ver the past few years, drug policy reform has been on a tear. It looked as if the decades-long war on drugs was finally winding down. In the face of the most acute overdose crisis in our nation’s history, elected officials found a new willingness to try fresh approaches to reducing the fatalities, which have exceeded 100,000 each year since 2021.
It was like a dam breaking. Harm reduction — a practice based on the idea that there is great value in keeping people who use drugs alive, disease free, and as healthy as possible even if they aren’t ready for full recovery — gained support at the federal level. Millions of dollars in grants were earmarked for services that had long been off limits, such as needle exchanges, to be disbursed by government agencies that had been barred from even using the term “harm reduction’’ in their public communications until recently.
Cities greatly reduced the number of minor drug arrests made by police. States from South Dakota to Mississippi (including Massachusetts) legalized the strips that test drugs for fentanyl, the opioid up to 50 times more potent than heroin. Naloxone, the opioid overdose reversal medication, has been deregulated nationwide and made available over the counter in every state. Physicians can now prescribe buprenorphine, an effective medication for treating opioid addiction, without having to get a special waiver — a step that had restricted its use for years. In 2021, New York City opened two overdose prevention centers, the first of their kind in the nation, where people can use drugs under supervision, be revived if they overdose, and get access to services they might need, including tests for blood-borne diseases like HIV and hepatitis. In January 2021, in the most historic and sweeping of these reforms, Oregon became the first state in the nation to decriminalize the personal possession of all drugs.
But just as quickly as these changes came about, many of them are now coming undone. San Francisco is engaging in a series of police-led crackdowns in the neighborhoods most beset with addiction and overdose. Philadelphia’s leaders preemptively banned overdose prevention centers and are pledging to ramp up drug arrests and limit the use of opioid settlement funds from the Purdue Pharma case for harm reduction programs. Jurisdictions in Indiana, West Virginia, and New Jersey have shut down needle exchanges, and other municipalities are threatening to follow suit. Meanwhile, states are passing legislation that imposes harsher penalties for drug crimes involving fentanyl. In a reversal that made world news, Oregon recently re-criminalized drugs after Portland’s mayor and the governor declared a state of emergency for a skyrocketing increase in overdoses and open-air drug use. It will set decriminalization efforts in other states back by years, if not decades.
Before going further, I should air my own views. I am a professor of medicine and public health who researches the government’s response to addiction. I also spent more than two decades as a police officer. Both of these experiences have convinced me that harm reduction and evidence-based drug policy reform are what we need to reverse the overdose crisis. The war on drugs has been an enduring and monumental failure, afflicting Black and brown Americans out of all proportion, not to mention drawing the nation’s police officers into an endless cycle of futility and burnout. Drugs are as accessible as ever and have only gotten more potent — increasing people’s risk of overdose and making it harder for them to recover and lead stable, productive lives.
Yet we have to acknowledge the emerging narrative that drug policy reform has failed. Critics can point out, accurately, that the nation’s drug overdose rate remains as high as ever. In fact, overdose deaths greatly increased after decriminalization in Oregon. I don’t think the change in the law is the reason for that increase — research my colleagues and I have carried out strongly suggests this overdose trend has much more to do with the wave of fentanyl that fully hit the Pacific Northwest in 2021, just as decriminalization was taking effect. But in any event, the overdose statistics are not what is driving the widespread rollback of reforms, most of which haven’t been in place long enough to be accurately evaluated. What people are really upset about is disorder in the streets.
An overdose rate is an impersonal statistic, not an experience. What most people do feel directly and acutely, however, is what it is like to walk down the street or take public transportation in their own neighborhoods. Of late, in many cities it has become an alarming journey marked by encounters with people deep in the throes of addiction. If there has been one blind spot among drug policy reformers, harm reduction activists, and their allies in the halls of government, it is the need to compassionately — but effectively — address the highly disruptive consequences of public drug use and to take heed of how resentful a community gets when problems are left to fester. If the public disorder that results from open-air drug use goes unaddressed and people conclude drug policy reforms played a role, history suggests those reforms are in danger.
The decades I spent in a police uniform showed me how true that is. As a precinct commander in the New York Police Department and chief of police in Burlington, Vt., the most contentious problems I faced occurred when everyday people felt they weren’t able to use their streets, parks, subways, and buses with equality, safety, and peace. Nothing vexed and angered my constituents more than the feeling that someone else’s unchecked behavior made them second-class citizens on their own sidewalks.
Although I hope a wide range of drug reforms will endure and that others will expand, I have been holding these desires in tension with the government’s unmistakable duty to broker — and when necessary, enforce — the fair and reciprocal terms of social cooperation in our nation’s public spaces. It is a democratic right of access owed to everyone in the present, not a promissory note about a future time when sweeping reforms will bear fruit. In other words, we all deserve to freely use our public spaces and feel safe doing so, and the reality is that open-air drug use and encampments make city streets feel less safe, and in turn inaccessible.
It’s not just pearl-clutching
The reporting out of Portland illustrates this tension. Decriminalization greatly reduced indefensible racial disparities in policing drugs and made it clear that addiction was a public health problem, not a crime or a moral failing. Decriminalization was intended to complement a vast increase in access to treatment that was only beginning to take shape when Oregon decided to reverse course. Part of the problem was that Oregon explicitly stripped its police of the power to physically remove a person from a public place for drug use. When a person was semiconscious in public with a needle in their arm, apart from voluntary medical treatment, the only recourse Portland’s police officers had was to hand the person a civil ticket with a fine they could easily ignore. Once that ticket was served, the legal expectation was that the officer would depart and leave the person to their own devices. Most of the time, this amounted to continued drug use in the same spot.
The change in tenor on the city’s streets was palpable. Stories emerged of people feeling scared or at least deeply uncomfortable walking around downtown and then avoiding the city center altogether. Small businesses felt abandoned to the disorder outside their storefronts, and police said they were powerless to do anything about it, which was largely true. Cab drivers passionately regaled their passengers from out of town with accounts of the city’s civic decay. My friends from Portland who visited me on the East Coast opened their conversations with tales of feeling unsafe in their own downtown and alienated from the reforms they once championed. They wondered if the responses to addiction I studied and believed in were enabling the problem to continue.
The reaction from the most progressive wings of the drug reform effort has been to discount these concerns as petty bourgeois pearl-clutching: Cities are gritty, we are in the midst of a terrible crisis, and a daily dose of other people’s struggles just might wake people up to the suffering of those around them. Reformers would say the problem is best solved by addressing its root causes: the need for treatment, housing, mental health care, and employment. But these dismissals are unfair to the communities contending with the loss of their public spaces today, and those communities are voting accordingly.
Seeing an unconscious person lying in the street is legitimately alarming, whether they are injured, asleep, high, or overdosing. It makes children visibly distressed and for good reason: They sense that something dangerous and unusual is happening in front of them. It triggers human instincts in all of us about peril and also conflicting urges to intervene or get away. Add to this the physical obstruction posed by people living in the street, in tents or in the open, doing the intimate and vulnerable things normally done in private, and you no longer have a community where people of modest means have fair, democratic access to their community’s public spaces. Some might become inured to this over time, but you can’t just ask people to ignore or change how experiencing these things makes them feel.
Of course, the people who always bear the greatest consequences of social problems are the poor and working class. In US cities, they are usually Black, Hispanic, and recent immigrants already facing disinvestment in their neighborhoods and a host of other challenges. They have little choice but to rely on public spaces to go about their lives, from public transportation and crowded sidewalks to public parks and open areas for recreation and exercise.
The affluent, on the other hand, are deft at finding ways to limit their exposure to places that make them uncomfortable, with refuges in doorman buildings, single-family homes, private transportation, and luxury gyms, to name a few examples. One of the main points of affluence is to insulate oneself from the need to depend on other people’s cooperation in public.
In Philadelphia, the political movement against the expansion of harm reduction programs is being led by city councilor Quetcy Lozada, the Democrat who represents Kensington — the city’s deeply impoverished epicenter of public drug use and the associated disorder. It is also overwhelmingly a community of color.
Following Portugal’s lead
The public-order problems of drug use loom large in urban electoral politics.
However, none of the existing efforts to restore fair access to public spaces will address the overdose crisis or do justice to people with addiction who need resources and support. If cities expect to help reduce our nation’s overdose crisis and not simply ride a policy pendulum back and forth between election cycles, their leaders need to enact compassionate, effective drug policies and ensure fair access to public space at the same time. Anything less is political whack-a-mole.
True progress will therefore require balancing two needs. One is for deep and sustained investments not only in harm reduction and treatment but in things that address the reasons why people relapse or become addicted in the first place, such as mental illness and homelessness. If this approach succeeds, our urban public spaces will again become more vibrant and inviting over time.
The second is the need for safe and secure public spaces for everyone in the meantime. The prospect of eventual success must be balanced with the fact that residents also deserve those conditions today, are right to demand them, and will vote accordingly.
In the short term, this involves policing. But not all enforcement is created equal. When police remove a person from the street for drug use or the crimes that feed an addiction, an option is to link them directly to services and treatment. By doing that, they are addressing the problem with a much more effective tool than a night in jail. To truly benefit all residents, police must do much more than simply make arrests.
Boston’s 2023 response to the sprawling homeless encampments at Mass. and Cass was an initial attempt to thread this needle. It was uncertain where the displaced would continue to get the services (sterile needles, medical treatment) provided by outreach workers at Mass. and Cass — services the area had become known for. But the sidewalks were cleared without making arrests. That is a start, but more can be done. Transformative change means combining effective policing with the resources to help people break out of the harmful cycles that so often come with addiction.
Such a system is precisely what Portugal enacted when it decriminalized drug possession over two decades ago. Its police still take people into custody, but the government uses that as an opportunity to provide free, effective addiction treatment and services rather than level the type of minor criminal charges that accomplish so little. The police bring their suspects in front of a commission whose purpose is to dissuade them from doing drugs by providing them with the means to stop, free of charge. If a person refuses this opportunity repeatedly and poses an intractable problem, only then does the government transition to escalating criminal penalties. Compared with our worsening morass, Portugal has seen success at policing its public spaces while keeping addiction and overdose in check. Only hubris and a sense of exceptionalism prevent us from learning from that country’s experience.
We can’t rely on activists, advocates, and reformers to strike this type of balance, because it’s not their job, and if one group gains outsized influence it can easily result in imbalanced policies that lead to backlash. On one side, some activists have worked their entire adult lives to stop an inhumane war against people with addiction. They need to push the limits of reform as far as they can, forcing us to expand our beliefs about what is possible. On the other side, there are residents who deserve accessible civic spaces. They aren’t wrong when they insist that reducing the harms of addiction shouldn’t come at great expense to a city’s public spaces or even, in some cases, its public safety. Politicians and public officials must strike the right balance between competing rights, the different ways to honor them, and the tradeoffs that will inevitably be a part of whatever they do. After all, that is their job.
Brandon del Pozo is an assistant professor of medicine and public health at Brown University. He also spent 23 years as a police officer: 19 in the New York City Police Department, and four as the chief of police of Burlington, Vt. His doctoral research in political philosophy concerned the role of the police in a liberal democracy.