In speaking with police about preventing overdose, the officers’ common refrain is “We aren’t going to arrest our way out of this” (https://bit.ly/3O3d4Vc). And among public health practitioners, there is weariness that our best efforts have not yet stemmed the tide of overdose deaths. In this context, an article in this issue of AJPH lends credence to law enforcement’s mantra and provides health policymakers with evidence to take bolder action.
In this issue of AJPH, Ray et al. (p. 750) explored whether overdose increased or decreased in proximity to drug arrests in Indianapolis, Indiana. They found that within a six-minute walk (500 m) of each drug arrest, opioid overdose deaths doubled. Elevated fatal and nonfatal opioid overdoses were sustained over one, two, and three weeks.
What could explain this remarkable finding? In an editorial in this issue of AJPH, Dietze (p. 745), drawing on experience from Australia, explores possible causal mechanisms related to interrupted opioid tolerance, which leaves people at higher risk for overdose when the same quantity is used after a period of abstinence. Correspondingly, Ray et al. did not find the same association with stimulants, which are not subject to the same discontinuation immediate overdose risk. Conceptualizing stimulants as a control group, and employing a counterfactual modeling strategy, provides a counterpoint to criticism that increasing drug arrests are only a parallel association with increasing overdoses.
Alternatively, interruption of supply drives people to new drug suppliers, who may have levels of active ingredient to which the individual is unaccustomed. Further investigations are needed to evaluate these ecological findings in causal inference frameworks.
Because of the importance of the findings and specialized methods, AJPH put the article through an extensive peer review process, with eight independent reviewers, who included legal scholars, epidemiologists, and geospatial statisticians, as well as internal statistical and methodological reviews by editors. The supplementary material includes additional data that were requested during review, including quantities of drugs seized.
We also invited the leadership of the Indianapolis Metropolitan Police Department (IMPD) to comment because they provided the data. Unfortunately, their duties could not accommodate our publication schedule. We welcome letters from the IMPD and other law enforcement agencies. We commend the IMPD for participating in this scientific inquiry because the policy questions have weighty importance. This study demonstrates that law enforcement data have applications in answering difficult public health questions.
Other forms of police data remain siloed. Currently, we find out what is in street drugs only when it is too late: crime labs after arrest or autopsy after overdose. Recently the Los Angeles Times revealed that law enforcement in Los Angeles, California, may have failed to inform public health authorities about an emerging dangerous fentanyl adulterant (xylazine) for four years (https://bit.ly/3VYYIak). The adulterant has been implicated in increased overdoses and the emergence of disfiguring skin ulcers. Those four years could have been used to develop education, prevention, and treatment.
These examples call into question whether US policing, as it currently stands, is a reliable agent of drug harm prevention. There is growing scientific evidence to support what many on the street already know: the narrow mission of law enforcement may exacerbate drug harms. Over the past decade, there has been a gradual ideological shift in law enforcement training, away from military-style “enforcers” and toward “guardians” of communities focused on crisis intervention and greater attention to social interactions (https://bit.ly/42LttSb).
Back in Los Angeles, in response to the earlier criticism, the sheriff’s department agreed to track xylazine in seized drugs and left open the door to update their detection methods if the information is helpful. With proper evidence and public health impetus, it is possible for some law enforcement agencies to change course (https://bit.ly/3nQl1Cn).
Ray et al. also provide useful metrics of law enforcement’s expected reach. In a city with a population of one million, there were seven drug seizures per day. By comparison, there were 17.2 nonfatal overdoses recorded by emergency medical services and 1.6 fatal overdoses. There are almost three times more overdoses than there are police interventions to seize drugs. Even with a predominantly law enforcement approach, interdiction is grossly outmatched. This lends credence to the refrain that we aren’t going to arrest our way out of this.
On the maps of Indianapolis, no one can be surprised that drug arrests are overrepresented in neighborhoods with lower financial resources and those with more racialized minority residents. Considering the finding that drug arrests may exacerbate overdose mortality, disproportionate policing of Black neighborhoods deserves renewed investigation, as overdose death rates in this demographic are now the highest (https://bit.ly/3BffcS5).
As a nation, our drug policies are collectively not working. Fleming et al. have noted the public health funding paradox, whereby taxpayers are simultaneously subsidizing separate government policies that prevent and exacerbate the same problem (https://bit.ly/3I4WnEJ). In an editorial in this issue of AJPH, Stahler et al. (p. 747) contextualize the findings in evidence-based interventions. To address the very real concerns from both law enforcement and public health practitioners, it is time to find new solutions.
54. Years Ago
Concerning Heroin Use and Official Records
“The present paper . . . takes exception to the view that all addicts ultimately come to police attention. It presents in support of its position several case histories of individuals in street drug use who mainlined heroin in heavy dosages over long periods of time. These subjects conceived of themselves as addicts . . . but remained, according to their personal testimony and our search of the records, unknown to either law enforcement or hospital authorities as being involved with drugs. . . . [W]e found our subjects with little difficulty, and . . . they maintained that they were aware of others of their kind. By no means would we suggest that their numbers are sizable. But we feel it important to document their existence because epidemiological information, upon which public health policies regarding drug use may be founded, should take into account the existence of undetected heroin addiction, as well as the polemic corollary of this fact which maintains that, absent criminal and civil commitment statutes, individuals may well be able to perform adequately while using opiates, particularly if the drugs are cheap and accessible.”
From AJPH, October 1969, p. 1888
109. Years Ago
Drug Addictions, A Public Health Problem
[I]t may seem a strong statement to make that over 50 per cent of drug users owe their habit to the medical profession, and yet I am convinced that my figures are not far wrong. . . . In many instances these first doses were not give at the bedside to allay severe pain, but handed out to office patients with apparently as little concern as a dose of calomel. Codeine, morphine, heroin and laudanum are all thus passed over to the temporary sufferer; the neurotic woman with obscure symptoms, the young mechanic with a broken arm, the over-tired businessman; to young and old, it matters not, who chance to stray into the wrong office and who pay the price of their evil choice years after their faces are forgotten and their fees spent by the “expert” who so readily relieved their symptoms. Not only are these drugs carelessly prescribed but we find many repeated orders to “refill the prescription and then let me hear from you,” the patient in entire ignorance, not infrequently learning for the first time from another physician or a conscientious druggist the nature of the “remedy” in which they have been placing their hope of cure.”
From AJPH, January 1914, pp. 32–33
Biography
