Almost nobody is taking America’s drug crisis seriously. To be sure, the ever-mounting deaths attract headlines. They get a mention in the State of the Union, or on the campaign trail. But based on the outcomes, policymakers appear to have more or less given up.

Some numbers put the problem in perspective. After Covid-19, drugs are now the leading driver of America’s steadily declining life expectancy. A reported 111,219 Americans died from a drug overdose in 2021. That figure has risen more or less unabated, and at an increasing pace, since the early 1990s. Back in 2011, 43,544 Americans died from a drug overdose — less than half the 2021 figure. Ten years earlier, in 2001, it was 21,705 — less than half as many again. And the problem keeps getting worse: The 2021 figure is nearly 50% higher than it was in 2019.

Compared to the scale of the problem, our ambitions to meet it are meager. In its 2022 National Drug Control Strategy, the Biden administration set a goal of reducing overdose deaths by 13% over the next two years. That would still mean 83,000 overdose deaths annually — higher than any year before 2020. Thus far, the trajectory is not positive: The National Center for Health Statistics estimates that there were roughly 110,000 overdose deaths in the year ending December 2022 — essentially unchanged from a year earlier.

Of course, President Biden is not uniquely to blame. Overdose deaths rose through the Obama and Trump administrations; the seeds of the crisis were planted as far back as Bill Clinton’s first term. The failure has been ongoing and systematic. It is in part a failure of know-how: Over a century into drug control, we still have only limited ideas about how to abate the harms of drugs. It is also a failure of knowledge. One can easily find out how many people died of Covid-19 last week, but we still have only estimates of how many people died of drug overdoses last year. And of course, it is in part a failure of political will.

But in crucial respects what we face is a failure of understanding. What many people — policymakers and the general public alike — fail to grasp is that today’s crisis is not like crises past. Historically, drug crises were characterized by the (re)emergence of a drug, followed by the spread of addiction and its attendant ills. The problems they caused affected individual and social health — physical illness, social dysfunction, frayed relationships, public disorder, etc. While these still play a role, today’s crisis is predominantly characterized by an unprecedented increase in the drug supply’s lethality. Historical crises inflicted many more or less equally weighty harms — to users’ health, to families, to communities. In this crisis, one problem dwarfs all others: death.

Drugs have changed, probably for good. They now kill their users. Until policymakers internalize this fact, they will not make any progress. A haphazard approach was tolerable when the harms of drug use took time to accumulate. But with tens of thousands being poisoned to death every year, bolder action is required.

THE NEW DRUGS

Humans have long used drugs, to the benefit of some and the detriment of others. But drug crises — society-scale problems caused by drugs — are a relatively recent phenomenon.

The first true drug crisis in American history did not occur until after the Civil War, when tens of thousands of soldiers received morphine via hypodermic needles — both recently invented — and brought the subsequent addictions home with them. In the half-century between that crisis and the first wave of national drug-control legislation, thousands more became addicted. The opiate epidemic did eventually decline, before emerging again in a different form in the late 20th century.

These early drug crises were crises of addiction and its attendant harms, to the user and to those around him. The various postwar drugs of abuse — Benzedrine, for example, and barbiturates — were controlled because they led to undesirable dependency and harmful misbehavior. Similarly, the thousands of soldiers who returned from Vietnam addicted to heroin were a cause for concern, both for the effects of chronic opioid use on users’ health and for the social harms of homelessness and other dysfunctions attending that use. The crack crisis of the 1980s added a wrinkle, insofar as the drug’s sale was associated with particularly violent gang crime. But even then, the problem was the harmful side effects of compulsive drug use. It was not, first and foremost, the fact that drugs killed people.

This is not to say that drugs did not kill people in the past; they certainly did. But compared to other causes of death, drug overdose was uncommon. Between the end of World War II and 1966, data compiled by the Social Capital Project of Congress’s Joint Economic Committee indicate that less than one in 100,000 Americans died from drug overdoses annually. As drug use grew more common, overdose death rates rose slightly. But even in the late 1980s — the height of the crack crisis — only about three in 100,000 Americans died from a drug overdose per year. In 1988, the peak year for drug overdose in the ’80s, Americans were roughly three times more likely to die by homicide, four times more likely to die by suicide, and six times more likely to die in a car accident than by overdose.

In the mid-1990s, something changed. Death rates began rising, slowly but exponentially. Between 1990 and 2000, the overdose death rate doubled, from 2.6 per 100,000 to 5.3 per 100,000. The decade between 2000 and 2010 saw another doubling. From 2010 to 2020, the rate tripled, to 29.2 per 100,000 — 10 times the rate in the 1980s, and 30 times the lows of the postwar period.

Drug overdose is now the leading cause of non-medical death in the United States. As of 2021, it was only slightly less deadly than all homicides, suicides, and motor-vehicle fatalities combined. Drugs still cause addiction, of course, and addiction still hurts addicts and society. But, likely for the first time ever, the primary harm of today’s drug crisis is death…..

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