Drug Use and the Compassion Trap

Just Say No didn't work. Neither did decriminalization and tolerance.

Something Sarah said during the live show is sticking with me. We were asking some "what if" questions, and our final version of that question was "what if we're paying attention to all the wrong things?" In that discussion, Sarah touched on the eternal struggle between the urgent and the important and how that struggle keeps growing exponentially. She talked about keeping clear eyes about what's important and making it a priority, so we're doing that today.

There are plenty of headlines swirling around our current administration. We're going to look away from those today to think about how we most effectively care for communities as a whole and for individuals within our communities.

Keith Humphreys is an internationally-renowned expert on addiction. He served as a drug policy advisor for both the Bush and Obama administrations, and he has advised state and national governments across the world on evidence-based approaches to addiction. He is currently a professor at Stanford, and he recently published findings about drug policy in the Pacific Northwest after studying decriminalization and cultural shifts that took place from 2020 - 2024.

Many of you know that I have radical views about criminal justice -- my biases favor redemption over retribution and liberty over incarceration and Keith's findings are challenging; they point to the need for real calibration and study and care. Also, like many of you, the very human side of the policy is real to me. I have been to funerals. I understand the wreckage, the grief, the despair.

I hope you find something in this conversation illuminating as we keep trying to keep more people alive and happy and safe together. -Beth

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Episode Resources

Pantsuit Politics Resources

• 10th Birthday Celebration - Live in Cincinnati | Livestream Recording (Pantsuit Politics Shop)

Keith Humphreys

• The Age of Addiction: How Bad Habits Became Big Business by David T. Courtwright

• Keith Humphreys (Stanford University School of Medicine)

• Keith Humphreys (X, formerly twitter)

• Blue states change course on mental health policies (Axios)

• The rise and fall of Pacific Northwest drug policy reform, 2020-2024 (Brookings)

Show Credits

Pantsuit Politics is hosted by Sarah Stewart Holland and Beth Silvers. The show is produced by Studio D Podcast Production. Alise Napp is our Managing Director and Maggie Penton is our Director of Community Engagement.

Our theme music was composed by Xander Singh with inspiration from original work by Dante Lima.

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Episode Transcript

Sarah [00:00:09] This is Sarah Stewart Holland.

Beth [00:00:10] This is Beth Silvers. You're listening to Pantsuit Politics. Everyone here is floating down from a truly spectacular weekend in Cincinnati, where we celebrated 10 years of making this podcast. It is an indescribable joy to be in person together. As Sarah said, we don't really like the word parasocial because the people who listen to our show tend to listen over many, many years, and they start to email us and comment, and then we eventually get to hug you and say, "Oh my God, you're Theodora. I loved the poem that you wrote during the meditation series." Or "Yes, you are Victoria and you're a doula, I remember." And "Brady, I'm so proud of you for making that career move we talked about ages ago." And for Sarah to alarm the entire room because she screamed so loudly when she met Liz Kay after so many years and messages. So if you're new here, welcome to a group of people that is so much greater than Sarah and me. I hope that someday you'll tell us that you met new best friends at one of our events. This weekend was smooth and happy for so many people because of months of behind the scenes work and a weekend of all hands on deck.

[00:01:16] Christy Matthews, a longtime executive producer, blew everyone away. She organized a retreat for our executive producers complete with a welcome party, a pool party, tours around Cincinnati, yoga, hospitality rooms. Christy crushed it and was so calm and generous and thoughtful in the process. Elise, our managing director, is a true force multiplier. She does the work of three people, and she brings out the best in everyone she interacts with. I can't begin to list everything she did; just know that if at some point you thought, "This was really great" you can probably trace it back to Elise. Maggie, our community engagement director, engaged the community. She loved meeting so many of you in person and chatting with so many of you online. My friends who I have to shout out by name, Maggie, Jen, Brian, Shannon, Malia, Sarah's family, my family, they were all so phenomenally supportive. Our executive producers helped out in a ton of ways. They hosted group dinners, they worked the photo lines, they checked people in, they sold merch. It took a village and it was extraordinarily special to me. So if you were involved in any way, if you came, if you watched, however you participated, thank you from the bottom of my heart and the top, too.

[00:02:25] If you are hearing this and feeling a little bit of FOMO, we understand. By request, we are going to put the recording of the live stream from our live event in our store this week. So you can still get in on the fun. If you were at the show or had purchased a live stream ticket before the event, you'll get a link to the recording this week as well. Just check the show notes, you'll find everything that you need. Something Sarah said during the live show is sticking with me. We were asking some ‘what if’ questions. And our final version of what if was, what if we're paying attention to all the wrong things? So in that discussion, Sarah touched on the eternal struggle between the urgent and the important and how that struggle keeps growing exponentially. She talked about keeping clear eyes about what's important and making it a priority. So we're doing that today. There are plenty of headlines swirling around our current administration. They're trying to create some new ones. I understand that's what you do when things aren't going well. We're going to look away from those swirling headlines to think about how we most effectively care for communities as a whole and for individuals within our communities.

[00:03:30] Keith Humphreys is here. He is an internationally renowned expert on addiction. He served as a drug policy advisor for both the Bush and Obama administrations. And he has advised state and national governments across the world on evidence-based approaches to addiction. He's currently a professor at Stanford and he recently published findings about drug policy in the Pacific Northwest after studying decriminalization and cultural shifts that took place from 2020 to 2024. Now, many of you know that I have pretty radical views about criminal justice. I favor redemption over retribution and liberty over incarceration. So some of Keith's findings are pretty challenging for me. They point to the need for real calibration and study and care. Also, like so many of you, the human side of this policy is real. I've been to funerals and it's just important to learn as much as we can learn here. So next up. I am grateful to be sharing this conversation with Keith Humphreys. Keith, thank you for joining me at Pantsuit Politics. I have so many questions for you, especially after reading the report that you published with Brookings about your study of drug policy reform in the Pacific Northwest. It made me think so much about the variables that you must have to try to contend with as you study drug policy. And I wondered how you think through those variables? Is there a place that you tend to start, like time or place? How do you begin a project like this?

Keith Humphreys [00:05:20] What a great question. By the way, thank you very much for having me on your show. The report, which focuses on the period from 2020 up to the present moment in the Pacific Northwest, had to contend with the fact we had two massive historically important events happened on top of each other. We had a COVID worldwide pandemic and all the reaction to it. And then we had the murder of George Floyd and the understandable reaction to that, on top a lot of changes in drug policy. So it's challenging when you're in that situation. What you do, and the best you can do, you just try to find other places that were affected by the same things. So that, for example, when Oregon passed their decolonization measure, and violent crime and property crime went up, that might not mean anything. Maybe it went up all over the country, but it happened and it was going up when the rest of the country was going down, or when overdoses skyrocketed in this region. Again, same thing. You have very slight change in the rest of the country and massive changes in this region. It's still not an experiment, but that's really the best you can do when you're trying to assess policies because policies aren't like a lab experiment where you get to control everything. You have to make your inferences in the context of a very complicated world where a lot of things are changing all the time.

Beth [00:06:43] It was very illuminating to me to read about all of the factors that influenced getting to those drug policy reforms. So I'm speaking to you from Northern Kentucky. It is very uncontroversial in my part of the world to say we want fewer people using drugs at all. We think drug use is objectively bad and something that we don't want for people. It was surprising to me to see how controversial the foundational goals around drug policy are in the Pacific Northwest. Could you talk a little bit about that?

Keith Humphreys [00:07:17] It was a new movement really. I think there's still a lot of people don't quite believe me when I say the San Francisco department of public health put up billboards showing attractive, successful, happy people using fentanyl that said "Fentanyl do it with friends." You'd think that's got to be a joke about San Francisco. No, it really happened. And it was part of the movement that rejected really what you say is the accepted understanding in Kentucky, which is drug use is not bad and not only bad but it should be legal and it should not be disapproved of. The only real problem is when people stigmatize people for using drugs or when the government doesn't spend enough to make drug use safer. But fundamentally drug use has a right to be preserved at the same level of the right to speech, for example, and the autonomy of the individual must reign supreme in what we choose to do in policy. That's different than traditional public health. In traditional public health, for example, if I say I would really, really like to own a fully automatic machine gun, it is usually considered a decent counter argument.

[00:08:34] But wait a minute, Keith, you don't even know how to use a machine gun. You might shoot somebody, so we're not going to let you do that. You constrain my autonomy because you worry about the community. And that's been the tradition in drug policy until this, where it was the rest of the community, that's a lot of pearl clutching. We're tired of hearing about neighborhood quality. We're tired hearing stories about kids being traumatized by open air drug scenes. The important thing is that the right to engage in this. And so if we want a city park to be turned over to drug selling and dealing, well, then the community doesn't really have a right to complain about that. And that was a really radical idea. And it's not surprising to me that although it commanded support right after the murder of George Floyd and the backlash against policing, it didn't hang on very long. You don't have to live under policies like that too long to experience some pretty serious downsides.

Beth [00:09:36] I would like to try to contend with where they're coming from seriously. I grew up in the early eighties in rural Kentucky, just say no and dare were big parts of my life. So I start with that lens. I'm also reading the Age of Addiction, David Courtwright's book that's been everywhere. And I think he makes a compelling argument that the history of humanity is a lot about seeking pleasure and escape. So I'm trying to put these pieces together to figure out how to even think about agency in the context of drug use. And I imagine you've thought about that a lot. I don't know how to evaluate for an individual where agency starts to get blurry as they get into an addictive situation.

Keith Humphreys [00:10:21] Yeah, well, I resonate with you. I grew up in West Virginia, not very far from Kentucky, and I've spent a lot of time in Kentucky. I'm older than you, but I certainly grew up with similar kinds of sentiments around me. And David, I'm proud to say, is a friend and is, in my view, a genius. He's really the great historian at this moment of addiction. And he's right that that is, obviously, in our nature to seek pleasure, and obviously in doing that as part of the survival of our species. It feels good to have sex, it feels good to eat, feels good to get warm when you're cold. And that basic sensibility is why we're still here on planet earth. Challenge with drugs is that they also generate pleasure, often pleasure far more intense than those other things we need to survive, but we don't need drugs to survive.

[00:11:10] And in addiction, eventually you get to the point where it seems to you absolutely imperative that you keep shooting the stuff into your arm or inhaling it or drinking it. More important than all those other things that pleasure was meant to guide us evolutionarily. So I haven't eaten for three days and I have $10 left and I spend it on cocaine powder, not on a sandwich. You notice that all of rationality in our evolutionarily conserved brain would seem to say, oh my gosh, he's going to eat. I mean, clearly, because we've got to eat. But to me it seems, no, to snort the powder is more important. And at that point I don't think it's reasonable to say, well, that's Keith's freely chosen decision. That's his good judgment, who am I to judge? Because the part of the body that we use to make those decisions is exactly what's impaired. My brain's not working at chief capacity when I'm really addicted to cocaine or heroin or fentanyl or something like that.

Beth [00:12:18] So how do you think about the liberty interest being advocated in drug reform, given that there is impairment for the individual?

Keith Humphreys [00:12:29] Yeah, so I've always thought we want the criminal justice response to people who use to be as minimal as possible, but no more than that. So we don't want to just grab people because you use a drug and lock you up into a prison, which happens in a lot of the world, not so much in this country, but it does. We don't people who pose no public safety risk to be treated like threats by, for example, law enforcement or by the criminal justice system. But we also need some because people are not doing their best thinking. So for example I'm perfectly comfortable. Let's say I volunteer in a neighborhood in San Francisco called the Tenderloin got a lot of serious drug problems. Let's say I'm in the Tenderloin and I'm addicted to fentanyl and a tourist is coming by taking a picture of his or her family and I knock them down, grab their phone and run off because I want to sell the phone for drugs. Now, I'm perfectly fine if I get caught.

[00:13:36] The criminal justice system says, Keith, you broke the law and you knocked down this tourist. And luckily for you, the tourist is willing and we are willing to give you a break. Normally, you would be put in jail for that, for a theft and assault. Instead, you can enlist in this drug court and you can stay out of jail, but there's some conditions. You have to enter treatment and we're going to be monitoring your treatment and monitoring your drug use. And, of course, I'm not going to like that, right? It's a constraint on my freedom, but same time, it's a lot less constraint than throwing me in a jail, which is what would happen to me otherwise. That's the trick; you got to find that balance. There's plenty of examples where societies have gone too far on the draconian end and really damaged the rights of people who have drug problems. In my region of the world, in that period, we went really much the other way, where we pretty much just let anyone do whatever they wanted. And that's not fair to the person who got knocked down and got their phone stolen.

Beth [00:14:33] And I'm not sure how fair it is to the person who did the knocking down and stealing either. I had a conversation on background a few years ago with a California policymaker. And we were talking about homelessness in California. And he said to me, the open secret that no one wants to discuss is that until we involuntarily put people in treatment programs, we cannot fix this issue. Now I know that doesn't really get to housing supply. There are a lot of complexities, but his view is that the single thing is getting people into treatment. I wonder how you view that comment.

Keith Humphreys [00:15:12] Yeah, so there's two different questions. Why is anyone homeless? And why isn't a particular person homeless? So if you thought of this as a game of musical chairs, what determines how many chairs there are? It tends to be macroeconomic things. How much property has been built? Is the economy up or down? Are there jobs that are causing people to move in to a community or out? Regulatory things, all that. But then when there aren't enough chairs, what determines who doesn't get that chair? It's very commonly the challenges that person experiences. The person who's got schizophrenia, the person who is addicted to cocaine, who would have trouble navigating getting housing and would not make a good impression say if he or she want to rent a room in the same room with all these roommates interview me and I'm high, things like that. And so that's going to stop me from engaging in-- I'm going to be the one without the chair left, basically, because of that.

[00:16:13] Do we need involuntary treatment? Well, we wouldn't if we believed conditions like addiction did not impair human judgment because that would actually be motivating. But we're like, wow, I can't even get housing because I tear everything up and I'm hard to live with and all that sort of thing. So now I'm really motivated to get the addiction together. But a huge number of people do not want that treatment and are out there, oftentimes with other comorbid problems like psychotic disorders. And so really the only way to give them a chance is in fact to use mandatory treatment. And we do have to do some of that. Plenty of people are homeless, don't have those problems and that's just a matter of housing. But there's a lot of people who do and would have trouble getting housing no matter how much housing was available.

Beth [00:17:02] So I want to get back to this question of the goals of drug policy. You mentioned in the reform efforts, that 2020 to 2024 period, the goals were really about reducing overdose deaths and racial equity. Can you talk a little bit about those motivators and what wasn't on the table that typically is in other drug policy reform efforts?

Keith Humphreys [00:17:26] Yeah. So, reducing overdoses was part of I would say a sub-goal of support the right of people to use drugs as safely as possible. So that would also include lowering the risk of infectious disease. And at least in part of the region, I wrote about British Columbia, giving them drugs. So the government actually paid to give people like a bottle of hydromorphone, no supervision, to say, you use this because we think that's safer than you being in illegal markets. And then the racial equity part is about the obvious fact that there's disproportionate enforcement across different racial groups. And George Floyd was black, as everybody knows, and the rage, the justifiable, understandable rage against police brutality, particularly towards African-Americans, a lot of that was centered on drug enforcement. And George Floyd himself, I believe he had fentanyl in his body when he was killed. So many people felt the best way to get police to not be a force for inequity racially was to get them out of the drug enforcement business.

[00:18:38] And so for many of the advocates, the fact that arrest went down in places like Oregon substantially for drugs and for other things, and that included many fewer African-Americans getting arrested, they saw that as that in itself is enough. This has been a great success. The challenge is, I'll just give a concrete example. In Oregon, there's a historic black neighborhood that was taken over by black drug dealing and it destroyed the neighborhood. If you look at a point of view of the dealers, you could say, well, those reduced arrests are great. That's justice, because they're black and they're not in prison. If you're looking at the point of view of people who live in that community, work in that committee, or trying to raise families in that community who are also all black, then its inequity. And I was struck how the attention of the advocates was only on people who used and sold drugs and none on the people who don't. So I found myself in this funny position in my region of the country, which I've spent 35 years trying to convince people that people who use drugs matter and have worth. In this particular area, I had to argue that people who don't use drugs matter and had worth.

Beth [00:20:01] So if you were in a new state, blank slate, what would the goals of drug policy be in terms of effectiveness? I mean, not just morality, but effectiveness too.

Keith Humphreys [00:20:13] Yeah. Well, there's no way to get out of the moral proposition for anybody in a sense because you have to say who matters and what matters. What are our ultimate goals? And there are tensions between certain things like unbridled autonomy, the wellbeing of others, the lives of children versus the lives of adults. The ability to start legal versus illegal businesses, which can impinge on each other. How much policing we want, the costs of policing, the benefits of policing all that kind of thing. So in the best democratic society, every single person with a stake should have a stake at the table. Not just (it's common here) the lived experience of people who use drugs, they should decide everything. It's like, no, all of drug policy can't work to do nothing but help people use drugs. It has to do other things like prevent the initiation of drug use. And it is better if young people who have fast developing brains or at the peak years when they're likely to become addicted don't use drugs or use fewer drugs. Or if they're going to use drugs, start them later in life so that they get more good brain development under their belt before they start to experiment. So that's one thing you want. Prevention.

[00:21:34] Second, law enforcement, although it cannot uproot drugs once they're there, can do a lot about the market for drugs. So, the Tenderloin neighborhood in San Francisco has an open air market. There are dozens, maybe hundreds of dealers all over their streets. You can't barely walk down. Families can't walk down. That is something law enforcement can do a lot about and they've had a lot of success in a number of American cities and European cities, just closing down the overt market, the most noxious part of the guy in the corner with a gun in his belt, basically. And there will still be drug use and there will still be drug dealing. There's drug use and drug dealing in here in this beautiful peninsular community I live in, but there's not drug dealers on the corner. So that's really important. That shared public space has to be policed so that everybody can use it. And then you want to have services for people who use drugs to reduce their morbidity and mortality. The classic I think everybody knows is naloxone. There are other drugs of that sort, but they're basically reverse, an opioid overdose usually. Things like programs that give people fentanyl test strips and clean hygienic injection equipment if there's an injection use. Those things you want to do stuff like that. And then you want help people in the state get out of it, and that's about treatment and recovery, which is a longer-term process that happens as much outside the health care system as in it.

Beth [00:23:10] So it seems like you just described a blend of prevention, harm reduction, and therapeutic justice.

Keith Humphreys [00:23:20] Yes, and law enforcement. All four.

Beth [00:23:22] And law enforcement. I wonder from your research and experience, how we deal with the fact that we're not great in policy making it blend, that the pendulum tends to swing wildly from one approach to another instead of finding that combination.

Keith Humphreys [00:23:41] Yeah, that's something I think about all the time. And I want to be clear, my idea of these four pillars is the least original thing. I deserve no credit for it. That's what the UN says to every country. These are the four pillars. These are four things we try to do. You are right about America. We tend to be oscillators. I'm not exactly sure why, but we seem to treat a lot of things like they're a switch. Like we have two settings. We can have all out, draconian, racist, carceral drug war, or we can already flip it the other way and say, well, now it's a free for all. Everybody use whatever you want, wherever you want. And really we need to think about these things as a set of dials. And you turn things up and down based on the results you're getting. And there are some qualitative shifts like if you turn policing down some, you get one set of facts, but if you're turning it down to zero, something new can emerge that you haven't had before, just as an example. We're not great at that. I think social media doesn't help. I think it's a force for pushing people to extremes and keeping them in those extremes. And I think leadership has made this better or worse. So there are people who lead, who are very polarizing on purpose. That's their political business model.

[00:25:00] But the best people, the people who are just great to have in government are the ones who say it's got to be balanced. And they say that over and over again. Well, I mean, for example, be concrete. So San Francisco has a new mayor, new team, pretty impressive people. One of the things they've done, they've had this complicated system with all these different teams. There's a team that does mental health for people on the street, then there's law enforcement, then there's people who do the substance use stuff, there's people who do the cleaning of the streets. And they said, well, this is silly. You're all going to have to work together. So let's just have one. And there were people who said, "I can't be on any team that has any police. Police are evil. All cops are bastards." And the reaction mayor, says, "Well, sorry, you can't work for us anymore because this is what we want. And this is a job. We all have things at jobs we have to work on. You're going to have learn how to work with a team." And maybe they are police who don't want to work with people who have been involved in the drug trade, who are now harm reduction workers. The police are going to have to get over it. But that was the message from the top that you are on the same team. Backed up with, look, I'm paying the bills and this is the policy. And I think that was an example of how leadership can bring people together.

Beth [00:26:22] How long do you think it takes for an approach like that to start to convince the public? That's a tough thing too, right? You might have a great leadership team that comes in and the public's patience doesn't hang in.

Keith Humphreys [00:26:34] Yeah. Well, politically, the public is more volatile than ever in my lifetime anyway. I mean, in all kinds of ways. If you just look at things like party switching, you don't run into many communities where we voted this way and we've always voted this way and my mother and my father and my grandparents always voted in this way. There are people who just like shoot back and forth. So switches can happen extremely fast and can build on themselves in ways that are hard to predict. It's also true that people can lose patience very fast. I don't think patience is a commodity that we've really built up too much. So again I just think like the new people in San Francisco, so far things seem to be getting better. They seem to at the moment popular and have a lot of support. I can imagine that, let's say three months from now, some high profile thing goes wrong that nobody can really control. And someone who doesn't like what they're doing, the demagogues, and the public feels things still aren't perfect, now we're mad. And then there's a recall. I mean, we've seen a bunch of those kinds of things. So that's really tough. That part of being an elected official in the United States right now is a genuinely challenging thing. I salute all of them who are trying, because it's tough work.

Beth [00:28:06] I couldn't decide reading your paper if I felt discouraged by how quickly attitudes can change and policy can follow, or if I should feel good that that's democratic responsiveness. That people saw things they didn't like; they elected new people and a new approach landed. I don't know, I guess it's both.

Keith Humphreys [00:28:29] Yeah. How we judge things, I guess, also depends where we stand and depends on where we sit. So there's been, like, in my life, when I was born, you know there was still a couple states where interracial marriage was against the law. And there was an accelerating shift in America to believe that that's wrong. Once it sorts of flipped over 50-50, then all of a sudden it was 60% of people thought it was okay, 70-80. Now it's pretty hard to find anybody like that. So I regard that as that's great how much people can change and how fast because I think that people should be able to get married to whoever they want to. But, of course, there might be people who are the holdouts, who don't like that, are very mad how fast attitudes can change.

Beth [00:29:21] I'm thinking about your four pillars and everything that wraps around an individual who is dealing with some kind of drug use disorder. What do you think about tying social services to drug testing or tying the ability to be in a shelter to sobriety? I guess that relates to social shame in a sense, but it does seem connected to those policies as well.

Keith Humphreys [00:29:47] Yeah, I think those are somewhat different situations. So let me start with the second one first. California at the moment has a rule that no housing paid for by the state can have any restrictions on your drug use. It's 100% housing first. And I have been working with the legislature, as have a number of people, to try to allow at least some recovery housing. And there are people on the other side who say any restriction on that goes back to these individual rights understanding people's right to housing should never be compromised in any way, even just allowing 25% of funds to make available. And I think that's wrong, because there are a lot of people who really want drug-free housing for their own benefit. So, for example, a charity I work for we have a year-long residential program. Most of the people in there are homeless, they've had very, very tough addictive histories. When people get to the end of that and they're ready to graduate, they need somewhere to live. Almost all of them are going to need some kind of public housing. They would love to be able to be promised you're going to be on the floor of a hotel or you're going to be in a shared house where everybody is in recovery and no drugs and alcohol are allowed. It's not an impingement on the rights; it's actually honoring what they want. And it's also recognizing, again, that there's a whole world out there around individual autonomy.

[00:31:17] If 10 of us are living in a recovery community kind of setting, and I start using drugs, it's just not about me. I'm putting other people at risk. So I think we do need to have recovery housing to support the health of those people. Go back to your first question about social services per se. There was a ballot proposition in San Francisco. It passed enormously, which was basically if you wanted welfare you had to go through a drug screening. And if you had drugs, you had to go to treatment or you wouldn't get your welfare benefits. And I said that was a bad idea. And I was virtually alone in that. And there are a couple reasons for that. First, we don't even do that with the person who knocks the person down and takes their phone. So this is now treating people worse than criminals because they're poor. Being poor is not a crime. I didn't like that just. Ethically, that didn't seem right to me. Second, I had grave doubts that it could actually be done because of what it would require would be two big parts of the bureaucracy keeping in close communication about Keith showed up to his appointment today, you should make sure he gets those food stamps so his kids can eat and nothing bad ever happening. I just imagined this very vulnerable population of people who don't have legal representation and not allowed to advocate for themselves, just getting crushed under those kinds of bureaucratic wheels. So, again, no one listened to me. It was incredibly popular, but I would not do that.

Beth [00:32:57] So I'm thinking again about our perfect state that we're designing that has the four pillars from the UN in place. Now we've established how we might approach social services and housing. What is needed to meaningfully advance the ball in terms of licensing, education? Are we giving professionals who want to help with drug policy and help individuals struggling with drug use disorder everything that they need?

Keith Humphreys [00:33:28] I would say no. So there's two groups of pressures we can talk about. So on the prevention side, often it's an overworked teacher who has a lot of other things here she needs to do, and is expected to do some lecture that's going to transform kids' lives, run the DARE program or something like that, which in the face of little evidence of help. Whereas, there are really good programs like Communities That Care is a well-known one, where people from the outside work with the school, people who do this all the time for a living and help them integrate not just like a drug prevention lecture, but change the shape of the classroom so that it's more supportive and kids who are more bonded to school, and they learn how to connect with their kids and it reduces bullying and reduces social isolation. And, yes, it reduces drug use, but just as good for kids. And the teachers can do it when they have that kind of support. So we definitely need more support than prevention side. It's so hard politically to get people interested in prevention because, one, people remember DARE from the 80s, and they think that's what it is, which is a bit like saying what a computer is a Texas Instrument Calculator. That is old, old technology. And the other thing is the political reality is it's hard to get people to devote resources for a benefit that's long-term. They want to see what am I going to get before the next election?

[00:34:52] And a friend of mine who's in the state legislature of California pointed out to me that we spend over a billion dollars a year in California through our Medi-Cal program on managing diabetes. And I think it's 100,000 on preventing it. And that's typical. So we need support on the prevention side. On the treatment side, it's a fraught time because at the moment, at this very moment, Congress is considering pretty dramatic cuts to Medicaid. And Medicaid has become the biggest public sector payer for addiction care. So if we disenroll people from Medicaid or we cut the benefits on Medicaid, that will very quickly resonate through the addiction treatment system because that has done well, the expansion of Medicaid to places, and certainly this is true in Appalachia where you and I both are from. That would be quite really cutting the legs out from a lot of these programs. We've done a bit better on the private insurer side. So for the last, it's almost 20 years now, there's been a bipartisan consensus that health insurance like your Blue Cross, your Blue Shield, your Aetna ought to cover mental health and addiction. And that's what parity laws, as they're called, are for.

[00:36:18] And those have gotten stronger and stronger at the federal level and in many states and have covered more and more types of insurance. And so that has helped. We need to continue though making sure that we enforce that because anyone who's dealt with a health insurer knows their number one goals to not pay for things, right? So, it usually takes a certain amount of good regulatory work and good advocacy to make sure that the things that are listed in those lovely brochures we get, or those lovely websites are in fact what families actually get from their private provided insurance. So that's really important. And that will support professionals too, obviously, because that's where salaries and buildings come from.

Beth [00:37:02] Is there anything that needs to change in the education of those professionals? I'm thinking about you talking about those kinds of cross-disciplinary teams in San Francisco.

Keith Humphreys [00:37:14] I'd say the average medical student in the United States gets ridiculously little information about addiction, even though it is a condition they will literally see every single day of their practice lives. They may not realize it. They may think, oh, how unfortunate you fell down the stairs again, or how unfortunate you've got a growth on your lung, or how fortunate you have an unstable cardiac arrhythmia. But what's behind it is addiction. And that is just poor. I would say the quality of education we give doctors is really poor. And nurses is, I would say, not much better. So, and that reflects a lot of things. It reflects poor payment systems, it also reflects stigma, discomfort. It's a very odd thing about doctors. I had a dear friend, he's passed away now, his name was Barry Rosen, he was a internal medicine and addiction doc, and he used to teach the residents as a guest in my class and he said, "You know something, we are members of the only profession that can look a stranger in the eye and say, 'Go into that room and take off your clothes' and they'll do it. So you can't tell me it would be too forward of you to ask somebody if they use drugs, given that."

[00:38:29] But a lot of them would say, well, I don't really want to do it. It's like medicine's pretty personal. We give people a lot latitude to get past that, whether it's stigma or shame or feeling they don't know what to do, to just ask people. I wrote your prescription for Vicodin. Have you been taking any trouble with it, or any cravings, all that kind of stuff. That sort of thing. So we need more people like Barry Rosen to charge doctors of taking this more seriously. And then also getting out of, for all health professionals, just the psychiatry and mental health space. So you see a lot of patients with addiction there, but there's a lot of addiction in the emergency room. There's a lot of addiction in the family medicine clinic. There's lot of addictions issues in pediatrics. And people who work in those specialties just often never think about it. They think like that's what psychiatry does and psychology does and social work. That's the mental health people. Yeah, that true that some of it, but there's a ton of it that appears throughout the healthcare system where people don't even think about. This is one of the things we should be trying to help people with.

Beth [00:39:34] We also often talk about these policies and I'm specifically now thinking of a situation like a drug court where it's a system on one side and an individual on the other side. Have you seen successful efforts to engage a person's family, a person community, a person friends in their recovery process?

Keith Humphreys [00:39:59] Yeah, this is a very culturally interesting thing. In much of the world, when there's an addiction, it is understood inherently to be a family problem and a community problem. In America, it's much more thought of as this is your individual thing. And most treatment, most drug courts do not engage beyond that individual person. But the power of doing so is really enormous. There's a bunch of studies of this program called CRAF which shows big effects when other members of the family are involved on things like does the person initiate a quid attempt? Do they go to treatment? Do they stay in treatment? Helping them understand the condition, knowing how to support, also helping them learn not how to enable and not how to minimize the severity of the problem of the person that they love. And it's just not done as much as it should. But from a policy viewpoint, my friend, John Calkins often brings up why is it when you have, say, an addiction, your insurance only authorizes you to get help? They mean as a positive thing, we could say the whole family can get help. Your spouse can come in and your spouse is covered too, or your kids are covered too or anyone else affected get something to help them with this really big challenge.

Beth [00:41:20] Do you know if anyone's tried that, to propose that as to Medicare and Medicaid?

Keith Humphreys [00:41:24] Very little. The only place I know that does some of that is the VA. Because it's a veteran benefit and obviously most veterans are not necessarily married to another veteran, but the VA will see couples on the grounds that can be helpful to the health care of the veteran and of course in the process and you can also help that other person. But broadly speaking in the U.S.? No, that's not the norm at all.

Beth [00:42:02] Thinking outside the US, you write in the paper about the Portugal model coming up in connection with Pacific Northwest drug reform.

Keith Humphreys [00:42:09] Yes.

Beth [00:42:10] And not getting Portuguese results. Can you talk a little bit about that? And then maybe other models that you would like to see the US drawing on more.

Keith Humphreys [00:42:18] Yeah. So many of the advocates, it's been said just very widely there's a lot of promotion of Portugal, particularly through the Cato Institute, which is a libertarian think tank in Washington, that it gets somewhere that's Portugal legalized drugs and their problems went away and it's all going great. And that's not true. First off, been a lot a time Portugal, including people who designed that policy, Portugal didn't legalize drugs. They reduced the penalties for using them, but it's still illegal to deal drugs and to use them in public and to traffic and drugs and all that. What they did do was they dramatically expanded treatment and other kinds of services for people. And they set up a system where you can pressure people into treatment. And this is studiously ignored by many of the advocates in the Pacific Northwest, but they call it a dissuasion commission, which it does what it sounds like where it's not punitive, but they can make an assessment and say you were using cocaine on a street corner, you were clearly impaired, the police have brought you here, and we think you have a health problem and you should go to treatment. And they have power, they can say and we notice also you're a cab driver or a Uber driver, and we're not going to let you keep that license until you go to a treatment.

[00:43:34] They don't throw people in jail or prison, they're not trying to punish, but it's dissuasion. It is a push. The other thing to remember is just Portugal is not the United States culturally. It is a Catholic, inflected, communitarian culture. It was a dictatorship and living memory. Their families are strong. People don't move anywhere near as much as they do. Out West, where everybody seems to be from somewhere else, there's lots of multi-generational families. There's a lot of love in those families. There's also a lot a watching and monitoring. And I've said this as a joke, but it's really not a joke. One reason why you might be discouraged from using drugs on the street in Lisbon is your mom will find out and then she'll tell your uncle and your priest. And that's not what San Francisco is like. That's not where Portland is like. Those are places where everybody's from somewhere else and often they came to get away from all that, to get way from family pressure, community pressure. I want to be my own person, which by the way, for some things works out very well, but doesn't work out very well for fentanyl use and meth use.

Beth [00:44:42] Any really creative approaches out there that we could learn from in the United States?

Keith Humphreys [00:44:47] Yeah, there's an approach actually started in the United States for one of our worst problems, which is drinking and driving and there is a pool of people who get arrested for drinking and drive over and over again. And we have tried all kinds of things. They've thrown them in the penitentiary when they eventually kill somebody, try to put an interlock on their car, fine them, suspend their license, none which is really that effective. And instead, what they do-- it started in South Dakota, a very smart prosecutor said, "Instead of trying to take away their right to drive, let's take away the right to drink where we will temporarily suspend it." And while you're under sentence, you can do whatever you want, you don't have to go to jail, but you will be monitored, your alcohol use will be monitor. Every morning, you'll come in and blow a breathalyzer and every evening you come in and you blow a breathalyzer. If it's negative, meaning you haven't been drinking, it's great, good job, have a nice day. If it's positive, they say, okay, well, there's an immediate, certain consequence. You're going to be arrested on the spot and you will spend that night in a jail cell, then you will be let go. Which is not that serious a penalty for this population because many of them have been in prison, often for extended periods, but unlike everything else the criminal justice system does, it's swift and it's certain. It's just 100% sure thing.

[00:46:11] You grab that bottle and you drink, you're going to spend that in jail 100% likely. And that is very motivating. And so at this point, they've done over 10 million of these scheduled breath test appointments and the proportion of the tests where a person has shown up in low negative is 99.1%. And they've had drops in drinking and driving. They've also had drops in domestic violence. It's mostly young men who drink a lot. And young men drink a lot and drink and drive, do other things they should not do when they get drunk. And that has spread out through a number of states. And it's also now spread to other countries too that was involved in doing this. England and Wales are doing this sort of thing all over. They call it mandatory sobriety. That's something that we should really be doing in all 50 states. It maintains freedom generally. Very few people end up having to be incarcerated in the first place. It gives more freedom to women, freedom from violence, freedom from the terror of that, and it makes the roads safer. So it's really win-win-win, and it's frustrating given that this started 20 years ago, that it isn't existing everywhere because it's awfully good.

Beth [00:47:27] Yeah, that gets to a question that I struggle with, and you touched on this in talking about school programs, but how far upstream should we be working this problem? When I was thinking through the election dynamic of fentanyl coming across the border, I heard a lot of response to that concern that sounded like, well, we should really be thinking about why does America have such a drug problem? Like, why is the demand there for this product to come across the board? And I agree with that. But it does seem like we have to constantly be first in just triage mode, that the terrible effects just keeping people alive, right? But then the supply side, the demand side, I wonder where are those points upstream that we can help prevent problems?

Keith Humphreys [00:48:13] Yeah, there's certain amount of effort that people put in to say that our drug problem has nothing to do with drugs, but it really does have a lot to do with drugs. And you can see this, if you go back to the beginning of the Oxycon thing, which started in the mid-90s, there were a few states that Purdue Pharma didn't market that drug in because they had very strict prescribing systems. And years later, those places did not have the opioid epidemic of other places, even though they had just as much poverty and just much dislocation, just much loneliness and despair and all the things that go on with being a person. And it really is the drugs. So when you flood communities with tons and tons of drugs, a lot of people are going to have their lives ruined. And you should still work by the way. Obviously, we want to have reduced poverty, we want to have reduce despair and all that kind of thing, but we shouldn't forget the drugs themselves matter a whole lot. And in fact, to be topical, we did see a substantial drop in fentanyl mortality in 2024, which we haven't seen before. And one possible reason for that could be a disruption on the supply side. I'm working with some people on figuring this out now, but at least seizure data and some intelligence data seem to suggest that fentanyl became less potent. And that might have been interventions made in China, it might have interventions made in Mexico. It might have been somewhere in between, but that saved lives. So we should try to do those things, even though in an absolute sense, of course, there will always be drugs. But there's all kinds of drugs at all different levels and some are more deadly than others.

Beth [00:49:50] Well, as we wrap up, what is the most important question that comes up in your work that I've not asked you?

Keith Humphreys [00:49:57] About recovery. So this is an area that is suffused with despair. The people who are addicted feel despair, their families feel despair. Frequently the voters and the policymakers feel despair. This just never changes. And what people have a hard time seeing is there's 23 million people in our country who have had a serious alcohol and drug problem and are now in recovery. That's reason for really rational optimism, not happy, clappy optimism, but really serious optimism. But we don't see that because active addiction is super visible, right? The person who's raving drunk or high on meth and all that, you can't not see them. But when they recover, they put on a suit and they become a high school teacher or a civil servant or mom or dad, whatever, and you don't look at them and say, well, that's also part of the story of addiction. You don't even think about addiction. It's like, that's just my neighbor. And that's something I always try to remind people of no matter where they are, whether they're on the outside trying to help this problem or they're experiencing it themselves, there's every reason to be hopeful and not despair.

Beth [00:51:12] Well, I love ending on rational optimism and a celebration of the 23 million people and all the people who were part of their recovery journey. So thank you so much for that and for spending time with me today.

Keith Humphreys [00:51:24] Really enjoyed it. Nice to talk with you.

Beth [00:51:27] Thank you so much to Keith for his time today. Thank you to all of you who I know will add layers of complexity and perspective about this topic in the comments and in our email. We'll be back with you on Friday. Between now and then we'll be on Substack where you can also find the recording of our live show on sale. Thank you for being here. Have the best week available to you.