By Jonathan P. Caulkins and Keith Humphreys

If, in 2015, someone had told you that the number of overdose deaths caused solely by the two most historically lethal drugs—heroin and cocaine—would drop by more than half by 2021, you would likely have assumed that the overdose crisis in the U.S. was finally coming to an end. Instead, drug overdose deaths soared to more than 100,000 per year due to the rise of synthetic drugs, a truly disruptive innovation with which U.S. drug policy is only beginning to grapple.

To clarify the key term: synthetic drugs are substances that can be produced in a lab and are not from plant-derived components. In Canadian and U.S. illegal opioid markets, synthetic fentanyl and its analogues are outcompeting heroin, which is made from the poppy plant. These synthetics claimed the lives of more than 70,000 Americans in 2021 (out of 106,699 total drug-involved overdose deaths, or 66%), either by themselves or in combination with other drugs.[1] Methamphetamine, another synthetic, has attained a larger share of the stimulant market than cocaine, which is made from coca leaves.[2] The rapid expansion of synthetic tranquilizers—such as xylazine and benzodiazepines—has spread addiction and death, particularly when these drugs are used in combination with opioids. The U.S. is also facing a bevy of so-called new psychoactive substances (NPS), such as MDMA and mephedrone, that collectively attract more users than do older, “minor” drugs such as LSD, GHB, and PCP.

Drug policy analysts, including the authors of this brief, are swamped with requests from desperate policymakers, clinicians, parents, and activists to find solutions to the problem of synthetic drugs. This brief comprises our answer. Unfortunately, it is not particularly upbeat. All four traditional pillars of drug policy—enforcement, treatment, harm reduction, and prevention—have limits, and there is no simple solution for the synthetic drug market. Nonetheless, the nation can do some things better and should stop doing other things that are harmful. Policymakers must:

• Maintain prohibition of the production and sale of synthetic drugs

• Expect law enforcement to shrink market-related harms, such as violence, but not necessarily to shrink the supply of the drugs themselves

• Keep expanding medication-assisted treatment and access to naloxone

• Embrace the shunning of illegal drugs as a cultural norm

• Be generous toward those who are struggling, including those suffering from drug addiction

Unfortunately, the widespread availability of potentially lethal temptations in the U.S. may be the new normal, and overdose deaths will continue to remain higher than historical norms. Such realism is depressing but honest, and honesty is the best foundation for policy.

New York: Manhattan Institute, 2023. 13p.

By A. Bukten , I. Skjærvø , M.R. Stavseth

Introduction: Despite a high prevalence of opioid use disorder (OUD) among people in prison, there is little knowledge of how many receive the recommended opioid agonist treatment (OAT) and what characterizes those who receive OAT and those who do not when it comes to mental health comorbidities. We aimed to describe people with OUD in Norwegian prisons over a ten-year period and their OAT status, and to investigate comorbidity of mental health disorders stratified by gender.

Methods: Data from the PriSUD study, including all people (≥19 years old) imprisoned in Norway between 2010 and 2019, linked to national patient registry data, including ICD-10 codes. We calculated the prevalence (1-year and 10-year) of OUD and OAT, and mental health comorbidity stratified on OAT-status and gender.

Results: Among the cohort (n=51,148), 7 282 (14.2%) were diagnosed with OUD during the period of observation. Of those, 4 689 (64.4%) received OAT. People with OUD had high levels of comorbidity, including other drug use disorders (92.4% OAT, 90.3% non-OAT), alcohol use disorder (32.1% OAT, 44.4% non-OAT) and any other mental health disorders (61.6% OAT, 68.2% non-OAT). The proportion receiving OAT among people with OUD increased markedly during the ten years of observation; from 35.7% in 2010–70.9% in 2019.

Conclusion. People with OUD, both receiving OAT and not, had substantially more mental health comorbidities than the non-OUD population. Understanding how the prison population changes over time especially in terms of mental health needs related to OUD, is important for correctional health service planning.

Drug and Alcohol Dependence. Volume 250, 1 September 2023, 110896

By Jon E. Zibbell , Arnie Aldridge, Megan Grabenauer , David Heller , Sarah Duhart Clarke, , DeMia Pressley, Hope Smiley McDonald

Summary Background The overdose epidemic in the United States (US) continues to generate unprecedented levels of mortality. There is urgent need for a national data system capable of yielding high-quality, timely, and actionable information on existing and emerging drugs. Public health researchers have started using law enforcement forensic laboratory data to obtain surveillance information on illicit drugs. This study is the first to use drug reports from the entire US to examine correlations between a changing drug supply and increasing opioid-involved overdose deaths (OOD) on a national scale. Methods This study is observational and investigates associations between law enforcement drug reports and OOD for the US from 2014 to 2019. OOD data are from the Centers for Disease Control and Prevention’s National Vital Statistics System restricted-use multiple cause of death files. The US Drug Enforcement Administration’s National Forensic Laboratory Information System (NFLIS) contains forensic laboratory–tested drug exhibit information for the entire US (NFLIS-Drug). Counts of forensic laboratory reports and OOD were aggregated for each state by month, quarter, and year. A two-way fixed effects model was used to estimate contemporaneous and lagged associations. Findings Between 2014 and 2019 in the US, 249,522 OOD were reported, with the annual number nearly doubling from 28,723 to 50,179. OOD involving illicitly manufactured fentanyls (IMF) also increased substantially during this period, from 19.4% to 72.9%. In addition, 3,817,438 forensic laboratory reports in the US that were reported to NFLIS-Drug contained an opioid, stimulant, or benzodiazepine. Reports of fentanyl and fentanyl-related compounds (FFRC) had the strongest association with OOD. Each additional FFRC exhibit was associated with a 2.97% (95% CI: 1.7%, 4.1%) increase in OOD per 100,000 persons per quarter. Interpretation Adding to the emerging consensus, protracted growth in IMF supply was more strongly associated with OOD than all other illicit drugs reported to NFLIS-Drug over the study time period. Findings demonstrate NFLIS-Drug data usefulness for research that require proxy indicators for the illicit drugs supply. A concerted effort between public health and public safety to make NFLIS-Drug more timely could strengthen its utility as a national, public health, drug surveillance system.

The Lancet Regional Health - Americas. Volume 25, September 2023, 100569

By the United States Government Accountability Office; Triana McNeil

Since 1999, more than 800,000 people have died from a drug overdose in the United States, with over 86,000 occurring during the 12-month period ending in July 2020, according to the most recent provisional data available from the Centers for Disease Control and Prevention’s National Center for Health Statistics. In recent years, some states have enacted Good Samaritan and Naloxone Access laws to help reduce overdose deaths and respond to opioid overdoses. The Comprehensive Addiction and Recovery Act of 2016 included a provision for GAO to review these laws. This report addresses the following: (1) the efforts ONDCP has taken to collect and disseminate information on Good Samaritan and Naloxone Access laws, (2) the extent to which states, territories, and D.C. have these laws and the characteristics of them, and (3) what research indicates concerning the effects of Good Samaritan laws. To answer these questions, GAO collected and reviewed ONDCP documents and interviewed agency officials. GAO also reviewed and analyzed selected characteristics of jurisdictions’ Good Samaritan and Naloxone Access laws. Further, GAO conducted a literature review of empirical studies published from 2010 through May 2020 that examined the effects of Good Samaritan laws. GAO provided a draft of this report to ONDCP for comments. ONDCP provided technical comments which we incorporated, as appropriate.

Washington, DC: U.S. Government Accountability Office, 2021. 57p.

By The National Audit Office (NAO) (UK)

The distribution, sale and consumption of illegal drugs causes significant harm to individuals, families and communities. In 2021, almost 3,000 people in England died because of drug misuse and thousands more suffered complex health problems. The government also estimated that around three million people in England and Wales take illegal drugs at a cost to society of approximately £20 billion a year. The drugs trade generates significant levels of violence and is believed to be responsible for around half of all murders in England and Wales.

Tackling the problems caused by illegal drugs is complex. It involves disrupting the organised gangs which supply and distribute drugs, and providing effective treatment and recovery services to help people with addictions. The government announced a £900 million increase in funding for 2022-23 to 2024-25 and committed to long-term targets to reduce drug use and drug-related crime and deaths. The government established the cross-government Joint Combating Drugs Unit (JCDU) to co-ordinate and oversee the development and implementation of the strategy.

t is almost two years since the government introduced its latest drugs strategy and less than 18 months remain in the current funding period to March 2025. This report examines whether the government is well positioned to achieve the strategy’s 10-year ambitions. It covers:

the development of the 2021 drugs strategy, its objectives and funding

progress in implementing the strategy

the approach to achieving the strategy’s long-term outcomes

It is too early to conclude whether the 2021 strategy will reduce the harm from illegal drugs. It will take time for new funding and interventions to address a complex set of issues, and many of the indicators used to measure progress lag behind activity. This report therefore assesses whether departments are making the planned progress in implementing the strategy, and whether the JCDU has an effective approach to understanding the impact it is having and managing the risks to achieving the strategy’s aims. It does not examine the effectiveness of interventions at the local level.

Conclusions

In 2021 the government estimated that the harm caused by illegal drugs costs society £20 billion each year. Its 2021 drugs strategy, led by the cross-government Joint Combating Drugs Unit, has provided new impetus to efforts to address these harms, and committed £900 million to 2024-25.

The strategy has established new partnerships across central and local government, and local authorities are taking steps to rebuild the workforce that was lost over the past decade. But these measures alone will not address all of the barriers to achieving a long-term reduction in drug use, deaths and related crime. The issues are complex and will require a sustained long-term response.

To inform government’s response, the JCDU and relevant departments need to develop a deeper understanding of the impacts of government spending, working closely with local service providers to understand and help address the practical challenges they face. The JCDU and departments need to be realistic about what is achievable in the first three years and assess how to adapt their approach to achieve the strategy’s 10-year outcomes.

In doing so, the JCDU should seek to provide confidence to local government: that this is a long-term commitment. It must also urgently develop a plan to reduce the demand for illegal drugs. The current lack of emphasis on preventing illegal drug use means that departments risk only addressing the consequences, rather than the causes, of harm. The government will only achieve value for money if it builds on the initial momentum of the new strategy and develops a longer-term, funded plan that delivers a joined-up, holistic response.

London: The National Audit Office (NAO), 2023. 56p.

By Jennifer J. Carroll

Against the backdrop of a post-Soviet state set aflame by geopolitical conflict and violent revolution, Narkomania considers whether substance use disorders are everywhere the same and whether our responses to drug use presuppose what kind of people those who use drugs really are. Jennifer J. Carroll's ethnography is a story about public health and international efforts to quell the spread of HIV. Carroll focuses on Ukraine where the prevalence of HIV among people who use drugs is higher than in parts of sub-Saharan Africa and unpacks the arguments and myths surrounding medication-assisted treatment (MAT) in Ukraine. What she presents in Narkomania forces us to question drug policy, its uses, and its effects on "normal" citizens. Carroll uses her findings to explore what people who use drugs can teach us about the contemporary societies emerging in post-Soviet space. With examples of how MAT has been politicized, how drug use has been tied to ideas of "good" citizenship, and how vigilantism towards people who use drugs has occurred, Narkomania details the cultural and historical backstory of the situation in Ukraine. Carroll reveals how global efforts supporting MAT in Ukraine allow the ideas surrounding MAT, drug use, and HIV to resonate more broadly into international politics and echo into the heart of the Ukrainian public.

Ithaca, NY; London: Cornell University Press Ithaca and London, 2019. 251p.

By The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA)

This report is based on information provided to the EMCDDA by the EU Member States, the candidate country Türkiye, and Norway, in an annual reporting process.

The purpose of the current report is to provide an overview and summary of the European drug situation up to the end of 2022. All grouping, aggregates and labels therefore reflect the situation based on the available data in 2022 in respect to the composition of the European Union and the countries participating in EMCDDA reporting exercises. However, not all data will cover the full period. Due to the time needed to compile and submit data, many of the annual national data sets included here are from the reference year January to December 2021. Analysis of trends is based only on those countries providing sufficient data to describe changes over the period specified. The reader should also be aware that monitoring patterns and trends in a hidden and stigmatised behaviour like drug use is both practically and methodologically challenging. For this reason, multiple sources of data are used for the purposes of analysis in this report. Although considerable improvements can be noted, both nationally and in respect to what is possible to achieve in a European level analysis, the methodological difficulties in this area must be acknowledged. Caution is therefore required in interpretation, in particular when countries are compared on any single measure. Caveats relating to the data are to be found in the online Statistical Bulletin, which contains detailed information on methodology, qualifications on analysis and comments on the limitations in the information set available. Information is also available there on the methods and data used for European level estimates, where interpolation may be used.

Lisbon: EMCDDA, 2023.

By The United Nations Office on Drugs and Crime (UNODC)

The World Drug Report 2023 comes as countries are struggling at the halfway point to revive stalled progress towards achieving the Sustainable Development Goals (SDGs). Crises and conflict continue to inflict untold suffering and deprivation, with the number of people forcibly displaced globally hitting a new record high of 110 million. Peace, justice and human rights, which should be the birthright of all, remain out of reach for far too many. The harms caused by drug trafficking and illicit drug economies are contributing to and compounding many of these threats, from instability and violence to environmental devastation. Illicit drug markets continue to expand in terms of harm as well as scope, from the growing cocaine supply and drug sales on social media platforms to the relentless spread of synthetic drugs – cheap and easy to manufacture anywhere in the world, and in the case of fentanyl, deadly in the smallest of doses. Drug use disorders are harming health, including mental health, safety and well-being. Stigma and discrimination make it less likely that people who use drugs will get the help they need. Fewer than 20 per cent of people with drug use disorders are in treatment, and access is highly unequal. Women account for almost half the people who use amphetamine-type stimulants, but only 27 per cent of those receiving treatment. Controlled drugs needed for palliative care and pain relief, namely pharmaceutical opioids, are denied to those who desperately need them, with too little access in many countries – mainly low- and middle-income countries, where some 86 per cent of the world’s population lives. Drug challenges pose difficult policy dilemmas that cannot be addressed by any one country or region alone. The United Nations Office on Drugs and Crime publishes the World Drug Report every year to provide a global perspective and overview of the world drug problem, offering impartial evidence with the aim of supporting dialogue and shared responses. This edition of the World Drug Report highlights the growing complexity of evolving drug threats. A special chapter explores how illicit drug economies intersect with crimes that affect the environment and insecurity in the Amazon Basin, with impoverished rural populations and Indigenous groups paying the price. Other sections of the report explore urgent challenges, including drug use in humanitarian settings, drugs in conflict situations and the changing dynamics of synthetic drug markets. The report also delves into new clinical trials involving psychedelics, medical use of cannabis and innovations in drug treatment and other services.   

New York: United Nations, 2023. 70p.

By Louis Favril

Background: Many people who enter prison have recently used drugs in the community, a substantial portion of whom will continue to do so while incarcerated. To date, little is known about what factors may contribute to the continuation of drug use during imprisonment. Methods: Self-reported data were collected from a random sample of 1326 adults (123 women) incarcerated across 15 prisons in Belgium. Multivariate regression was used to investigate associations between in-prison drug use and sociodemographic background, criminological profile, drug-related history, and mental health among participants who reported pre-prison drug use. Results: Of all 1326 participants, 719 (54%) used drugs in the 12 months prior to their incarceration and 462 (35%) did so while in prison. There was a strong association between drug use before and during imprisonment (OR = 6.77, 95% CI 5.16–8.89). Of those who recently used drugs in the community, half (52%) continued to do so while incarcerated. Factors independently associated with continuation (versus cessation) were young age, treatment history, polydrug use, and poor mental health. In a secondary analysis, initiation of drug use while in prison was further related to incarceration history and low education. Conclusion: Persistence of drug use following prison entry is common. People who continue to use drugs inside prison can be differentiated from those who discontinue in terms of drug-related history and mental health. Routine screening for drug use and psychiatric morbidity on admission to prison would allow for identifying unmet needs and initiating appropriate treatment. 

International Journal of Drug Policy Volume 115, May 2023, 104027

By Xiguang Liu , Mendel E. Singer 

The combination of opioids and cocaine has been increasingly implicated in overdose fatalities, but it is unknown how much is intentional vs. fentanyl-adulterated drug supply. 2017–2019 data from the nationally representative National Survey on Drug Use and Health (NSDUH) was used. Variables included sociodemographics, health, and 30-day drug use. Opioid use captured heroin, and prescription pain reliever use not according to own doctor. Modified Poisson regressions were used to estimate prevalence ratios (PRs) for variables associated with opioid and cocaine use. Among the 167,444 responders, 817(0.49%) reported use of opioids on a regular or daily basis. Of these, 28% used cocaine ≥1 of prior 30 days, 11% >1 day. Of 332(0.20%) who used cocaine on a regular/ daily basis, 48% used opioids ≥1 of prior 30 days, 25% >1 day. People with serious psychological distress were >6 times as likely to use both opioids and cocaine regularly/daily (PR = 6.48; 95% CI = [2.82–14.90]) and people who have never been married were 4 times as likely (PR = 4.17; 95% CI = [1.18–14.75]). Compared to those living in a small metropolitan region, people living in a large metropolitan region were >3 times as likely (PR = 3.29; 95% CI = [1.43–7.58]) and the unemployed were twice as likely (PR = 1.96; 95% CI = [1.03–3.73]). People with post-high school education were 53% less likely to use opioids and cocaine at least occasionally (PR = 0.47; 95% CI = [0.26–0.86]). People who use opioids or cocaine commonly choose to use the other. Knowing the characteristics of those most likely to use both should guide interventions for prevention and harm reduction.  

Preventive Medicine Reports 33 (2023) 102227

By The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA)

This report provides a technical review of the current body of knowledge regarding synthetic cannabinoids that are monitored by the EU Early Warning System. The aim of this report is to strengthen situational awareness of synthetic cannabinoids in Europe and to help stakeholders prepare for, and respond to, public health and social threats caused by such substances.

Lisbon: European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), 2021. 70p.