A Really Good Day

by Ayelet Waldman

  The fact that conservative thinkers are making these arguments is an indication that change is, if not probable, then possible.

  Some countries around the world have begun to rethink their drug policies. In 2001, Portugal decriminalized all drugs, including heroin and cocaine. It did not legalize drugs. Possession and use are still prosecuted, but as administrative violations instead of crimes. Distribution is still a criminal offense. The results of this dramatic change in approach are striking. As was anticipated by advocates of harm reduction, the spread of disease, petty crime, and overdose were substantially reduced or eliminated. More interesting: the massive increase in rates of drug use and addiction that opponents of decriminalization threatened simply did not materialize. As the award-winning journalist and author Glenn Greenwald writes in a white paper published by the Cato Institute,

  By freeing its citizens from the fear of prosecution and imprisonment for drug usage, Portugal has dramatically improved its ability to encourage drug addicts to avail themselves of treatment. The resources that were previously devoted to prosecuting and imprisoning drug addicts are now available to provide treatment programs to addicts. Those developments, along with Portugal’s shift to a harm-reduction approach, have dramatically improved drug-related social ills, including drug-caused mortalities and drug-related disease transmission.*3

  Turns out, when you stop fighting a war, fewer people die.

  I asked a number of drug policy analysts, including Michelle Alexander, Dr. Carl Hart, Ethan Nadelmann (executive director of the Drug Policy Alliance), Stephen Gutwillig (its deputy executive director), and Major Neill Franklin (a thirty-four-year veteran of the Baltimore and Maryland state police departments, now the executive director of Law Enforcement Against Prohibition), to help me imagine what a world without drug prohibition might look like. They all embraced the challenge.

  Ethan Nadelmann believes that to effect real change one would need to imagine the existence in our Constitution of a freedom over consciousness, in the same way that there is a right to free expression. As difficult as this is to contemplate, he points out that when the Bill of Rights was first imagined, it, too, was radical. Freedom of speech was considered something that could bring down a society. In the same way, he urges us to imagine a core freedom over our minds around which to structure any efforts to regulate drug use and abuse.

  My experts all agree that there is an inherent human instinct to alter consciousness, one so powerful that there has never in human history existed a drug-free society. As Neill Franklin told me, “There have always been drugs, and there will always be drugs.” At the core of our current punitive system, Stephen Gutwillig argues, is a profoundly puritanical rejection of this impulse to alter consciousness, a hatred of drugs and drug users. Ending prohibition would require letting go of this control.

  I asked them to imagine a world without this puritanical impulse, or at least a world where governments recognized that drugs will always exist, and the only question is who will control their promulgation: criminal enterprises or governments. Would the ideal system be one like Portugal’s, with the use of drugs decriminalized? Or would a system of full legalization be preferable, in which the production and distribution of currently illegal drugs were actually made legal? In that system, would I be able to use my sixty feet of accumulated CVS ExtraBucks to buy my next little blue bottle of diluted LSD?

  Dr. Hart told me that, though he used to support a policy of decriminalization such as Portugal’s, he is now in favor of the legalization of all drugs, with a regulatory system put in place like the one we currently have for the drug he views as the most dangerous—alcohol. Nadelmann and Gutwillig agree, though they don’t aspire to a world where all drugs are commodified and controlled by the free market. They believe that a sensible drug policy includes a public health component, with regulators playing a role by making decisions about which drugs should be available to adults under what circumstances. They seek “to reduce the role of the criminal justice system in drug control as much as possible while still advancing health and safety.” All of my experts, in fact, advocate a public health model that begins with a robust system of education for adults and children about both the benefits and the risks of drugs.

  Though Dr. Hart rejects what he calls “drug-by-drug bullshit,” to the Drug Policy Alliance and to Michelle Alexander, it makes sense to treat different classes of drugs in different ways. Marijuana, for example, is a drug for which they support full legalization. Unlike nearly every other medicine, marijuana has no lethal dose. Simply put, you cannot ingest enough of the drug to kill you (no matter what your freaked-out mind thinks when you’ve gobbled up too many edibles). This does not mean that there aren’t harms associated with frequent marijuana use, especially by children and adolescents, but Gutwillig and Nadelmann believe that we can model marijuana legalization on our current approach to the far more harmful drugs nicotine and alcohol. In those situations, we leave it up to individual communities to decide how to regulate distribution.*4

  Recently, I took a trip to Louisiana, where you can buy alcohol not only at gas stations and supermarkets, but in drive-through liquor stores, which will sell you a Jell-O shot covered in a plastic film, the way we here in California sell bubble tea.*5 I asked Gutwillig how he would feel about marijuana’s being sold in a similar manner. He told me that he’s not personally comfortable with having marijuana available outside of dedicated marijuana outlets, such as the ones currently licensed under Colorado’s legalization scheme. When I posed the same question to Neill Franklin, he told me that he has no problem with seeing supermarkets sell drugs in their “natural” plant-based state—drugs like low-THC*6 weed or even coca leaves, which South Americans have chewed and brewed in tea for millennia as a low-grade stimulant similar to coffee. In fact, Franklin believes that under such a regulated system marijuana would end up being used as a substitute for alcohol, which he, like Dr. Hart, views as the drug associated with the most risk and negative outcomes. If marijuana use increases and alcohol use decreases, we will avoid at least some of the deaths associated with alcohol toxicity, and other harms as well. Driving under the influence of marijuana, though hardly safe, is much less dangerous than driving under the influence of alcohol. Furthermore, alcohol use is closely associated with violence, including sexual and domestic violence. Marijuana use is not.

  Like marijuana, classic psychedelics such as LSD and psilocybin don’t cause substantial harms if taken in appropriate doses. Gutwillig suggested online drug markets as a way to distribute psychedelics in a controlled and safe manner.

  “How would that work?” I asked. “Would I be able to just go online and buy LSD?”

  “Yes,” he said. An adult would be able to go online and order a small dose of a psychedelic or of MDMA. She would be assured that what she received was in fact pure and unadulterated. In addition, she would receive warnings about potential dangers, and clear information about safe dosages relative to body mass, age, and experience. Such a system would have a substantial impact on individual and public health outcomes, because the harms associated with MDMA, and to a lesser extent psychedelics, are generally a function of dose and adulteration. As Dr. Hart says, “Focus on purity, focus on unit dose, focus on education.”

  If classic psychedelics and MDMA were available in a well-regulated and safety-tested manner, people would be far less likely to turn to new psychoactive substances, sometimes referred to as NPSs or alphabetamines,*7 synthetics with which all sorts of harms have been associated, including death.*8 Franklin suggested that in an ideal system there would be a role for psychedelic guides, perhaps centers where one could go to take psychedelics, offering a setting that maximized the potential for positive experiences and minimized the potential for harm. Kind of like a day spa, for tripping.

  The topic of opioids is far more fraught, given the current surge in heroin use, the drug’s high addiction rate (24 percent of users become addicted), and the recent dramatic spike i
n overdose and death. Any potential medical model for regulated heroin legalization would have to take these dangers into consideration. Fortunately, we have evidence that shows that there are far better ways to treat heroin and opioid addiction and overdose than through interdiction and imprisonment. Back in the 1990s, a psychiatrist in Liverpool, Dr. John Marks, experimented with an alternative model of treating addicts. Rather than incarcerating them or attempting to cure their addictions, he simply focused on keeping addicts alive, healthy, and out of the criminal justice system. He did this by prescribing to each addict her drug of choice, including heroin.

  The U.S. government responded with outrage, demanding that British authorities put a stop to Marks’s project, but for a while at least, he was allowed to continue. His results were striking. Patients in heroin maintenance, those who actually received heroin from their physicians, did not suffer high rates of HIV and AIDS, because they were not sharing needles. There were far fewer overdoses and deaths, because the drugs they used were clean and carefully administered. Plus, the patients didn’t commit crimes. All of this is to be expected: with ready access to their drugs, they didn’t need to rob, cheat, or steal. The addicts in Marks’s heroin maintenance program were healthy, most of them had jobs, and they had strong family ties.

  What surprised everyone, however, was that addiction rates actually decreased in places where heroin maintenance was offered. Giving heroin to addicts didn’t make them use more, or even make more people use. It actually stopped the spread of drug use and abuse. Why? The easiest way to think of this is like a scale. On one side of the scale is heroin. Addicts are obsessed with one thing, and one thing only: getting the next fix; doing whatever they can to get that fix takes up all of their time and energy. Marks simply removed the desperation and effort from the equation. Addicts in his program got their drugs in the morning and then spent the day with their families or at their jobs, just like Halsted, the founder of Johns Hopkins, the cocaine-and-morphine addict who invented modern surgery. Slowly but surely, the other side of the scale began to fill up with the satisfactions of work and relationships. When the scale reached the tipping point, when the pleasures of normal life outweighed the pleasure of the drug, the addicts were inspired to get clean. Every year, 5 percent of Marks’s patients simply stopped using, without the help of methadone or rehab or any other intervention.

  Who knows what might have happened had Marks been allowed to continue his project? But the United States wields a mighty sword when it comes to international drug policy. It put pressure on the British government, and Marks’s program was eventually shut down. Within two years, twenty-five of his patients were dead, and all the rest were back on the streets or in jail—collateral damage of the unending, unwinnable worldwide war on drugs.

  Inspired by Marks’s results, Swiss researchers carried out a comparison study. Eight hundred volunteers were given heroin, one hundred were put on methadone, and one hundred were given morphine. They were followed for three years. The results for the eight hundred? As the author Mike Gray writes in Drug Crazy: How We Got into This Mess and How We Can Get Out, “Crime among the addict population dropped by 60 percent, half the unemployed found jobs, a third of those on welfare became self-supporting, nobody was homeless, and the general health of the group improved dramatically. By the end of the experiment, eighty-three patients had decided on their own to give up heroin in favor of abstinence.”

  In the United States, we spend more than twenty billion dollars a year on rehab, the majority of that not on evidence-based programs but on programs that have been shown again and again to be ineffective. The success rates for typical abstinence-based rehab programs are less than 25 percent. By some estimates, 90 percent of addicts who go through rehabilitation relapse within the first year.*9 Medication-based opioid rehabilitation programs that prescribe drug-replacement medications that alleviate the symptoms of detox, such as buprenorphine, trade name Subutex, and Suboxone, a compounded mixture of buprenorphine and the opioid antagonist naloxone, are more successful, but they, too, have substantial limitations.

  We can imagine a regulatory system like the one operated by Marks in Britain, which allows for the distribution of pure, unadulterated heroin and other opioids within clinical confines, and which also provides other services to addicts and other users. That system would not just maintain the health of addicts and preserve the peace, but would actually help people overcome their addictions.

  It’s important when talking about opioids to remember what Dr. Hart stresses. The vast majority of people who use will not become addicted, so “it’s a waste of time and effort to offer them treatment.” Both he and Franklin would make these drugs available to the public and provide treatment to those who need it, “making sure that the unit dose enhances safety and minimizes toxicity.” They would also provide clear, honest, and thorough education about the risks and benefits of these and all drugs.

  A legalization scheme for stimulants such as cocaine and methamphetamine is even more challenging to imagine than one for opioids, because stimulants are, next to alcohol, the drugs most commonly associated with antisocial behavior.*10 According to Dr. Hart, “Methamphetamine abuse is associated with multiple deleterious medical consequences, including paranoia mimicking full-blown psychosis.”*11 Adopting a purely market-based approach for drugs with such potential negative consequences made Gutwillig uncomfortable, though Franklin less so. Franklin can imagine a variety of possible regulatory schemes for cocaine, amphetamine, and methamphetamine, and pointed out that we currently have a medical model for the use of stimulants that, though hardly perfect, does function tolerably well. The millions of Americans who are prescribed Adderall, a stimulant in the same class of drugs as methamphetamine, fill their prescriptions legally at pharmacies. A similar system for cocaine, amphetamine, and methamphetamine might allow a patient or user to go to a pharmacy, present her ID to prove she is of legal age, and receive a dose of the drug appropriate to her size and experience.

  “Treat methamphetamine like Adderall?” I asked. “Does that really make sense?”

  In fact, it does. According to Dr. Hart, d-amphetamine, the main ingredient in Adderall, and methamphetamine, are chemically virtually identical.*12 They function in the same way in the brain. Like Adderall, methamphetamine improves focus and performance. The intensity of both drugs is enhanced when they are smoked or snorted, as is commonly the case in illicit use, as opposed to swallowed in pill form. Meth is a more problematic drug than Adderall because of how it’s ingested, and because it’s illegally obtained and thus often adulterated—not because of anything intrinsic to the drug itself. Individuals who are prescribed pharmaceutical methamphetamine in appropriate doses suffer no more harm than those prescribed Adderall. Because of this, and despite their concerns, all my experts agree that it would make sense to treat methamphetamine like Adderall and the other stimulants in its class.

  I asked my experts if they would anticipate an increase in casual drug use were we to abolish prohibition. Most agreed that rates of use are likely to rise initially, before settling down to rates comparable to what we see now. However, increased use does not, according to Franklin, “necessarily equate with problematic use. Products would be safer to use, education would be robust, and thus use would be less problematic. If we move drug use to a place of health instead of criminal justice, then there would be quicker access to treatment. What we’re spending now for cops, courtrooms, and prisons would go instead to public health.” Less scare, more care.

  Though imagining a more sane and sensible system with these experts was a fascinating exercise, I sympathize with Dr. Hart’s frustration when he told me, “I’m over the rethinking of drug policy. We need to actually just do it.” Fortunately, pressures to liberate us from the horrible damage caused by the War on Drugs have intensified internationally. In April 2016, the UN General Assembly held a special session on drugs, in anticipation of which former Secretary General Kofi Annan called for the
decriminalization of all drugs for personal use, the increase in treatment options for drug abusers, the implementation of harm-reduction strategies such as needle exchange programs, and a focus on regulation and public education, rather than criminalization. In an op-ed in the Huffington Post, Annan wrote, “It is time to acknowledge that drugs are infinitely more dangerous if they are left solely in the hands of criminals who have no concerns about health and safety. Legal regulation protects health.”*13

  This is remarkable, given that the slogan of the last UN General Assembly Special Session on Drugs in 1998 was “A Drug-Free World—We Can Do It!” It took nearly twenty years, but finally at least some in the international community have come to realize that we will never have a drug-free world. What we need to strive for is a world free of a drug market controlled by vicious criminal syndicates, where hundreds of thousands are murdered and hundreds of thousands more die of drug reactions and overdose, where millions are incarcerated, and where none can gain legal access to drugs that have the potential for markedly improving their lives.

  I have worked on drug policy issues for over two decades. When I first began speaking about decriminalization, back in the 1990s, when politicians were inveighing against “super-predators” and calling for ever-more draconian penalties, people thought I was at best a naïve dreamer, and at worst a dangerous drug advocate. And yet now here we are with the United Nations practicing radical sanity. It’s entirely possible that we may in fact one day see a system in which drug use is decriminalized, treatment is available to those who need it, and drugs like psilocybin and MDMA can be prescribed under certain limited conditions. I wonder what that brunch mom will say if this happens? Will we be having conversations about the age at which our children are allowed to smoke a doobie, and will that be before or after they’re allowed to cross the street?