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 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.