In Louisville, Kentucky, not long ago, I heard the story of a woman named Mary. She grew up middle-class, cheerful at times, though she struggled with depression. She took antidepressants. After her marriage broke up in 2006, Mary switched to pain pills, and her life spiraled.
She had a son in 2016. A couple of years later, methamphetamine from Mexico flooded Louisville, and she began using meth too. After that, her mother, Carole, told me, Mary heard voices coming from a ceiling vent, saw a phantom hand reaching from the back seat of her car. She abandoned her son and lived on the street. Her teeth withered. “She became a person I didn’t recognize,” said Carole, who is now raising Mary’s son. (Carole asked that their last name not be used, because she’s concerned that the late father’s family might seek custody.)
Mary would show up on rare occasions, then head back to the street. In late 2021, she detoxed and came to her mother’s house sober, the daughter Carole remembered. Only two days later, at a playground with her son, who was then 4, Mary announced that she had to go see a friend. “I said, ‘Please don’t leave us,’” Carole told me. “‘You haven’t seen him for a year.’ We had an argument. She kissed [her son] goodbye and said, ‘I’ll see you tomorrow.’”
Three days after that, a woman called saying that Mary was pale, hungry, and in need of insulin for her diabetes. She was living in a tent encampment in Jeffersonville, Indiana, across the Ohio River from Louisville. Carole delivered money and clothes and then called the police. “I wanted them to arrest her, to get her off the streets. I wanted to save her life.” But the police could do nothing, she said, and even in midwinter, Mary refused to leave the encampment.
Early one morning in 2022, she froze to death in a tent.
A week later, I met Eric Yazel, a Jeffersonville emergency-room doctor and the county’s health officer. Yazel told me that cases of frostbite had surged as fentanyl, meth, and the ensuing tent encampments spread throughout the area. Countywide, he said, people were dying of fentanyl overdoses in record numbers. Still, like Mary, many refused to leave the encampments.
All addictive drugs, to some degree, redirect the brain’s immense power toward finding and using dope, often despite life-threatening risks. But the drugs that are prevalent now are different from what they were even a decade ago: more potent, easier to find, cheaper, and deadlier. Most people seem to have some inkling of this. Still, having spent more than a decade reporting on illicit drug distribution and use, I believe that few people truly understand the extent of the change, or its implications.
America’s approach to drugs and addiction today—which in many regions has shifted toward forbearance until users volunteer for treatment—is both well intentioned and out of date, given the massive street supplies of fentanyl and meth. It is failing just about everyone.
If we’re serious about curbing use of these most damaging illicit drugs, I believe we need to move to an approach that both the left and the right may find uncomfortable. We need to use arrests and the threat of confinement to break the hold of addiction. We also need to transform jail, and change what it means for people with a drug addiction to be in jail.
Over the past 40 years, the prevailing views on drug policy have slowly gone from one extreme to the other. In the decades following President Ronald Reagan’s “War on Drugs,” law enforcement was essentially the only tool used in the U.S. to address both drug trafficking and addiction. Harsh mandatory minimum sentences for drug use proliferated; jails and prisons filled.
The social costs of the War on Drugs eventually pushed many jurisdictions to question this approach. By the middle of the 2010s, support for treatment of addiction had grown. Drug courts, which suspend prison sentences in return for closely monitored entry into treatment, began to proliferate. Acceptance of medication-assisted treatment (MAT) to calm or block opioid cravings grew too.
Over time, the old Reagan-era approach was displaced by a new convention, that of “harm reduction”: mitigating the bodily damage that addicts may inflict on themselves through their drug use; keeping them alive with syringe exchanges and naloxone—the antidote to opioid overdose sold under the brand name Narcan—until they are ready to voluntarily accept drug rehabilitation. Decriminalization of drug possession and use followed, at least partially, in some jurisdictions. The pandemic amounted to an unofficial experiment in decriminalization: Even if the laws didn’t change, many counties stopped making small-time drug arrests. Jails kicked folks loose.
Compassionate intentions may have fueled this progression, and many of the early steps made sense. Yet as this philosophical shift was happening, so too were seismic changes in the supply of illegal street drugs.
Two synthetic drugs—fentanyl and methamphetamine, both made in Mexico—have flooded the United States. They are produced year-round by sophisticated traffickers who have access through Mexican ports to global chemical markets. No plants or growing seasons are necessary; the supply is massive, cheap, continual, and difficult to suppress.
Illicit fentanyl kills users more quickly than any other drug to ever appear on American streets. Preliminary data from the CDC show that overdose deaths hit an all-time high in 2022, at nearly 110,000—almost 70 percent of which involved fentanyl.
Fentanyl is so potent and cheap that dealers add it to other street drugs, creating opioid-addicted daily customers from, say, casual cocaine users, even at the risk of killing them. It has all but chased heroin from the market. Users could live for decades on heroin. But as one Kentucky addict in recovery told me a few years ago, when fentanyl settled into his region, “There’s no such thing as a long-term fentanyl user.” He recently relapsed and died of what is believed to be a fentanyl overdose.
Methamphetamine, for its part, has achieved alarming potency over the past decade, and the way it’s made has changed. Ingredients now include an ever-evolving lineup of toxic industrial chemicals. Meth use is now often accompanied by rapid-onset symptoms of mental illness—paranoia, hallucinations—symptoms that in many cases seem to far outlast the high itself.
Homelessness has many causes, but partly because of the way the new meth tangles the mind of its users, the drug has undoubtedly made people homeless and kept many others on the street. It is a regular feature of tent-encampment life across the country. Many users, like Mary, prefer the encampments to homeless shelters because tents provide a place to use more freely.
Meth and fentanyl upend many of the prevailing beliefs about drug policy. Perhaps the most important is that people must be “ready” to leave the street for treatment. The meth now being sold in the U.S. deprives many users of the mental ability to find readiness and opt into treatment. Fentanyl deprives them of the time to do so. Unlike heroin, it requires addicts to use several times a day to keep dope sickness at bay. Each use is potentially deadly.
The prevalence of these drugs does not reduce the need for some harm-reduction measures. Syringe exchange, for example, seems an essential tool in preventing the spread of HIV and hepatitis. The common use of Narcan to revive users who overdose is just as important for saving lives.
But when you zoom out, harm reduction alone looks perverse.
Take Narcan: It keeps people alive and is necessary in the moment of overdose. But the harm-reduction model holds that we should keep reviving people who overdose and then do nothing more than hope they come to their senses and opt into treatment. Paramedics I’ve spoken with report routinely reviving people who have overdosed on fentanyl a dozen times or more within a few months—sometimes twice in the same day.
In overdose, the brain’s oxygen is reduced. How much and for how long depends on the person and the time before she is revived. Any oxygen deprivation beyond some unknown threshold, however, damages parts of the brain that govern memory, motor skills, and, especially, reason and long-term decision making. A survey of studies published in 2021 in the journal Drug and Alcohol Dependence concluded that a period of oxygen deprivation was likely to cause “toxic injuries to multiple organs including the central nervous system, even when a fatal outcome is averted.”
John Corrigan, a psychologist at Ohio State University who has studied brain injuries since 1982, told me that, following brain impairment, a person is less likely to control harmful behavior, perceive an action’s consequences, postpone gratification, and make plans to change. Thus, damage from repeated overdoses makes it progressively more difficult for addicts to stop using. “There’s a cumulative effect,” Corrigan said.
Addiction specialists in Pasco County, Florida, are in the middle of a three-year federal-grant program studying the effects of repeated overdose—which has grown common since fentanyl arrived there five years ago—on about 100 female clients. So far, they have found that a greater number of overdoses correlates with lower reading levels among those clients, according to Robert Neri, who oversees programs and research for WestCare, the nonprofit treatment center that is managing the effort. Fifth- and sixth-grade reading levels are common within the group.
The ability to focus, follow schedules, understand new concepts, and remember things that have just happened is likewise lower than expected. Adding to the damage from overdose is the blunt-force brain trauma that so often accompanies addiction and street life: from falls, fights, accidents, beatings. A policy of allowing a person to return to the streets to use fentanyl after a Narcan-revived overdose is not compassion; it’s an invitation to more trauma, more overdose, death.
When I began reporting on these issues 13 years ago, I was agnostic about how to help the people who became addicted to illicit drugs. But those years—spent, in no small part, within communities ravaged by drug epidemics—have altered my perspective.
Taking away a person’s freedom is never something to be done lightly. But once addicted to fentanyl or the new meth, many users are not “free” to choose treatment—or any path out of addiction—in any meaningful way. Time away from these drugs, I believe, can help them regain their agency.
“Fentanyl is so powerful,” Robert Neri, of WestCare, told me. “Where somebody might have been able to pull their lives together on heroin,” many fentanyl addicts need structure, and time “away from access to the drug.”
Tolerances among people who survive their first exposure to fentanyl grow quickly, and withdrawal symptoms are fiercer than they are even from heroin—“like living hell,” says Heather Moore, a drug-clinic director in Tucson, Arizona, where counterfeit pills containing fentanyl now go for a dollar or less. Counselors and recovering addicts in the city told me that users there sometimes smoke 50 to 100 pills a day. Choosing to enter treatment is uniquely difficult.
Neri said that treatment providers and advocates are still catching up to the many changes wrought by pervasive fentanyl: the cumulative effects of repeated overdoses on users’ brains, a stronger aversion to opting into treatment. The shift “from plant-based drugs to laboratory-based drugs” has been profound, he said, and the addiction-treatment industry has not yet adjusted.
The use of law enforcement to help address drug addiction will be tarred by some as a return to the drug war of old, just casting users into prison. I understand the concern, and—more on this later—that’s not what I’m suggesting. Still, it is worth noting that the drug war failed not because we used law enforcement, but because we only used law enforcement.
Addiction is a problem deeply set in the chemistry of the brain. Using just one tool to address it is folly. A community approach, enlisting everything at our disposal, is essential. That includes law enforcement, which can provide both leverage and a respite from drugs.
As one recovering addict in Ohio, who is now a paramedic, told me, “You’re not going to get better unless you’re willing to get better. Finding that emerging willingness is critical.” For some people, he said, that willingness may be self-generated. “For me, it was the threat of doing years in prison.”
“You’d think fentanyl would cause people to pause; it does not,” says Mary Ellen Diekhoff, a drug-court judge in Monroe County, Indiana. What has caused more people to opt into her court, Diekhoff told me—and what has also strengthened their engagement with the process the court requires—is a recent modification to state law making it more likely that those with the lowest-level drug felonies may face prison. “Treatment is not easy,” she said. “If there’s no impetus to stay, why would you? You need to have something to lose.”
A handful of cities, watching synthetic drugs ravage their communities, are moving away from convention and trying new ideas.
One of those is Denver. Supplies of methamphetamine and fentanyl have inundated the city in the past several years. In 2019, Colorado passed a law that, among other things, made possessing four grams or less of most drugs—including fentanyl—only a misdemeanor. (Fentanyl gets mixed into all kinds of substances, including other drugs and powders, but for reference: Four grams of pure fentanyl will yield roughly 2,000 potentially deadly doses.) Denver’s drug-overdose numbers are now higher than they have ever been.
The homeless population, some 6,900, is likewise believed by city officials to be at least a 10-year high. Housing prices are doubtless one reason: They doubled in the 2010s. But homelessness is nonetheless what initially prompted the city to rethink its approach to drug use.
Evan Dreyer, the mayor’s deputy chief of staff in charge of homeless response, told me when we spoke last spring that the city’s shelters housed more than 1,800 people a night—but also that 300 to 400 beds typically went unused, even in winter. (Since then, an influx of migrants and refugees have increased occupancy.) Dreyer, who has worked for the city on homelessness since 2011, said that people living on the street have routinely balked at accepting housing. When he asked them why, they would say they had pets, or romantic partners, or a lot of belongings. In some instances, the city wrote into contracts that shelters needed places for pets, for partners.
Still, Dreyer said, he and his colleagues struggled to find takers, and of those who went into housing, many returned to the street. For some, mental illness is to blame. But “what often goes unsaid in those conversations is the need to use” drugs, he told me. In February 2021, temperatures dropped below zero for several days. Relatively few people left the encampments. On each of those days, Dreyer said, an encampment resident died
The mayor’s office still believes in the importance of housing, especially in a city as costly as Denver, Dreyer said. Much of the $250 million the city will spend on affordable housing and homelessness response this year will be for lodging—shelters, single-occupancy rooms, apartments. But city officials have seen enough to understand that many factors contribute to homelessness, including addiction.
Michael Hancock, Denver’s mayor and a liberal Democrat who initially embraced some of Colorado’s drug-policy-reform measures as a way of reducing incarceration, told me he now believes that the move to decriminalize drug possession and drug use went too far. “What is it that will make individuals reject the opportunity to get off the street?” he asked. “It’s mental-health and substances issues. We have to make sure we can drive them to these services.” And as for people who are selling illegal synthetic drugs: “We must have a system that holds you accountable.”
City crews now regularly remove tent encampments, though some reconstitute. The people who are removed are offered shelter and services, including drug treatment if they are using. Last year, lawmakers made it a felony to possess more than one gram of a substance containing fentanyl, which city officials hope will lead to the prosecution of dealers. The law also made certain other crimes count as felonies unless the person charged agrees to drug treatment.
The city has expanded its use of drug courts to help push users toward treatment. Defendants can avoid prison and expunge a drug-related felony by following a program of sobriety, peer-led meetings, work, and in many cases MAT—all supervised by a judge, usually over two to three years.
In the drug courts I’ve observed across the country, the judge, prosecutor, probation officer, and others work collaboratively with the defendant as he battles for sobriety. It is not easy; screwups happen maddeningly often. But I’ve come to see a personal touch, combined with accountability, as essential when dealing with the complexities of an individual’s addiction.
Crucially, Denver is also rethinking its jail system with addiction treatment in mind. I spoke with Elias Diggins, Denver’s sheriff and jailer, who had recently opened a 64-bed men’s recovery pod in the jail. The unit now offers classes in life skills and understanding drug abuse, peer-run meetings, and MAT for opioid addiction; it also connects inmates to continuing medication once they leave the jail.
The idea, Diggins said, is to make jail into a place where solutions can begin—an opportunity presented when a person is in custody, detoxed, and away from dope on the street. Entry into the recovery pod is voluntary, and the people who choose it, with good behavior, serve out their sentence there.
Fentanyl and meth have made rethinking jail essential. County jail, where sentences of less than a year are usually carried out, is the first and most common interface an addict has with the criminal-justice system. These encounters don’t always stem from drug-possession charges; many sentences result from property crimes or other crimes involving drug use, in one way or another.
Even the traditional jail system has been a boon to many people whose lives have been captured by drugs—a time to be away from dope, to eat, to get health care, to think a bit more clearly. I’ve known quite a few people—too many to ignore—who credit their recovery to their arrest, saying they’d be dead otherwise.
In its current form, however, jail is too often traumatic, throwing lives even further off course. The clarity that drug users may achieve away from dope tends to be wasted. Typical jail activities don’t extend much beyond sleeping, playing cards, watching the History Channel, and trading crime stories. Negativity and tedium often mix with predation to intensify mental illness, criminality, and addiction. Street drugs are prevalent in many jails—overdoses among inmates have risen nationally in recent years. Those in custody trying to leave dope behind are sometimes ostracized as “quitters” or accused of snitching.
But in a growing number of places—Denver and Columbus, Ohio, among them—jail is being redesigned as an opportunity for addicts and a long-term investment in recovery.
One model for this new approach is Kenton County (population 166,000), in Northern Kentucky, across the Ohio River from Cincinnati. In August 2015, Kenton County’s jail opened a 70-bed men’s recovery pod for inmates who were in and out of custody because of addiction. As in Denver, medication-assisted treatment—Suboxone or naltrexone—is provided to block cravings. Inmates volunteer to go into the pod, agreeing to participate daily in their recovery. They rise by 6 a.m. and make their bed. Their day is then filled with GED classes, plus classes on parenting, anger management, and other life skills. Inmates run 12-step meetings. The jail employs nine social workers. This is the kind of treatment addicts would receive in a rehab center on the outside. Jail ensures that they stay long enough for their brain to get a needed respite from dope.
Judges can also order people into the recovery pod, or offer it as a chance for defendants to knock time off their sentences. Marc Fields, Kenton’s jailer, told me that plenty of people opt in hoping to game the system. But as their mind defogs, he said, many slowly find readiness for sobriety in a way they don’t on the street.
Kenton County has added a 35-bed recovery pod for women. Both pods are policed and kept up by inmates committed to recovery. They are the cleanest pods in the facility, generally free of drugs, weapons, and fights, Fields said. At a time when fentanyl overdoses are taking place in jails and prisons nationwide, Kenton’s recovery pods report none. Inmates who don’t abide by the rules can be booted to traditionally run parts of the jail, from which they can work their way back to a recovery pod, if they wish. A waiting list to get into the pods has existed since soon after they opened.
Kenton County’s jail experiment has helped forge a local constituency to support recovering drug addicts once they’ve resumed life on the outside, as well. The Life Learning Center, a large nonprofit, expanded its mission in response to the jail experiment and now serves inmates leaving Kenton’s recovery pods. As an inmate’s release date nears, jail staff help them arrange sober housing. When they’re released, a shuttle first takes them directly to the center, allowing them to avoid city buses, where they might meet old friends and use again. A Life Learning Center social worker signs them up for Medicaid and helps get them continued treatment with Suboxone or naltrexone. The center provides clothes, food, a workout space, tattoo removal, visits to a salon to get hair and nails done, and 12-step meetings. A continuum of care is common in other forms of medicine, but not in addiction treatment. In Kenton County, it began with the jail recovery-pod experiment.
Those who complete their jail time in a recovery pod and get post-release care seem to do much better than those who serve time in other parts of the jail. The Life Learning Center’s study of graduates from 2018 to 2020 found a 24 percent recidivism rate among those who came out of the jail’s recovery pod and completed the center’s after-release program; nationwide, recidivism rates hover above 80 percent for inmates who get no treatment in jail or in an after-release program.
Communities across America are now beginning to receive funds dislodged from drug companies as part of settlements for their role in creating the opioid epidemic. The country will be stronger if these billions of dollars help create recovery-ready communities. Addiction recovery, among many benefits, is a key to the resuscitation of many neighborhoods and small, rural American towns.
In an era of rampant fentanyl and meth use, drug courts and a reimagined jail—alongside robust support for voluntary treatment—should be foundations for that revival. An arrest can be an act of compassion when the odds are that, outside, meth will drive a user mad and fentanyl will kill him.
Kenton’s recovery-focused jail pods—and those being developed in Denver, in Columbus, and elsewhere—are giving us ideas of what works and what doesn’t. They are not panaceas; this crisis has no single solution. But in a polarized debate, they offer a third way—rejecting both the “throw away the key” philosophy of yore and the “harm reduction” doctrine that we should simply wait for addicts in tents to develop readiness for treatment on their own, or that selling fentanyl ought to be a misdemeanor. I find them to be welcome jolts of innovation at a time when towns everywhere are desperate for new ideas.
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