This article was originally published on Persuasion on April 24, 2023.
At a little after 11 o’clock on a Wednesday morning last spring, I watched cartoons with three small children while their mother talked to her parole agent in the next room. Community supervision can be an intimate process, and over the course of several months of field research I sat in many similar living rooms listening to many similar conversations. Rain made marshes out of the plowed fields across the highway while the children stared ahead at the screen, apparently unperturbed by the presence of armed strangers in their house. “You been using?” the agent asked in a tone that was almost confessional, as if they shared a secret. The woman looked down, said nothing, and cried quietly. She had just tested positive for fentanyl, a substance that has upended the landscape of drug abuse in the United States.
The opioid epidemic was kindled by the oversupply of prescription pain relievers in the late 1990s and fanned by new sources of heroin in the early 2010s. Today, however, fentanyl is king. The drug, which is primarily produced from Chinese chemicals by Mexican cartels and trafficked through major U.S. cities, is everywhere. It’s easy to see why. Fentanyl is about fifty times as potent as heroin, and is attractive for smugglers looking to minimize their profile and for distributors eager to stretch their inventory. An innocuous white powder, it can be easily mixed with other substances or pressed into counterfeit pills, making it a versatile (and dangerous) ingredient in multi-drug cocktails.
The boys’ mother, like most fentanyl users, was formerly a prescription pill and heroin user who barely noticed the gradual change in the drugs she was buying. But fentanyl is uniquely dangerous to her: the chemical is quickly metabolized by the human body, which makes for an intense but relatively short high that leaves users wanting more. Its potency means that getting the dosage right is difficult, and the line between satisfaction and fatality is vanishingly thin. Between 2016 and 2020, fentanyl deaths increased in all but seven states, a trend that contributed to the first national drop in average life expectancy in more than a century. More than half of the nearly 108,000 drug overdose deaths in the United States in 2021 were caused by synthetic opioids like fentanyl.
For parole agents and other frontline public safety workers, making sure clients aren’t on drugs used to be about keeping them out of jail. These days, it’s about keeping them alive. Fentanyl has made that job incredibly difficult: markets for the drug are remarkably resilient to disruption, and experts suggest that even after a major bust, supply can rebound in under three weeks. What’s more, the criminal justice system doesn’t have the capacity to adequately deter drug abuse among problem users. The rate of drug dependence may be as high as 65 percent among people in prison and around 40 percent among people on probation or parole. One parole agent told me that drug use is so prevalent that “the assumption is that they’re fucked up. We’re basically social workers with a gun these days.”
Without the ability to disrupt markets or deter users, policymakers have largely failed to contain the opioid epidemic as it enters its third and deadliest decade. There’s a growing understanding that if the drugs are here to stay, we need to focus resources on attacking addiction itself.
But addiction is a complex problem, and considerable disagreement exists about the best way to fight it. Two attitudes have dominated policy and practice throughout the epidemic, which might be called the “spiritual approach” and the “medical approach.” Each has its strengths; but their limitations mean they are unlikely to abate the death toll on their own.