more common approach to treating addiction is the medical approach, which has dominated America’s response to substance abuse since former National Institute of Drug Abuse director Alan I. Leshner published an article in the journal Science in 1997 titled “Addiction is a brain disease, and it matters.” In contrast to the spiritual approach, the medical approach removes morality (and choice in general) from the addiction model, focusing on prescribed medication or psychiatric treatment.
When implemented well, these interventions do prevent overdoses and related morbidity and mortality. But medications and psychiatric care are expensive, beyond the means of most people who struggle with long-term addiction, many of whom are not insured. Fewer than 15 percent of people diagnosed with opioid use disorder receive treatment each year. Furthermore, prolonging life does not equate to a better life. Like dialysis, going to a methadone clinic every day is burdensome. Relapse rates among medical treatment participants can be as high as 70 percent after six months. Until medical treatment is less expensive, more widely available, and better executed, it alone cannot halt the death toll. Achieving that will take time, and in the meantime hundreds of thousands of people will die.
The pivot toward medicalization has also produced some unintended consequences. Legal opioid-mimicking drugs are now frequently over-prescribed or diverted to illicit markets. They are not as dangerous as heroin and fentanyl, but their misuse prolongs rather than curbs addictive behaviors.
More fundamentally, the medical approach, which is supposed to humanize people who are addicted, often has the opposite effect. Even as public sentiment grows more sympathetic toward people who abuse drugs, characterizing addiction primarily as a medical problem isolates and marginalizes users, treating them like people with a contagious disease. The framing of addiction as a brain malady has been useful for prompting political action, but it denies the social attributes of addiction and too often removes choice from the equation.
Today, most people who test positive will, like the mother I observed last year, receive a stern warning from a figure of authority, but little else by way of either support or punishment. Supervision for people with opioid addiction is a dance of pleading and promises on both sides, until the client disappears or commits another crime in the service of their habit. “She’ll go back before she gets clean,” the mother’s parole agent told me as we left the house that day. “But prison’s better than her being dead.”
There is another way to treat addiction, one that is slowly being rolled out across the country, which might be called the “behavioral approach.” Interventions of this sort, rooted in behavioral economics, have the potential to effectively leverage the existing mechanisms available to the criminal justice system, while minimizing harm to users from both punishment and morbidity. Unlike the spiritual approach, the behavioral approach removes moral imperatives from the recovery process and strives for the minimal effective penalties to prevent relapse. And unlike the medical approach, it doesn’t universally mandate treatment: the aim is to keep users in their communities for as long as possible while respecting their individual agency.
The behavioral approach begins with how you frame the problem. Addiction corrupts the brain’s reward feedback system through a form of operant conditioning that diminishes the ability of the sufferer to rationally choose. It foreshortens the informational lens by overweighting the payoff of an immediate high at the expense of freedom, health, and financial solvency. But as the psychiatrist Sally Satel has argued, this process of atrophy is not indelible. People retain the ability to change their behavior when presented with well-calculated incentives. The sensible way to correct the problem of addiction is to reverse the operant conditioning, helping the person recondition themselves to accurately calculate the costs and benefits of their actions and act accordingly.
What would this look like in practice? Rather than grudging tolerance of her drug use, the mother I visited might face consequences each time she used drugs, consequences small enough to be consistently applied, but big enough to create inconvenience. People struggling with substance abuse are not good at hiding their failures, even small ones. As one agent told me: “When you start seeing red flags pop up you know it’ll be a matter of time before you have to say, ‘put your hands behind your back.’” If each of those flags was addressed in the moment, the eventual loss of liberty (and life) might be avoidable. The idea is to nudge people rather than cudgel them.
This is not a hypothetical exercise. Fueled by an interest in rational choice among scholars of crime and addiction, several programs that aim to appropriately balance the benefits and harms of punishment have emerged across the country. The most prominent example is Hawaii’s Opportunity Probation with Enforcement (HOPE), which began in 2004. Under HOPE, all detected violations of supervision conditions are punished as quickly as possible. This may seem harsh; but by raising the likelihood of detection and punishment, HOPE reduces the need for severity. Had the mother I visited been on HOPE supervision, her failed drug test might have resulted in increased reporting, a spell with an electronic monitoring device, or a night in jail. Such punishments do no permanent harm to the person on supervision, but they are extremely inconvenient. This inconvenience seems to pay off. Initial evaluations of HOPE were ebullient, and while subsequent iterations have sometimes failed to replicate Hawaii’s success across metrics such as criminal recidivism, HOPE seems to diminish drug abuse consistently and lastingly.
Another attribute of the behavioral approach is to narrowly focus on preventing the behavior that is most dangerous—in this case, substance abuse that could lead to death—instead of trying to transform all aspects of a person’s life. People caught up in the criminal justice system face an often overwhelming set of rules and restrictions. Agents I’ve interviewed confirm that the people they supervise rarely remember or understand the importance of the many conditions they are supposed to follow.
To tackle this, some experts advocate paring the rules down to only those that are important to public safety: a process called “zero-based conditioning.” One particularly successful program that has adopted this philosophy is 24/7 Sobriety, pioneered in South Dakota. By giving repeat drunk drivers one rule—abstain from alcohol use—and by enforcing this through daily testing coupled with immediate but non-severe penalties for violation, law enforcement agencies allow the people in their trust to focus on recovery rather than rules. Evaluations of 24/7 have shown that the program not only improves alcohol abuse and recidivism rates, but also reduces all-cause mortality where it is implemented: participants are estimated to be 55 percent less likely to die in the five years after the program.
HOPE and 24/7 Sobriety were initially designed for methamphetamine and alcohol users, respectively, but the carnage of the opioid epidemic has spurred community supervision agencies to adapt their principles for people who misuse opioids. And it works. Several recent initiatives along these lines, including one in New Jersey, have reduced drug use and extended the amount of time people on supervision spend in their communities. These programs don’t mandate treatment, which is often out of reach, and they don’t rely on draconian penalties. What is more, by keeping participants under close supervision without long periods of incarceration, they act as a form of what economist Angela Hawken calls “behavioral triage”: they allow supervision agents to identify users who are only marginally dependent, separate them from those with more deeply entrenched addictions, and allocate scarce resources accordingly.
No silver bullet exists to solve the opioid crisis. Even if it did, it would be unlikely to hit such a fast-moving target. Yet everyone who walks the path of addiction between pleasure and death has at least one price they are not willing to pay to keep using, and therein lies the key to recovery. “I got tired of never having anything,” was how one woman on parole I spoke with explained her effort to end four decades of heroin addiction. Another person in recovery put it this way: “The thing that made me even try was admitting to myself that just because I wasn’t putting a gun in my mouth, that didn’t mean I wasn’t trying to kill myself. I realized I couldn’t make my dad bury me.”
For the mother of the three boys I watched cartoons with that morning last spring, things did not seem so simple. “Getting sober is like building my life back from scratch,” she told me. She may be in jail right now, or she may be cooking her kids’ supper, or she may be getting high. But whatever she is doing, she still has choices—and we need to use all of the tools available to help her choose well.
Richard Hahn is a Senior Fellow for Research specializing in criminal justice at the Niskanen Center, a think tank in Washington, D.C.
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Really refreshing to see a great argument for novel demand-side interventions instead of the tired "build the wall" supply-side arguments. Would love to see the studies on the "supply can rebound in under three weeks" stat if available. It's incredible to me just how much air time and focus the supply-side receives at the expense of the demand, even though the supply is clearly a hydra that will continue sprouting heads no matter how many we manage to chop off.
You can see this supply bias in a lot of other areas too. The media's production of polarizing and sensationalist news coverage is a lot like the production of fentanyl - hard to stop and driven by an insatiable demand from a huge portion of the public. Effective solutions for both clearly need to come from the demand-side. Politicians are similar. Attempts to get politicians to cooperate across the aisle and engage in less partisan warfare are misguided as long as there's strong underlying demand from consumers (constituents) for such behavior.
Supply-side economics doesn't elicit much sympathy today. I hope pieces like this will push supply-side socio-cultural interventions in the same direction.
I read up on this a year ago, and it had already been studied by the Rand Corp, which said it worked. The psychology of this seemed pretty obvious, but there was one idea (missing from this article) that really opened my eyes. Because the law is so harsh when it was applied as it usually is, I had thought that legalizing drugs and having good treatment programs was the only humane possibility.
But the trick turns out to be keeping drugs illegal and using the law differently. The problem with treatment programs is that people drop out. The programs mentioned above fix that, half by leaving treatment up to the individual. But here's the other half of the fix.
By keeping drugs illegal, you can say: You have a choice; we will throw the book at you and lock you up, or you can agree to our frequent-testing program. Guess which they choose "voluntarily"? So the testing program is cheap because they don't send out a probation officer, they say "You get yourself to the testing office every day (that varies a bit) and if you don't show, we do come after you and you spend a night in jail. It turns out that they show up.
In short, keeping it illegal with a potentially harsh penalty allows the enforcement (if you're creative) of a very humane, paternalistic and simple conditioning scheme.