Eli Reed / Magnum Photos

The Public Square

Ted Alcorn

December 13, 2023

The state of the policy conversation on substances and their abuse

The state of the policy conversation on substances and their abuse

The United States’ approach to drugs and alcohol, once frozen in place, has begun to shift rapidly, propelled by changing attitudes, new markets, advancing science and a supply of substances that is itself rapidly evolving (and not necessarily for the better). Due to the sheer size of New York City as well as its willingness to experiment, the city has been at the vanguard of many of those changes. These are some of the latest conversations and events shaping the future of substance use in the city and nationwide. 

It’s the deaths, stupid

The most essential, urgent story about drugs and drug policies in today’s New York City is that of overdose deaths, which have accelerated to a record-setting pace with no sign of slowing down. The city Health Department counted more than 3,000 such deaths in 2022, or one every three hours, according to Commissioner Dr. Ashwin Vasan. 

But as with an alarm bell whose clamor has become so deafening it ceases to be heard, many New Yorkers have accepted the crisis as a matter of course. Chief Medical Examiner Dr. Jason Graham told the New York Times the OD deaths would be “the public health emergency of our lifetimes,” if not for the COVID-19 pandemic. Instead, his office, which investigates all sudden, unusual and suspicious deaths, has had to adapt to “the new normal.” 

Most experts agree that the spike in fatalities is largely caused by an increasingly dangerous drug supply, specifically the now omnipresence of the synthetic opioid fentanyl. The majority of New Yorkers who inject drugs don’t mean to consume the substance, according to a recent study by NYU researchers, but “people who inject drugs seem to have little agency in avoiding fentanyl,” according to lead author Dr. Courtney McKnight. In 2015, one in six overdose deaths in the city involved fentanyl; last year, nearly five in six overdose deaths did.

There’s also been a rocketing increase in opioids cut with xylazine, an animal tranquilizer whose injection use can induce gruesome wounds. In April, the White House designated the drug combination an emerging threat to the country. It was present in more than a fifth of opioid overdoses in New York City last year and seemed poised to spread further in 2023.

Outside of the Health Department’s annual releases of mortality data, overdose deaths make headlines on only rare occasions. One such grim reminder arrived on Sept. 15, when children at a Bronx day care were apparently exposed to fentanyl hidden beneath a trap door in a play area, killing a 1-year-old and sending three others to the hospital. At a press conference the following week, Mayor Eric Adams called it “one of the worst days I’ve had.”

What Curbed reporter Clio Chang called 'The Great ‘Fentanyl Trash Can’ Freak-Out' wound down as soon as parents learned it wasn’t likely a threat to them.

The event may have primed parents to the specter of fentanyl exposure, because two weeks later, when students at the Brooklyn Waldorf School discovered drug paraphernalia at a nearby playground and their parents were notified, it set off a panic. “Fentanyl vial that looks like candy found at Brooklyn playground,” blared the New York Post in the first of a series of scaremongering articles. Soon parks and schools across Brooklyn were sharing warnings, and parents were meeting with their lawmakers and calling for action — even after the original rubbish turned out not to be laced with fentanyl at all. What Curbed reporter Clio Chang called “The Great ‘Fentanyl Trash Can’ Freak-Out” wound down once parents learned it wasn’t likely a threat to their families.

If you can’t beat it, legalize it?

For years, harm reduction advocates urged the U.S. to open “supervised injection facilities” to limit some of the most harmful impacts of addiction, and in 2017 it seemed Seattle would be the first city to do so. But after city and county leaders there approved the sites, the effort got caught up in state politics and never advanced. Then, in February 2020, Philadelphia seemed on the cusp — until the local U.S. Attorney sued, arguing the sites violated federal law, and the courts ruled in his favor. (Two years later, Philadelphia’s City Council passed legislation preemptively banning the sites from opening.) San Francisco and Boston made their own fruitless gestures, so it finally fell to New York City to cross the threshold first, when, in November 2021, authorized by the City Council, nonprofit OnPoint NYC opened two Manhattan sites, in East Harlem and Washington Heights. 

The facilities, dubbed “overdose prevention centers” by their supporters, were expected to be a lightning rod, and they lived up to it. Former Mayor Bill de Blasio, who opened the sites in the waning days of his administration, did so “at arm’s length.” Although the district attorneys of four New York City boroughs supported them, Staten Island’s Michael McMahon maintained that they “normalize heroin use and increase crime.” And the New York Post editorial board has advertised its vociferous opposition to all modes of harm reduction, even calling a Health Department initiative to dispense Narcan and drug test strips a “white flag of surrender to addiction.”

Still, Mayor Adams has stuck by the centers, calling their work “lifesaving,” and has pledged to expand their operations and to open three new facilities by 2025. In September, his Health Department issued guidelines for organizations operating the sites.

Some have questioned the approach on the merits. Howard Husock, a senior fellow at the American Enterprise Institute, ticked off questions he said a rigorous evaluation should answer: How do the facilities affect clients’ frequency of drug use? Are they at a higher risk of overdose after they leave the facilities? Have overdose deaths declined citywide as a result?

In City Journal, Manhattan Institute fellow and Vital City contributor Charles Fain Lehman criticized the sites for serving just a tiny share of the city’s drug-using population and for referring few clients to medical treatment, calling them a “band-aid on the problem of drugs and drug addiction,” and “not a particularly effective band-aid” at that.  

On the narrow question of whether the sites have a harmful impact on their immediate neighborhood, an answer began to come into focus with the publication this fall of a first peer-reviewed evaluation whose authors included Vital City contributors Aaron Chalfin and Brandon del Pozo. Their study detected no changes in crime or disorder around the facilities as compared to needle-exchange sites, a finding that New York Times opinion writer and Vital City contributor Maia Szalavitz was eager to tout, even if she cautioned that the sites were “harm reduction, not harm elimination.”

The facilities, dubbed 'overdose prevention centers' by their supporters, were expected to be a lightning rod, and they lived up to it.

The facilities are still on precarious ground. In August, U.S. Attorney Damian Williams told the New York Times they violated federal, state and local law, which he viewed as “unacceptable,” and he threatened to act “if this situation does not change in short order.” A chorus of Republican lawmakers cheered that comment, including New York City Council Minority Leader Joe Borelli and U.S. Reps. Nicole Malliotakis (“Good on this U.S. Attorney for taking a stand against this illegal scheme!”) and George Santos (“It's about time we stop coddling illegal behavior and encourage people to seek help.”)

All eyes are on Albany for some clarifying regulations, which Gov. Kathy Hochul, who lost her nephew Michael to addiction, was said to be considering. In November, she took a definitive stance against the sites, rejecting a state board’s recommendation to use opioid settlement funds to fund them. She supports harm reduction strategies, she said, so long as they “are proven to be successful but also legal.”

… But what if you can’t legalize it?

Even when there’s near-consensus on rolling back restrictions on possession of a substance, it can prove difficult in practice. Or at least New York is making it look that way. 

The state’s beleaguered legalization of cannabis continued to hit road bumps. After two years in which regulators had allowed just a handful of legal dispensaries to open, even as thousands of unlicensed ones opened in flagrant violation of the law, State Supreme Court Judge Kevin R. Bryant put further licensing on hold — until a settlement unsticking the gears was reached in mid-November

“It really feels like we’re doing everything we can in New York to make it so that the legal, licensed cannabis operators end up struggling. While the illegal ones on every corner thrive,” tweeted Bloomberg editor Joe Weisenthal.  

To guide the future rollout, the state’s Office of Cannabis Management has identified communities disproportionatelyaffected  by marijuana possession arrests since 1980 and published a map online for the public to explore.

In mid-November, Hochul also signed the Clean Slate Act, which creates a process to automatically seal the criminal records of roughly two million New Yorkers dogged by their past. When the state legalized recreational marijuana in 2021, it made some charges eligible for automatic expungement, but the new measure adds more, including Class A drug possession felonies.