drug abuse and crime rates essay

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Criminal Justice DrugFacts

The substantial prison population in the United States is strongly connected to drug-related offenses. While the exact rates of inmates with substance use disorders (SUDs) is difficult to measure, some research shows that an estimated 65% percent of the United States prison population has an active SUD. Another 20% percent did not meet the official criteria for an SUD, but were under the influence of drugs or alcohol at the time of their crime. 1

Decades of science shows that providing comprehensive substance use treatment to criminal offenders while incarcerated works, reducing both drug use and crime after an inmate returns to the community. Treatment while in jail or prison is critical to reducing overall crime and other drug-related societal burdens—such as lost job productivity, family disintegration and a continual return to jail or prison, known as recidivism. Inadequate treatment while incarcerated also contributes to overdoses and deaths when inmates leave the prison system.

What are the challenges in addressing substance use disorders in this population?

To be effective for this population, treatment must begin in prison and be sustained after release through participation in community treatment programs. By engaging in a continuing therapeutic process, people can learn how to avoid relapse and withdraw from a life of crime. However, only a small percentage of those who need treatment while behind bars actually receive it, and often the treatment provided is inadequate.

Inmates with opioid use disorders particularly pose a challenge. During their time in prison, many untreated inmates will experience a reduced tolerance to opioids because they have stopped using drugs while incarcerated. Upon release, many will return to levels of use similar to what they used before incarceration, not realizing their bodies can no longer tolerate the same doses, increasing their risk of overdose and death. 2 One study found that 14.8 percent of all former prisoner deaths from 1999 to 2009 were related to opioids. 3 Insufficient pre-release counseling and/or post release follow-up are partially responsible for this alarming increase in mortality. 4

Why is treatment so critical in this population?

Scientific research since the mid-1970s shows that treatment of those with SUDs in the criminal justice system can change their attitudes, beliefs, and behaviors toward drug use; avoid relapse; and successfully remove themselves from a life of substance use and crime. 5-7 For example, studies suggest that using medications for opioid use disorder treatment in the criminal justice system decreases opioid use, criminal activity post-incarceration, and infectious disease transmission. 8-10 Studies have also found that overdose deaths following incarceration were lower when inmates received medications for their addiction. 11-12

How are substance use disorders treated in the criminal justice system?

The recent National Academy of Sciences report on Medications for Opioid Use Disorder stated that only 5% of people with opioid use disorder in jail and prison settings receive medication treatment. 13 A survey of prison medical directors suggested that most are not aware of the benefits of using medications with treatment, and when treatment is offered, it usually consists of only behavioral counseling, and/or detoxification without follow-up treatment. 13

Effective treatment of substance use disorders for incarcerated people requires a comprehensive approach including the following:

• cognitive-behavioral therapy, which helps modify the patient’s drug-use expectations and behaviors, and helps effective manage triggers and stress
• contingency management therapy, which provides motivational incentives in the forms of vouchers or cash rewards for positive behaviors
• Medications including methadone, buprenorphine, and naltrexone
• Wrap-around services after release from the criminal justice system, including employment and housing assistance
• Overdose education and distribution of the opioid reversal medication naloxone while in justice diversion treatment programs or upon release. 15

What about the cost of treatment?

Failure to treat substance use disorder in the criminal justice system not only has negative societal implications, but also proves to be expensive. One study of people involved in the criminal justice system in California showed that engagement in treatment was associated with lower costs of crime in their communities in the 6 months following treatment. In addition, the economic benefits were far greater for individuals receiving time-unlimited treatment.

A report from the National Drug Intelligence Center 14 estimated that the cost to society for drug use was $193 billion in 2007, a substantial portion of which—$113 billion—was associated with drug related crime , including criminal justice system costs and costs borne by victims of crime. The same report showed that the cost of treating drug use (including health costs, hospitalizations, and government specialty treatment) was estimated to be $14.6 billion, a fraction of these overall societal costs.14 It is estimated that the cost to society has increased significantly since the 2007 report, given the growing costs of prescription drug misuse.

Science suggests that even those who are not motivated to change at first can eventually become engaged in a continuing treatment process, suggesting it is a myth that treatment has to be voluntary to work. More information can be found in the Principles of Drug Abuse Treatment for Criminal Justice Populations: A Research-Based Guide .

NIDA funded scientists are actively seeking solutions through the NIH HEAL (Helping to End Addiction Long-Term) initiative . In addition, to support those who work with juveniles and adults within the court system, including judges, counselors, social workers, case workers, and others, NIDA has created materials and has identified other helpful resources that can be used in educating offenders and those who work with them about the science related to drug use, misuse, and addiction.

Additional Resources

• The Science of Drug Use - Discussion Points
• NIDA Research Dissemination Center
• NIDA Justice System Research Initiatives
• Family Resource Center

Points to Remember

• There are high rates of substance use within the criminal justice system.
• 85% of the prison population has an active substance use disorder or were incarcerated for a crime involving drugs or drug use.
• Inmates with opioid use disorder are at a higher risk for overdose following release from incarceration.
• Treatment during and after incarceration is effective and should include comprehensive care (including medication, behavioral therapy, job and housing opportunities, etc.)
• Despite the cost, treatment in the criminal justice system saves money in the long run.
• Research is underway to find better solutions.
• Center on Addiction, Behind Bars II: Substance Abuse and America’s Prison Population, February 2010. https://www.centeronaddiction.org/addiction-research/reports/behind-bars-ii-substance-abuse-and-america’s-prison-population
• Krinsky, C. S., Lathrop, S. L., Brown, P., & Nolte, K. B. (2009). Drugs, detention, and death: A study of the mortality of recently released prisoners. The American Journal of Forensic Medicine and Pathology, 30(1), 6-9.
• Binswanger, I. A., Blatchford, P. J., Mueller, S. R., & Stern, M. F. (2013). Mortality after prison release: Opioid overdose and other causes of death, risk factors, and time trends from 1999 to 2009. Annals of Internal Medicine, 159(9), 592-600.
• Møller, L. F., Matic, S., van Den Bergh, B. J., Moloney, K., Hayton, P., & Gatherer, A. (2010). Acute drug-related mortality of people recently released from prisons. Public Health, 124(11), 637- 639.
• Gordon, M. S., Kinlock, T. W., Schwartz, R. P., & O’Grady, K. E. (2008). A randomized clinical trial of methadone maintenance for prisoners: Findings at 6 months post‐release. Addiction, 103(8), 1333-1342.
• Wakeman, S. E., & Rich, J. D. (2015). Addiction treatment within U.S. Correctional facilities: Bridging the gap between current practice and evidence-based care. Journal of Addictive Diseases, 34(2-3), 220-225.
• Lee, J. D., Friedmann, P. D., Kinlock, T. W., Nunes, E. V., Boney, T. Y., Hoskinson, R. A. J., . . . O’Brien, C. P. (2016). Extended-release naltrexone to prevent opioid relapse in criminal justice offenders. New England Journal of Medicine, 374(13), 1232-1242.
• Mattick RP, Breen C, Kimber J, et al. Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence (review). Cochrane Database of Systematic Reviews. 2009; 3: Art. No CD002209. doi: 10.1002/14651858.CD002209.pub2
• Mattick RP, Breen C, Kimber J, et al. Buprenorphine maintenance therapy versus no opioid replacement therapy for opioid dependence. Cochrane Database of Systematic Reviews. 2014; 2: Art. No CD002207. doi: 10.1002/14651858.CD002207.pub4.
• Schwartz RP, Gryczynski J, O’Grady KE, et al. Opioid agonist treatments and heroin overdose deaths in Baltimore, Maryland, 1995-2009. Am J Public Health. 2013; 103(5):917-922. doi: 10.2105/AJPH.2012.301049
• Green TC, Clarke J, Brinkley-Rubinstein L, et al. Postincarceration Fatal Overdoses After Implementing Medications for Addiction Treatment in a Statewide Correctional System. JAMA Psychiatry. February 2018. doi:10.1001/jamapsychiatry.2017.4614
• Marsden J, Stillwell G, Jones H, et al. Does exposure to opioid substitution treatment in prison reduce the risk of death after release? A national prospective observational study in England. Society for the Study of Addiction. 2017; 112(8): 1408-1418. doi: https://doi.org/10.1111/add.13779
• National Academies of Sciences, Engineering, and Medicine. 2019. Medications for Opioid Use Disorder Save Lives . Washington, DC: The National Academies Press. https://doi.org/10.17226/25310
• National Drug Intelligence Center, The Economic Impact of Illicit Drug Use on American Society. Washington D.C.: United States Department of Justice, 2011. https://www.hsdl.org/?abstract&did=4814
• Gicquelais RE, Mezuk B, Foxman B, Thomas L, Bohnert ASB. Justice involvement patterns, overdose experiences, and naloxone knowledge among men and women in criminal justice diversion addiction treatment. Harm Reduct J. 2019;16(1):46. Published 2019 Jul 16. doi:10.1186/s12954-019-0317-3

This publication is available for your use and may be reproduced in its entirety without permission from NIDA. Citation of the source is appreciated, using the following language: Source: National Institute on Drug Abuse; National Institutes of Health; U.S. Department of Health and Human Services.

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Race, Mass Incarceration, and the Disastrous War on Drugs

Unravelling decades of racially biased anti-drug policies is a monumental project.

• Nkechi Taifa
• Cutting Jail & Prison Populations
• Social & Economic Harm

This essay is part of the  Brennan Center’s series  examining  the punitive excess that has come to define America’s criminal legal system .

I have a long view of the criminal punishment system, having been in the trenches for nearly 40 years as an activist, lobbyist, legislative counsel, legal scholar, and policy analyst. So I was hardly surprised when Richard Nixon’s domestic policy advisor  John Ehrlichman  revealed in a 1994 interview that the “War on Drugs” had begun as a racially motivated crusade to criminalize Blacks and the anti-war left.

“We knew we couldn’t make it illegal to be either against the war or blacks, but by getting the public to associate the hippies with marijuana and blacks with heroin and then criminalizing them both heavily, we could disrupt those communities. We could arrest their leaders, raid their homes, break up their meetings, and vilify them night after night in the evening news. Did we know we were lying about the drugs? Of course we did,” Ehrlichman said.

Before the War on Drugs, explicit discrimination — and for decades, overtly racist lynching — were the primary weapons in the subjugation of Black people. Then mass incarceration, the gradual progeny of a number of congressional bills, made it so much easier. Most notably, the 1984  Comprehensive Crime Control and Safe Streets Act  eliminated parole in the federal system, resulting in an upsurge of  geriatric prisoners . Then the 1986  Anti-Drug Abuse Act  established mandatory minimum sentencing schemes, including the infamous 100-to-1 ratio between crack and powder cocaine sentences.  Its expansion  in 1988 added an overly broad definition of conspiracy to the mix. These laws flooded the federal system with people convicted of low-level and nonviolent drug offenses.

During the early 1990s, I walked the halls of Congress lobbying against various omnibus crime bills, which culminated in the granddaddy of them all — the  Violent Crime Control and Safe Streets Act  of 1994. This bill featured the largest expansion of the federal death penalty in modern times, the gutting of habeas corpus, the evisceration of the exclusionary rule, the trying of 13-year-olds as adults, and 100,000 new cops on the streets, which led to an explosion in racial profiling. It also included the elimination of Pell educational grants for prisoners, the implementation of the federal three strikes law, and monetary incentives to states to enact “truth-in-sentencing” laws, which subsidized an astronomical rise in prison construction across the country, lengthened the amount of time to be served, and solidified a mentality of meanness.

The prevailing narrative at the time was “tough on crime.” It was a narrative that caused then-candidate Bill Clinton to leave his presidential campaign trail to oversee the execution of a mentally challenged man in Arkansas. It was the same narrative that brought about the crack–powder cocaine disparity, supported the transfer of youth to adult courts, and popularized the myth of the Black child as “superpredator.”

With the proliferation of mandatory minimum sentences during the height of the War on Drugs, unnecessarily lengthy prison terms were robotically meted out with callous abandon. Shockingly severe sentences for drug offenses — 10, 20, 30 years, even life imprisonment — hardly raised an eyebrow. Traumatizing sentences that snatched parents from children and loved ones, destabilizing families and communities, became commonplace.

Such punishments should offend our society’s standard of decency. Why haven’t they? Most flabbergasting to me was the Supreme Court’s 1991  decision  asserting that mandatory life imprisonment for a first-time drug offense was not cruel and unusual punishment. The rationale was ludicrous. The Court actually held that although the punishment was cruel, it was not unusual.

The twisted logic reminded me of another Supreme Court  case  that had been decided a few years earlier. There, the Court allowed the execution of a man — despite overwhelming evidence of racial bias — because of fear that the floodgates would be opened to racial challenges in other aspects of criminal sentencing as well. Essentially, this ruling found that lengthy sentences in such cases are cruel, but they are usual. In other words, systemic racism exists, but because that is the norm, it is therefore constitutional.

In many instances, laws today are facially neutral and do not appear to discriminate intentionally. But the disparate treatment often built into our legal institutions allows discrimination to occur without the need of overt action. These laws look fair but nevertheless have a racially discriminatory impact that is structurally embedded in many police departments, prosecutor’s offices, and courtrooms.

Since the late 1980s, a combination of federal law enforcement policies, prosecutorial practices, and legislation resulted in Black people being disproportionately arrested, convicted, and imprisoned for possession and distribution of crack cocaine. Five grams of crack cocaine — the weight of a couple packs of sugar — was, for sentencing purposes, deemed the equivalent of 500 grams of powder cocaine; both resulted in the same five-year sentence. Although household surveys from the National Institute for Drug Abuse have revealed larger numbers of documented white crack cocaine users, the overwhelming number of arrests nonetheless came from Black communities who were disproportionately impacted by the facially neutral, yet illogically harsh, crack penalties.

For the system to be just, the public must be confident that at every stage of the process — from the initial investigation of crimes by police to the prosecution and punishment of those crimes — people in like circumstances are treated the same. Today, however, as yesterday, the criminal legal system strays far from that ideal, causing African Americans to often question, is it justice or “just-us?”

Fortunately, the tough-on-crime chorus that arose from the War on Drugs is disappearing and a new narrative is developing. I sensed the beginning of this with the 2008  Second Chance Reentry  bill and 2010  Fair Sentencing Act , which reduced the disparity between crack and powder cocaine. I smiled when the 2012 Supreme Court ruling in  Miller v. Alabama  came out, which held that mandatory life sentences without parole for children violated the Eighth Amendment’s prohibition against cruel and unusual punishment. In 2013, I was delighted when Attorney General Eric Holder announced his  Smart on Crime  policies, focusing federal prosecutions on large-scale drug traffickers rather than bit players. The following year, I applauded President Obama’s executive  clemency initiative  to provide relief for many people serving inordinately lengthy mandatory-minimum sentences. Despite its failure to become law, I celebrated the  Sentencing Reform and Corrections Act  of 2015, a carefully negotiated bipartisan bill passed out of the Senate Judiciary Committee in 2015; a few years later some of its provisions were incorporated as part of the 2018  First Step Act . All of these reforms would have been unthinkable when I first embarked on criminal legal system reform.

But all of this is not enough. We have experienced nearly five decades of destructive mass incarceration. There must be an end to the racist policies and severe sentences the War on Drugs brought us. We must not be content with piecemeal reform and baby-step progress.

Indeed, rather than steps, it is time for leaps and bounds. End all mandatory minimum sentences and invest in a health-centered approach to substance use disorders. Demand a second-look process with the presumption of release for those serving life-without-parole drug sentences. Make sentences retroactive where laws have changed. Support categorical clemencies to rectify past injustices.

It is time for bold action. We must not be satisfied with the norm, but work toward institutionalizing the demand for a standard of decency that values transformative change.

Nkechi Taifa is president of The Taifa Group LLC, convener of the Justice Roundtable, and author of the memoir,  Black Power, Black Lawyer: My Audacious Quest for Justice.

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Informed citizens are democracy’s best defense

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Studying the Relationship Between Drugs and Crime

Sidebar to the article Identifying New Illicit Drugs and Sounding the Alarm in Real Time , by Jim Dawson, published in NIJ Journal issue no. 281.

In 1976, Congress directed NIJ to collaborate with the National Institute on Drug Abuse to explore the relationship between drug use and crime. By 1980, a team of four NIJ-sponsored researchers had compiled and published Drugs and Crime: A Survey and Analysis of the Literature . [1] This report summarized existing research on patterns of drug use and criminal behavior and the effects of drug treatment strategies on criminality, setting the stage for NIJ to launch its Drug Use Forecasting (DUF) program in 1987. DUF measured and tracked drug use among arrestees to generate reliable and current information on drug use in relation to the criminal justice system. After a decade of collecting data, NIJ refined and expanded DUF to form the Arrestee Drug Abuse Monitoring (ADAM) program, improving the quality of its annual estimates of drug use prevalence. ADAM was in operation until 2003. [2] The data from these two NIJ efforts proved foundational for understanding the changing landscape of drug use across regions and over time.

In addition to tracking drug use trends, NIJ has also invested significant resources in original research on how to decrease drug use. NIJ-funded studies in the 1990s showed that drug treatment could be integrated into the criminal justice system to effectively reduce criminality. Building on these findings, NIJ began to evaluate an array of drug treatment modalities for persons convicted of crimes, including drug courts, residential drug treatment corrections programs, intensive probation supervision, and systemwide approaches. NIJ’s drugs and crime portfolio over the past decade has focused on crime reduction by studying prevention and intervention strategies for drug-related crimes, tactics for disrupting and dismantling drug markets, and technologies for improved drug detection and recognition.

More recently, NIJ research has focused on the policies, practices, and resources available to law enforcement to deter, investigate, and prosecute opioid use. As part of the U.S. Department of Justice’s overall response to the opioid epidemic, NIJ’s current priority is to address drug trafficking, markets, and use related to heroin and other opioids such as fentanyl and its analogues.

About This Article

This article was published as part of NIJ Journal issue number 281 , published May 2019, as a sidebar to the article Identifying New Illicit Drugs and Sounding the Alarm in Real Time , by Jim Dawson.

[note 1] Robert P. Gandossy, Jay R. Williams, Jo Cohen, and Henrick J. Harwood, Drugs and Crime: A Survey and Analysis of the Literature , Washington, DC: U.S. Department of Justice, National Institute of Justice, May 1980, NCJ 159074.

[note 2] Although NIJ ended ADAM in 2003, the Office of National Drug Control Policy operated ADAM II from 2007 to 2013. Ten of the original ADAM sites were selected for geographic diversity to address questions regarding methamphetamine trends beyond the Southwest, and instrumentation was modified to add items specific to methamphetamine.

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In This Article Expand or collapse the "in this article" section Drugs and Crime

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Drugs and Crime by Richard Wright , Scott Jacques LAST REVIEWED: 14 December 2009 LAST MODIFIED: 14 December 2009 DOI: 10.1093/obo/9780195396607-0061

The relationship between drugs and crime has a long history and is a mainstay of fiction, widely documented in media reports, and the subject of substantial scientific investigation. Drugs are not always illegal, and their sale and use does not always lead to crime. Nevertheless, drugs and crime are related to each other in at least three ways. First, the immediate effect of drugs on the mind and body may create mental or physical states that somehow facilitate aggression or theft. Second, drugs are connected to crime when a drug user has a pressing need to consume them but lacks the necessary funds to do so; such situations may lead to predatory crimes, including burglary, robbery, or theft, among others. A third way in which drugs and crime are related is that some psychoactive substances are illegal to use, trade (buy or sell), or grow/manufacture. When drugs are illegal, illicit market participants are unlikely to report being victimized to the police, which means that predators are more likely to prey on them; in turn, there may be retaliation when this happens. In short, drugs can be related to crime if they cause a mental or physical state conducive to lawbreaking, lead to a perceived need that results in the motivation to steal, or result in a decrease in access to formal mediation and a corresponding increase in predatory and retaliatory crimes.

Several general treatments provide a comprehensive review of the drugs-crime relationship. Although Goldstein 1985 is limited by its focus on violence, the framework it suggests is obviously applicable to nonviolent crimes. Conceived in general terms, Goldstein is suggesting that the psychopharmacological effect of drugs can increase the chances of any kind of crime occurring, the perceived need for drugs can increase predatory crimes (e.g., robbery, burglary, and theft) and entrepreneurial crimes (e.g., drug dealing or prostitution), and the absence of formal mediation can increase crimes of predation but can also spark retaliatory measures such as assault and murder. Two edited volumes, Tonry and Wilson 1990 and National Institute of Justice 2003 , offer a wide-ranging look at the current knowledge concerning the drugs-crime relationship. Goldstein, et al. 1997 provides qualitatively and quantitatively oriented chapters on the relationship between crack cocaine and violence. Inciardi and McElrath 2007 contains a series of papers on the drugs-crime connection, including Paul J. Goldstein’s influential paper on the topic. The basic facts surrounding the drugs-crime connection, such as definitions and statistics, are available from the ONCDP ( Office of National Drug Control Policy 2000 ) and the BJS ( Bureau of Justice Statistics 1998 and Bureau of Justice Statistics 2009 ).

Bureau of Justice Statistics. 1998. Alcohol and crime: An analysis of national data on the prevalence of alcohol involvement in crime . Washington, DC: U.S. Department of Justice.

Presents and discusses statistical relationships between alcohol and crime.

Bureau of Justice Statistics. Drug and Crime Facts .

Website that provides an array of statistics on various drug-crime connections in the United States.

Goldstein, Paul J. 1985. The drugs/violence nexus: A tripartite conceptual framework. Journal of Drug Issues 15:493–506.

Provides the conceptual foundation for much of the post-1985 work on the drugs-violence relationship. This is a necessary read for all persons interested in the link between drugs and crime, especially violent crime.

Inciardi, James A., and Karen McElrath, eds. 2007. The American drug scene: An anthology . 5th ed. New York: Oxford Univ. Press.

Provides a general overview of illicit drugs and drug use. One section, however, consists of a series of papers on the drugs-crime relationship. Included are discussions of the “date-rape drug” and Paul J. Goldstein’s classic article ( Goldstein 1985 ) on the drug-violence connection.

National Institute of Justice. 2003. Toward a drugs and crime research agenda for the 21st century . Washington, DC: U.S. Department of Justice.

A comprehensive review of concepts, theories, and research on the drugs-crime relationship. Suggests avenues for future work based on the limitations of and gaps in previous research. This work is especially useful for persons interested in the economics of drugs and drug control. Available online .

Office of National Drug Control Policy. 2000. Drug-related crime . Rockville, MD: Drug Policy Information Clearinghouse.

Defines various potential drug-crime relationships and provides statistical data pertaining to those relationships. Available online .

Tonry, Michael, and James Q. Wilson, eds. 1990. Drugs and crime . Vol. 13 of Crime and justice: A review of research . Edited by Michael Tonry. Chicago: Univ. of Chicago Press.

Explores several drugs-crime relationships, including the link between drugs and prostitution, predatory crime, and aggression.

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• v.54(1); 2022

How the war on drugs impacts social determinants of health beyond the criminal legal system

Aliza cohen.

a Department of Research and Academic Engagement, Drug Policy Alliance, New York, NY, USA

Sheila P. Vakharia

Julie netherland, kassandra frederique.

b Drug Policy Alliance, New York, NY, USA

Associated Data

Data sharing is not applicable to this article as no new data were created or analysed in this study.

There is a growing recognition in the fields of public health and medicine that social determinants of health (SDOH) play a key role in driving health inequities and disparities among various groups, such that a focus upon individual-level medical interventions will have limited effects without the consideration of the macro-level factors that dictate how effectively individuals can manage their health. While the health impacts of mass incarceration have been explored, less attention has been paid to how the “war on drugs” in the United States exacerbates many of the factors that negatively impact health and wellbeing, disproportionately impacting low-income communities and people of colour who already experience structural challenges including discrimination, disinvestment, and racism. The U.S. war on drugs has subjected millions to criminalisation, incarceration, and lifelong criminal records, disrupting or altogether eliminating their access to adequate resources and supports to live healthy lives. This paper examines the ways that “drug war logic” has become embedded in key SDOH and systems, such as employment, education, housing, public benefits, family regulation (commonly referred to as the child welfare system), the drug treatment system, and the healthcare system. Rather than supporting the health and wellbeing of individuals, families, and communities, the U.S. drug war has exacerbated harm in these systems through practices such as drug testing, mandatory reporting, zero-tolerance policies, and coerced treatment. We argue that, because the drug war has become embedded in these systems, medical practitioners can play a significant role in promoting individual and community health by reducing the impact of criminalisation upon healthcare service provision and by becoming engaged in policy reform efforts.

KEY MESSAGES

• A drug war logic that prioritises and justifies drug prohibition, criminalisation, and punishment has fuelled the expansion of drug surveillance and control mechanisms in numerous facets of everyday life in the United States negatively impacting key social determinants of health, including housing, education, income, and employment.
• The U.S. drug war’s frontline enforcers are no longer police alone but now include physicians, nurses, teachers, neighbours, social workers, employers, landlords, and others.
• Physicians and healthcare providers can play a significant role in promoting individual and community health by reducing the impact of criminalisation upon healthcare service provision and engaging in policy reform.

Introduction

Social determinants of health (SDOH) are “the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” [ 1 ] There is a growing recognition in the fields of public health and medicine that SDOH play a key role in driving health inequities and disparities, such that a focus on individual-level medical interventions will have limited effects without the consideration of the macro-level factors that dictate how effectively individuals can manage their health. For instance, differences in access to nutritious foods, safe neighbourhoods, stable housing, well-paying job opportunities, enriching school environments, insurance, and healthcare can lead to differential health outcomes for individuals, their families, and their communities. And as these mid- and downstream SDOH have gained more attention, we must also focus on more macro SDOH in order to understand “how upstream factors, such as governance and legislation, create structural challenges and impose downstream barriers that impact the ability and opportunity to lead a healthy lifestyle.” [ 2 ]

One underexplored upstream SDOH is the “war on drugs” in the United States and how it exacerbates many of the factors that negatively impact health and wellbeing, disproportionately affecting low-income communities and people of colour who already experience structural challenges including discrimination, disinvestment, and racism [ 3 ]. President Richard Nixon launched the contemporary drug war in the U.S. in 1971 when he signed the Controlled Substances Act and declared drug abuse as “public enemy number one.” [ 4 ] Since the declaration of the U.S. drug war, billions of dollars each year have been spent on drug enforcement and punishment because it was made a local, state, and federal priority [ 5 ]. For the past half century, the war on drugs has subjected millions to criminalisation, incarceration, and lifelong criminal records, disrupting or altogether eliminating access to adequate resources and supports to live healthy lives.

Drug offences remain the leading cause of arrest in the nation; over 1.1 million drug-related arrests were made in 2020, and the majority were for personal possession alone [ 6 ]. Black people – who are 13% of the U.S. population – made up 24% of all drug arrests in 2020, despite the fact that people of all races use and sell drugs at similar rates [ 6–8 ]. While incarceration rates for drug-related offences skyrocketed in the 1980s and 1990s, they have decreased in recent years motivated both by cost savings and criminal legal reform efforts to promote a public health approach to drug use. However, estimates still suggest that roughly 20% of people who are incarcerated are there for a drug charge, and racial disparities in incarceration persist [ 9 , 10 ].

Meanwhile, the illicit drug supply has become increasingly unpredictable and contaminated due to drug supply disruptions, contributing to an exponential increase in drug overdose deaths [ 11 , 12 ]. Estimates suggest that one million people died of a drug-involved overdose between 1999 and 2020, with over 100,000 deaths occurring in a calendar year for the first time in 2021 [ 13 , 14 ]. Since 2015, overdose deaths have disproportionately impacted racial and ethnic minorities; Black people have had the biggest increase in overdose fatality rates, and today, Black and Native people have the highest overdose death rates across the U.S [ 15 ]. The most recent “fourth wave” of the overdose crisis can be attributed to a fentanyl-contaminated drug supply caused by drug prohibition; criminalisation that leads to stigma and fear of punishment that deters people from getting support they might need; and a lack of robust, scaled-up investment in harm reduction and evidence-based treatment services [ 16 , 17 ]. Although harm reduction interventions, including supervised consumption spaces (also called supervised injection facilities, drug consumption rooms, or overdose prevention centres) and heroin-assisted treatment have been widely studied and found effective outside of the U.S., these strategies have not been widely adopted in this country [ 18–21 ].

The drug war has also become deeply embedded within many of the systems and structures of U.S. life well beyond the criminal legal apparatus [ 3 ]. Since the health impacts of incarceration have been studied elsewhere, this paper will specifically discuss the impacts of criminalisation in other facets of life [ 22 ].

We argue that an underlying drug war logic has fuelled the expansion of drug surveillance and control mechanisms in numerous facets of everyday life in the U.S. We define drug war logic as a logic that prioritises and justifies drug prohibition, criminalisation, and punishment to purportedly address the real and perceived health harms of drug use over a public health approach to address these issues. In coining this term, we hope to make more visible the implicit assumptions about drug use that are often unnamed but common in the policies and practices across different institutions. We acknowledge that many actors in these settings where drug war logic is embedded, including physicians and other healthcare providers, are often well-intentioned yet unaware of how they may be perpetuating this logic through their own actions. We argue that drug war logic defies and contradicts widely accepted understandings of addiction as a health issue and has, in many cases, made a public health approach more challenging to implement [ 23 ]. Notably, the American Society of Addiction Medicine defines addiction as “a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences.” [ 24 ] As this paper will outline, drug war logic undermines rather than supports the health of people who use drugs, their families, and their communities by treating drug use as a criminal issue.

Drug war logic is made concrete, not just within criminal legal systems, but also through mandated drug reporting and monitoring systems in treatment and healthcare settings, compulsory drug testing in employment and for the receipt of social services, the proliferation of zero-tolerance workplaces and school zones, mandated treatment in order to receive resources or avoid loss of benefits, background checks for work and housing, and numerous other measures which will be discussed in detail below. As a result, the drug war’s frontline enforcers are no longer police alone but now include physicians, nurses, teachers, neighbours, social workers, employers, landlords, and others who are required to engage in these forms of surveillance and punishment.

This commentary will use a SDOH lens to explore a number of systems where the drug war and its logic have taken root, impacting individual and community health and subjecting many people in the U.S. to surveillance due to suspected or confirmed drug use. Healthcare providers must have a robust understanding of the impact of drug war logic in employment, housing, education, public benefits, the family regulation system (commonly referred to as the child welfare system), the drug treatment system, and the healthcare system because these deeply impact the health of their patients, particularly their patients who use drugs (For the purposes of this paper, we are using the term “Family Regulation System,” coined by Emma Williams and used by other scholars, instead of the more commonly used term “Child Welfare System” to reflect the fact that, particularly for low-income families and families of color, state intervention often occurs in order to regulate their families rather than to prioritize the welfare of the entire family unit, of which the child is a part).

Employment, with its link to income and health insurance, is an important determinant of health. However, drug testing, criminal background checks, and exclusions of those with criminal histories from certain professions create significant barriers to obtaining and maintaining employment. Beginning in the 1980s, employment-based drug testing became widespread. In a 1994 report, the National Research Council noted that “[i]n a period of about 20 years, urine testing has moved from identifying a few individuals with major criminal or health problems to generalized programs that touch the lives of millions of citizens.” [ 25 ] Between 2017 and 2020, the National Survey on Drug Use and Health found that approximately 21% of respondents were tested as part of the hiring process, and 15% were subject to random employee drug testing [ 26 ].

Despite the widespread use of testing, less than 5.5% of results are positive for any drug, according to data from Quest Diagnostics, one of the largest testing companies in the country [ 27 ]. There is little evidence that these policies are effective in reducing drug use, improving workplace safety, or increasing productivity [ 28–30 ]. Notably, drug tests cannot specify how much of a drug was consumed, whether the person is currently intoxicated or impaired, or if they have a SUD. Drug tests cannot indicate if drug use will impact a person’s ability to perform their work or if they present a safety risk. Rather, drug tests simply show whether or not someone has a particular metabolite in their system [ 31–35 ].

Beyond workplace drug testing, hundreds of thousands are excluded from stable, well-paid work because of drug-related convictions. Over 70 million people – more than 20% of the U.S. population – have some type of criminal record [ 36 ]. A drug arrest or charge, even without a conviction, can be a barrier to getting a job because it can appear in many web searches and background checks [ 37 ]. Criminal background checks have become cheaper and easier to access, even though these records are notoriously inaccurate [ 38 , 39 ]. In addition, more than a quarter of jobs in the U.S. require some kind of licence, and a drug conviction history can automatically prevent people from getting a professional licence for their trade, like trucking or barbering [ 40 ].

These employment barriers disproportionately affect Black men, who already face additional impediments to employment and who are most harmed by the drug war and criminalisation [ 41 ]. The federal Equal Employment Opportunity Commission issued guidance stating that denying employment based on criminal records could be a form of racial discrimination because people of colour are more likely to be targeted by law enforcement and thus more likely to have an arrest or conviction record [ 42 , 43 ]. As a recent report by the Brennan Centre points out: “the staggering racial disparities in our criminal justice system flow directly into economic inequality” [ 36 ]. This same report found that those with a history of imprisonment earned 52% less than those with no history of incarceration.

Employment is a health issue that should be of concern to healthcare providers because it provides income, access to health insurance and medical treatment, and social connection [ 44 ]. Precarious employment and low income are linked to poor health, and some research has shown that people who use drugs and who are precariously employed face increased vulnerability to violence and HIV infection [ 45–47 ]. Being unemployed can lead to poverty and negative health effects and is associated with increased rates of drug use and SUDs [ 48 ].

Rather than supporting people who use drugs in accessing employment and the health benefits attached to it, drug war logic in employment settings can erect barriers. Eliminating or greatly restricting workplace drug testing as well as banning criminal background checks and professional licencing restrictions are important steps towards restoring access to employment and the many health benefits it confers.

Housing is another key SDOH that is significantly impacted by drug war policies and practices. Drug war surveillance in housing began with the passage of the Anti-Drug Abuse Act of 1988, which prohibited public housing authorities (PHAs) from allowing tenants to engage in drug-related activity on or near public housing premises and deemed such activity grounds for immediate eviction [ 49 ].

The Cranston-Gonzalez National Affordable Housing Act of 1990 expanded on this so that if a tenant’s family member or guest - regardless of whether they live on-site - engages in drug-related activity, the tenant and their household can be evicted [ 50 ]. Additionally, the Act states that evicted households must be banned from public housing for a minimum of three years unless the tenant completes an agency-approved drug treatment program or has otherwise been “rehabilitated successfully.” [ 50 ]

Six years later in 1996, Congress passed the Housing Opportunity Program Extension Act, which established “One Strike” laws and expanded on previous acts to give PHAs the authority to evict tenants if they or a guest was suspected of using or selling drugs, even outside of the premises [ 51 ]. This series of public housing policies requires neither a drug arrest nor proof that a tenant or their guest is involved in drug use, sales, or activity [ 52 ].

Private housing markets can also enforce zero-tolerance drug policies. In over 2,000 cities across the U.S., landlords can certify their property as “crime-free” by taking a class, implementing “crime prevention” architecture, and including clauses in their leases that allow for immediate eviction should a tenant, family member, or guest engage in “criminal activity,” particularly drug-related activity, on or off the premises [ 53 , 54 ]. Landlords, in close partnership with law enforcement, can invoke these laws by claiming to enforce crime-free ordinances, regardless of whether the alleged drug-related activity is illegal. In states across the U.S., private landlords have evicted tenants following an overdose [ 55–59 ]. In practice, these programs and ordinances increase the surveillance and displacement of low-income Black and Latinx tenants while not decreasing crime and potentially deterring someone from calling 911 for medical assistance in case of an overdose [ 55 ].

Evictions can lead to unstable housing or homelessness, which is associated with a host of chronic health problems, infectious diseases, emotional and developmental problems, food insecurity, and premature death [ 60–63 ]. Lacking a permanent address and reliable transportation makes it more difficult to receive and store medications and travel to a hospital or clinic; this is compounded with the stigma and discrimination that unhoused people often face from healthcare providers [ 64 ]. Being unhoused or housing unstable is also associated with difficulty obtaining long-term employment and education [ 65–67 ]. Longitudinal studies have found that family eviction has both short- and long-term impacts among newborns and children, including adverse birth outcomes, poorer health, risk of lead exposure, worse cognitive function, and lower educational outcomes [ 68 ]. These negative health outcomes are compounded for people with SUDs [ 69 ]. Unhoused people who use drugs are often forced into more unsafe, more unsanitary, and riskier injection and drug-using practices to avoid detection [ 70 ]. Evictions and homelessness are also associated with increased risk of drug-related harms, including non-fatal and fatal overdose, infectious diseases, and syringe sharing [ 71–73 ]. In addition, evictions can disrupt relationships between users and trusted sellers, making an already unregulated drug supply even more unpredictable [ 70 ].

While housing is understood as a key component of health and safety for all people, including people who use drugs, drug war logic can encourage and facilitate displacement, making it hard for housed people to remain so and creating barriers for those who are unhoused to find safe, affordable housing options. Solutions for improving housing access include ending evictions and removing housing bans based solely on drug-related activity or suspected activity, restricting landlords from using criminal background checks to exclude prospective tenants, and ending collaborations between housing complexes and law enforcement. Housing interventions that can improve the health of people who use drugs, in particular, include investing in Housing First programs and permanent supportive housing, providing eviction protection to people who call for help during an overdose emergency (i.e. expanding 911 Good Samaritan laws), and establishing overdose prevention centres.

Education is also understood as a strong predictor of health [ 74–76 ], but drug war logic in educational settings can subject young people who use drugs to punishment rather than needed support. Adolescent substance use is associated with sexual risk behaviour, experience of violence, adverse childhood experiences, and mental health and suicide risks, which should justify greater mental health and support services in schools [ 77 ]. Despite this, punitive responses to suspected or confirmed drug use, ranging from surveillance and policing to drug testing and expulsion, are commonplace in the field of education.

In 2018, 94% of high schools used security cameras, 65% did random sweeps for contraband, and 13% used metal detectors [ 78 ]. Twenty-four states and the District of Columbia have almost as many police and security officers in schools as they do school counsellors [ 79 , 80 ]. Drug use is one of the most common sources of referrals of students to police [ 80 ]. And recent estimates show that over a third of all U.S. school districts with middle or high schools had student drug testing policies [ 81–83 ].

Drug war policies also impact higher education, which is integral to economic mobility [ 84 ]. Prior to December 2020, federal law prohibited educational grants and financial aid to people in prison, one-fifth of whom were there for a drug offence, and drug convictions could lead to temporary or indefinite suspension of federal financial aid for students [ 85 ]. Still today, fourteen states have some temporary or permanent denial of financial aid for college or university education for people with criminal records [ 86 ].

These education policies – surveillance, policing, drug testing, zero tolerance, and barriers to financial aid – restrict access to education and ultimately impede economic wellbeing and positive health outcomes. For example, dropout risk increases every time a student receives harsh school discipline or comes into contact with the criminal legal system, including through school police officers [ 87 ]. Dropping out, in turn, is associated with higher unemployment and chronic health conditions [ 88 ]. In addition, discipline, such as expulsion for a drug violation, can contribute to more arrests for drug offences or the development of SUDs [ 89–91 ]. In contrast, school completion can help reduce higher risk substance use patterns [ 92 ], and education is a strong predictor of long-term health and quality of life [ 93 ].

Rather than supporting young people in completing their education and getting the support they may need, drug war logic prioritises punishing them in schools while often restricting access to financial aid and educational services for those seeking higher education. If we want to improve the health of young people, we need to reverse these policies. For example, the American Academy of Paediatrics opposes the random drug testing of young people based on an exhaustive review of the literature finding it did more harm than good [ 94 ]. Removing police from schools, ending zero-tolerance policies, and offering young people who use drugs counselling and support, instead of expulsion, could also help improve completion rates, ultimately leading to better health outcomes.

Public benefits

Though economic and food insecurity are linked with poor health outcomes, decades of drug policies have restricted access to public assistance programs. In 1996, Congress passed the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) [ 95 ], and one of the stated goals was to facilitate the transition from reliance on public assistance to full-time employment [ 96 ]. This law restricted benefits for people who use drugs, people with prior drug convictions, and their families in several ways.

The PRWORA introduced a lifetime ban on Supplemental Nutrition Assistance Program (SNAP) and Temporary Assistance for Needy Families (TANF) cash assistance benefits for people with felony drug convictions, unless the state modified or opted out of the ban. Today, one state - South Carolina - fully bars people with felony drug convictions from receiving SNAP, and twenty-one states have instituted a modified SNAP ban [ 97 ]. Seven states fully bar people with felony drug convictions from receiving TANF, and seventeen states and the District of Columbia have instituted modified TANF bans [ 97 ]. Common features of modified bans can include mandatory drug treatment, drug testing, and parole compliance [ 98 , 99 ]. These zero-tolerance bans have discriminatory and disproportionate impacts among Black and Latinx people and women, who are disproportionately incarcerated for federal and state drug offences [ 100 ].

Drug testing of public benefits applicants is less discussed in the peer-reviewed literature [ 101 ]. Although the PRWORA authorised, but did not require, drug screenings of public benefits applicants, today 13 states drug test TANF applicants [ 102 , 103 ]. States that drug test as a condition of receiving TANF can only test if drug use is suspected. For example, some states automatically require people with felony drug convictions to take a drug test [ 104 ], while other states require all applicants to undergo a drug screening questionnaire and then require a test if there is suspicion of drug use [ 105 ]. Many TANF applicants, who are already low income, are expected to pay for their drug tests. The impact of drug testing on people with felony drug convictions is compounded since they are already disproportionately poor, unemployed, and food insecure compared to people who have never been incarcerated [ 106–108 ].

In most states that test, a positive drug test can temporarily or permanently disqualify a person from receiving TANF benefits [ 105 ]. Even if cash assistance is allocated to other household members (e.g. children) through a different parent or guardian, overall benefits for the family can be reduced. In some cases, a person who tests positive for drugs may still receive benefits but only if they complete mandated, abstinence-based treatment [ 105 ]. Such policies and practices can deter many eligible candidates and those in need of support from ultimately seeking these public benefits altogether [ 109 ].

There are numerous negative health consequences associated with food and economic insecurity [ 110–112 ]. In particular, studies have found that loss or reduction of SNAP is associated with increased odds of household and child food insecurity and increased odds of forgoing health or dental care [ 113 ]. Loss or reduction of TANF is associated with increased risk of hunger, homelessness or eviction, utility shutoff, inadequate medical care, and poor health [ 114 ].

When people are seeking financial and nutritional support to better care for themselves and their families, especially in crisis, drug war logic justifies more barriers to SNAP and TANF and the discontinuation of assistance precisely when people need it the most. To better support financial and economic security of low-income people, advocates can support removing TANF and SNAP bans for people who have felony drug convictions, ending drug testing requirements for public assistance, eliminating mandatory drug treatment requirements for public benefits applicants and recipients, and adequately investing in public benefit programs to ensure they provide enough assistance for families.

Family regulation

The family regulation system (FRS) often treats any drug use as a predictor of child abuse or neglect, even though research shows that poverty is one of the largest predictors of adverse infant and child health outcomes [ 115 ]. Drug war logic within the FRS justifies the separation and punishment of families for drug use even absent evidence of abuse or neglect. Half of all states and the District of Columbia require healthcare professionals to report any suspected drug use during pregnancy to FRS authorities, and eight states require them to drug test patients suspected of drug use [ 116 ]. Statutes in nineteen states and the District of Columbia define any drug use during pregnancy as a form of child maltreatment [ 117 ]. These policies exist even though most people who use drugs use them infrequently and do not meet criteria for SUDs [ 118 ]. Additionally, evidence proving causal links between prenatal drug use and child harm and maltreatment is limited. Research finds that in utero exposure to drugs may not have long-term negative developmental impacts on the child and that confounding variables, like poverty and food insecurity, have significant and often stronger impacts on child development than drug use [ 117 ].

Drug testing, mandatory reporting, and the prospect of punishments result in poorer health outcomes for pregnant people who use drugs, especially if they struggle with their use. A fear of punishment and family separation leads some pregnant people who use drugs to avoid honest, open conversations about healthcare needs or how to reduce drug use harms so that many delay, avoid, or forgo prenatal care altogether [ 119 , 120 ].

Like healthcare professionals, most school teachers, counsellors, social workers, and mental healthcare providers are required by law to report any suspicion of child maltreatment or neglect, which then initiates an FRS investigation [ 121 ]. A child can be removed from their home if the caregiver tests positive for drugs, even absent any other evidence of mistreatment or abuse. In addition, a positive drug test can lead to a parent being mandated to complete abstinence-based treatment even if the parent does not meet criteria for a diagnosable SUD [ 122 ]. Intervention by the FRS, such as placing children in foster care, can lead to adverse education, employment, and mental and behavioural health outcomes among children; increased parental mental illness diagnoses; and increased parental drug use to cope with the trauma of family separation [ 123–125 ].

These policies have disproportionate impacts on Black people. Black pregnant women are more likely to be tested for drug use, and Black women are reported to the FRS at higher rates than white women [ 126–128 ]. Over half of Black children will experience an FRS investigation at some point during their lifetime [ 129 ]. One study that analysed cumulative foster system removals between 2000 and 2011 found that 1 in 17 U.S. children, 1 in 9 Black children, and 1 in 7 Indigenous children will experience foster placement before they turn 18, and data show that many FRS cases involve allegations of parental drug use at some point [ 130 ]. These disparities in FRS involvement are not because Black parents are using drugs or mistreating their children at higher rates; rather, it’s because Black families, especially poor Black families, more often encounter state systems – like public hospitals and public benefits offices – and mandated reporters within these systems that monitor behaviour and drug use [ 131 ].

Drug war logic prioritises separation, coercion, and punishment in families where drug use occurs or is suspected. For pregnant people and parents who do use problematically, their use should be treated as a public health issue, according to international bodies like the United Nations General Assembly Special Session on drugs [ 132 ]. Advocates can support legislative policy changes to prohibit removals based on drug tests alone, eliminate mandatory reporting for drug use alone, and repeal laws that define drug use during pregnancy as de facto child abuse or maltreatment. Healthcare professionals can also advocate to only allow drug testing when medically necessary and when the parent provides informed consent; support practices that keep parents and infants together, like breastfeeding and skin-to-skin contact, that can mitigate the effects of neonatal abstinence syndrome [ 133 , 134 ]; and create programs providing both perinatal healthcare and SUD treatment to improve access and continuity of care as well as initiation and maintenance of medications for addiction treatment.

Substance use treatment system

Substance use treatment can be an essential lifeline for people with SUD working towards recovery. Yet surveillance and punishment are embedded into SUD treatment through the numerous constraints placed upon clients because of the role of institutional referral sources in treatment, such as the criminal legal system, the FRS, social services, and others. Studies suggest that roughly 25% of clients in publicly funded treatment were referred from the criminal legal system as a condition of their probation, parole, or drug court program [ 135 ]. This has led to therapeutic jurisprudence: the belief that the criminal legal system can support and facilitate efforts towards rehabilitation using the threat of incarceration [ 136 ]. Another 25% of clients are referred to treatment by other sources, including the FRS, social services, schools, and employers [ 133 ]. Criminal legal controls such as those from the courts, or formal social controls such as those from the other aforementioned institutions, coerce clients to either comply with treatment or face other harsh consequences, like incarceration, the termination of parental rights, or losing public benefits [ 137 ].

Treatment providers monitor client compliance and abstinence by conducting and observing routine urine drug tests, and providers are often in regular contact with referral sources about client progress in treatment. Any drug use or negative progress reports can be used as grounds to sanction those on probation, parole, or in drug court which can lead to incarceration and, in cases of drug courts, longer sentences than if participants had accepted a jail sentence [ 136 ]. Clients referred by other sources can also face ramifications for positive drug tests or treatment non-compliance, impacting child custody hearings as well as their ability to secure certain social services and resources, stay enrolled in school, or remain employed.

Referral sources influence the type of care that clients receive in facilities, including evidence-based treatments. Research suggests that only 5% of clients with opioid use disorder (OUD), who were referred to treatment from the criminal legal system, received either methadone or buprenorphine, compared to nearly 40% those who were not referred by the system [ 138 ]. This represents an extension of a broader problem within the criminal legal system wherein access to these gold standard medications for OUD is almost nonexistent in most jails and prisons across the U.S [ 139 ].

Drug war logic is also deeply rooted in the restrictions for prescribing and dispensing methadone and buprenorphine since they are controlled substances under the oversight of the Drug Enforcement Agency, a federal law enforcement entity. When taken in effective doses, these life-saving medications can cut the risk of overdose and all-cause mortality dramatically among people with OUD [ 140 ]. However, due to tight federal restrictions and guidelines for these controlled medications, patients can be subjected to routine drug testing, counselling requirements, daily clinic visits, and observed or highly monitored medication dispensing. Patients deemed non adherent to medications or who test positive for other drugs can then be subjected to dose reductions, required to attend treatment more frequently, or even terminated from care altogether [ 141 ]. The tight restrictions on both methadone and buprenorphine, combined with the oversight of the DEA, create obstacles for prescribers and stigmatise these medications by conveying that they cannot be used like other medications in routine healthcare [ 142 ]. These policies have also contributed to striking racial disparities in who receives buprenorphine versus methadone due to costly co-pays and insurance coverage issues [ 143 ]. Studies also suggest that the DEA’s involvement in monitoring buprenorphine has made pharmacies reluctant to stock the medication or to dispense it to patients for fear of triggering an investigation [ 144 , 145 ]. Ultimately, it is estimated that only 10% of all people with OUD receive these medications [ 146 ].

Providers can take steps to extract the drug war from our substance use treatment system, through their conscious and judicious documentation of treatment progress since those records could be used by criminal legal and other referral sources in decisions about clients and their families. In addition, eligible buprenorphine prescribers should begin prescribing to patients and join advocacy efforts to change policies to expand access to buprenorphine and methadone through looser restrictions.

Healthcare system

People with SUDs often have high rates of co-occurring medical needs requiring treatment, including psychiatric disorders, infectious diseases, and other chronic health conditions. However, research suggests that people with SUDs are often deterred from seeking healthcare to address their medical needs due to prior negative and stigmatising experiences with providers, and that having experienced discrimination in healthcare is associated with greater risk behaviours, psychological distress, and negative health outcomes among people who use drugs [ 147–149 ]. Some of these challenges are due to a lack of training on how to work with patients with SUDs, in addition to pre-existing personal biases and stigmatising views held by healthcare professionals, which impacts the type of care they provide [ 142 ].

The widespread use of drug testing in healthcare settings also creates ethical challenges and conflicts for providers and patients since results are often entered into the electronic health record (EHR). While EHRs are typically thought of as beneficial and intended for greater transparency and access, they also pose challenges surrounding patient privacy, confidentiality, and autonomy; they can, therefore, make patients reluctant to disclose drug use or consent to drug testing [ 150 ]. For instance, medical records that include drug test results, can be accessed by a wide variety of actors in the medical system, subpoenaed for court, and used in future medical decision making without the patient’s knowledge or consent. Providers might not receive adequate training to weigh the need for these tests as part of treatment adherence monitoring with the potential social or legal ramifications of these tests for the patient. Patients might also not be adequately informed of these potential consequences prior to testing.

Universal drug screening and testing in obstetric and gynecological care is an example wherein testing intersects with the role of most healthcare providers as mandated reporters. Mandated reporting for suspected child abuse or neglect due to parental drug use is purported to protect the foetus or children in the parents’ custody, yet this can often be a deterrent for patients to seek medical treatment altogether if they believe that they may lose their children or be subject to other mandates. The racial and class disparities in how such testing is used, as well as the punitive measures used against families, have been noted earlier in the text but is a compelling reason for healthcare providers to consider making recommendations for counselling or supportive case management in order to address family challenges.

Healthcare providers need more training and resources to work with patients with SUDs to ensure that they are engaging them in evidence-based treatments and treating their complex medical needs while avoiding some of the lifelong and harmful ramifications that can occur when drug testing, health records, and mandated reporting deter patients from seeking and receiving care.

Because of the social, economic, and health effects of drug policies, the work of ending the drug war cannot be situated within criminal legal reform efforts alone. The drug war and a punitive drug war logic impact most systems of everyday life in the U.S., subjecting people to surveillance, suspicion, and punishment and undermining key SDOH, including education, employment, housing, and access to benefits. Combined, these have resulted in poorer health outcomes for individuals, families, and communities, particularly for people who use drugs. These policies and practices, while race-neutral as written, are not [ 151 ]. The targeted effects on people of colour further entrench health and economic disparities. As the public and policymakers call for a health approach to drug use, it is vital to recognise how systems meant to care and support are often unable to serve their intended purposes; rather than help people who use drugs or are suspected of using drugs, they frequently punish them.

In their day-to-day practice, healthcare professionals must understand the deep roots of the drug war as well as their role in both perpetuating and undermining drug war logic and practices. Healthcare providers can treat people who use drugs with dignity, respect, and trust and ensure that healthcare and treatment decisions are made in partnership with individuals. Medical professionals can also work to situate drug use within a larger social and economic context [ 152 ], understanding that drug-related harms often stem from lack of resources – like housing and food precarity, economic insecurity, and insufficient healthcare – rather than from drugs themselves. Treatment need not be the only antidote for people who experience drug-related harms but should be one option among an array of health services, resources, and support.

At the mezzo- and institutional levels, healthcare providers can advocate to shift hospital and programmatic policies around drug testing, mandatory reporting, and collaborations with law enforcement. As outlined in this paper, drug testing is not an effective monitoring strategy for care and support, but rather, it is more often a punitive tool of surveillance. If drug testing cannot be eliminated, at the very least, patients should have the right to understand the implications of drug testing and provide explicit consent for the test. To the extent possible, providers should not share private patient information with police or state agencies. Healthcare professionals should understand the implications of reporting positive drug tests and suspicion of use and should work to change these policies where possible and inform their patients of them. Providers can ensure that their patients who use drugs have access to evidence-based, non-coercive harm reduction and treatment options in addition to robust and supportive primary healthcare. Healthcare professionals involved with medical education and licensure can work to ensure that all students graduate with a deep understanding of SDOH and the impact of the drug war on individual and community health.

Finally, healthcare providers can get involved with policy-level changes to end drug testing, mandatory reporting, zero-tolerance policies, coerced treatment, and denial of services and resources based on arrest or conviction records at the municipal, state, and federal levels. Providers can follow the leadership and expertise of people who use drugs, some of whom have organised themselves into user unions [ 153 ]. Policy advocacy can include drafting and joining sign-on letters, delivering expert testimony, speaking to media, writing op-eds, and lobbying medical professional organisations to release policy statements. Providers, who see firsthand the consequences of the war on drugs, are well positioned to be effective advocates in undoing these harmful policies that have for too long undermined key SDOH [ 154 ]. In order to improve individual and collective health, healthcare providers should resist drug war logic and work to transform these systems so they can truly promote health and safety.

For the purposes of this paper, we are using the term “Family Regulation System,” coined by Emma Williams and used by other scholars, instead of the more commonly used term “Child Welfare System” to reflect the fact that, particularly for low-income families and families of color, state intervention often occurs in order to regulate their families rather than to prioritize the welfare of the entire family unit, of which the child is a part.

Authors contribution

All authors (AC, SV, JN, KF) were involved in the conception and drafting of the paper, revising it critically for intellectual content; and the final approval of the version to be published. All authors agree to be accountable for all aspects of the work.

Disclosure statement

All authors are employed by the Drug Policy Alliance, a non-profit policy advocacy organisation. No other interests to disclose.

Data availability statement

The views expressed in the submitted article are those of the authors.

Drug Abuse and Its Negative Effects Essay

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Introduction

Works cited.

One of the consequences of using drugs is, eventually, an individual becoming addicted. Addiction refers to a neuropsychological disorder that involves persistently feeling an urge to engage in particular behaviors despite the significant harm or negative effects. The psychology that explains addiction covers many areas, such as an illness or personal problem, an effect of someone’s lifestyle, family history, or socioeconomic demographics. This paper aims to highlight what the field of psychology says about the negative effects of drugs and why people continue using despite the consequences.

Using drugs once does not necessarily mean someone will never consume them again. In most cases, the drugs contain elements that can cause a person to become addicted. From a psychological perspective, it is important to understand how people enter into addiction. At the root of addictive behavior is a level of emotional stress deeply hidden within someone’s subconscious mind, and addressing it becomes a challenge. To relieve stress, pleasure is discovered in excess (Bechara 100). An example is when people choose to drink alcohol to ease their pain and ultimately find fun.

Stopping the behavior is a danger to someone’s mental state as they fear returning thoughts of the initial source of emotional stress. When a person is addicted, it suggests they lack healthy coping methods for the problem. The only mechanisms are distracting as well as unhealthy such as substance usage. Individuals dealing with addiction do not care about what matters since what is important to them is the desire to do something when that stress appears (Bechara 101). Some can stop their behaviors as their emotional stress does not manifest as among the addictive behaviors. Meanwhile, for others, their drug usage indicates an issue they may not have known and needs treatment. This leads to associative learning, which refers to learning to do something according to a novel stimulus.

Associative Learning

It is regarded as associative learning when an individual finds and takes drugs and ultimately gets high. The concept can be further explained using Ivan Pavlov’s experiment, where he rang a bell to call a dog and then rewarded it with food (Fouyssac and David 3015). A specific part of the brain controls associative learning, which it does via a neurotransmitter named dopamine. Dopamine is produced naturally by the brain when an individual does something rewarding or pleasurable.

The dopamine effect is a survival mechanism whereby eating or drinking feels good. It ensures continuity of life, family, and species in general. The element’s production is among the key drivers behind sex since, as much as the act is rewarding and pleasurable simultaneously, it is needed for survival (Fouyssac and David 3015). The main effect is that it creates a memory of the experience, which pushes people to seek the feeling again. People forget about the negative effects of drugs due to the moments of pleasure. As mentioned earlier, it is most likely that someone who uses the drug once will consume it again. The feeling established, regardless of how long, is enough to convince a person to forget everything they know concerning the negative effects and pursue a minute or two of a great time.

The paper has highlighted what the field of psychology says about the negative effects of drugs and why people continue using despite the consequences. It has been established that, in most cases, individuals experience addiction due to the pursuit of stress relief. Using the logic of the dopamine effect, once someone experiences something pleasurable or rewarding to them, they are most likely to pursue that feeling again. Eventually, it becomes impossible to convince them against the drugs as their desire to end their problem is more than the need to remain healthy.

Bechara, Antoine, et al. “A Neurobehavioral Approach to Addiction: Implications for the Opioid Epidemic and the Psychology of Addiction.” Psychological Science in the Public Interest, vol. 20, no. 2, 2019, p. 96–127.

Fouyssac, Maxime, and David Belin. “Beyond Drug‐Induced Alteration of Glutamate Homeostasis, Astrocytes May Contribute to Dopamine‐Dependent Intrastriatal Functional Shifts That Underlie the Development of Drug Addiction: A Working Hypothesis.” European Journal of Neuroscience, vol. 50, no. 6, 2019, p. 3014-3027.

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Home — Essay Samples — Nursing & Health — Drugs — The Effects of Drugs on Our Society

The Effects of Drugs on Society: Health Problems

• Categories: Drugs Society

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Words: 1471 |

Published: Dec 3, 2020

Words: 1471 | Pages: 3 | 8 min read

Table of contents

Introduction, drugs in history, effects of drugs on society: health issues, works cited.

• Center for Substance Abuse Treatment. (2006). Substance abuse treatment for persons with co-occurring disorders. Substance Abuse and Mental Health Services Administration.
• Drug Enforcement Administration. (2019). Drugs of abuse: a DEA resource guide. US Department of Justice.
• Green, L. W., Kreuter, M. W., Deeds, S. G., & Partridge, K. B. (1980). Health education planning: A diagnostic approach. Mayfield.
• National Institute on Drug Abuse. (2021). Commonly abused drugs. National Institutes of Health.
• National Institute on Drug Abuse. (2021). DrugFacts: Understanding drug use and addiction. National Institutes of Health.
• Pinto, F. A., & Pinto, M. A. (2019). Health risks of addiction to illicit drugs. Advances in preventive medicine, 2019.
• Reuter, P., & Pollack, H. A. (2006). Drug war heresies: Learning from other vices, times, and places. Cambridge University Press.
• Substance Abuse and Mental Health Services Administration. (2019). Key substance use and mental health indicators in the United States: Results from the 2018 National Survey on Drug Use and Health. US Department of Health and Human Services.
• The National Center on Addiction and Substance Abuse. (2010). Addiction medicine: Closing the gap between science and practice. Columbia University.
• World Health Organization. (2019). Substance abuse: Key facts. WHO.

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Essay on Drug Abuse and Illicit Trafficking

Students are often asked to write an essay on Drug Abuse and Illicit Trafficking in their schools and colleges. And if you’re also looking for the same, we have created 100-word, 250-word, and 500-word essays on the topic.

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100 Words Essay on Drug Abuse and Illicit Trafficking

Introduction.

Drug abuse and illicit trafficking are global problems. These issues affect society’s health, safety, and well-being. Drug abuse refers to the harmful use of drugs, while illicit trafficking involves illegal trade of drugs.

Effects of Drug Abuse

Drug abuse can lead to health problems, including mental disorders and physical illnesses. It can also cause social issues like unemployment, crime, and broken families.

Illicit Drug Trafficking

Illicit drug trafficking is a serious crime. It involves the manufacture, distribution, and sale of illegal drugs. This trade fuels crime, violence, and corruption.

To fight drug abuse and illicit trafficking, we need education, law enforcement, and treatment programs. It’s a fight that needs everyone’s participation.

250 Words Essay on Drug Abuse and Illicit Trafficking

The scourge of drug abuse.

Drug abuse is not confined to any demographic or socio-economic strata. It’s a pervasive issue that affects individuals, families, and communities. The repercussions extend beyond health problems, leading to broken families, lost potential, and increased crime rates. The abuse of prescription drugs and new psychoactive substances (NPS) has emerged as a significant concern, highlighting the evolving nature of drug abuse.

Illicit Trafficking: A Global Problem

Illicit drug trafficking fuels organized crime, destabilizes societies, and undermines economic growth. The clandestine nature of drug trafficking makes it a complex issue to tackle. It’s a lucrative business for criminal networks due to the high demand for drugs and the significant profits involved.

The Interplay and Impact

Drug abuse and illicit trafficking form a vicious cycle. Increased availability of drugs due to illicit trafficking leads to higher rates of drug abuse. Conversely, the demand created by drug abuse fuels illicit trafficking. This interplay exacerbates the social and economic issues associated with each problem.

Addressing drug abuse and illicit trafficking requires a holistic approach that includes education, prevention, treatment, and law enforcement efforts. It’s crucial to break the cycle of demand and supply to effectively combat these issues. By understanding the complexities and interconnectedness of drug abuse and illicit trafficking, we can develop more effective strategies to address these global problems.

500 Words Essay on Drug Abuse and Illicit Trafficking

Drug abuse and illicit trafficking are significant global issues that continue to pose a serious threat to public health, social stability, and economic development. They are intrinsically linked phenomena that reinforce each other, creating a vicious cycle that is challenging to break.

Illicit Drug Trafficking: A Global Concern

Illicit drug trafficking, on the other hand, is a global black market dedicated to the cultivation, manufacture, distribution, and sale of drugs that are subject to drug prohibition laws. It’s a highly profitable, yet dangerous business, often associated with powerful transnational organized crime networks. Its impacts are far-reaching, undermining social and economic development, political stability, and public health.

The Interplay between Drug Abuse and Illicit Trafficking

The relationship between drug abuse and illicit trafficking is symbiotic. The demand for drugs fuels the illicit trade, while the availability of drugs promotes abuse and addiction. This interplay creates a self-perpetuating cycle that exacerbates both problems.

Addressing the Issue

Addressing drug abuse and illicit trafficking requires a comprehensive, multi-pronged approach. This includes prevention efforts aimed at reducing the demand for drugs, harm reduction strategies to minimize the negative health impacts of drug use, and supply reduction measures to disrupt the illicit drug trade.

Education plays a crucial role in prevention. By raising awareness about the dangers of drug use and promoting healthy coping mechanisms, we can help individuals make informed decisions and reduce the likelihood of drug abuse.

In conclusion, drug abuse and illicit trafficking are interconnected global problems that require concerted efforts to address. By understanding their interplay and implementing comprehensive strategies, we can work towards a future free from the devastating impacts of these phenomena. The challenge is daunting, but with the right approach, it is surmountable.

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Rape and murder of doctor in hospital sparks protests in India

Early on Friday morning, a 31-year-old female trainee doctor retired to sleep in a seminar hall after a gruelling day at one of India’s oldest hospitals.

It was the last time she was seen alive.

The next morning, her colleagues discovered her half-naked body on the podium, bearing extensive injuries. Police later arrested a hospital volunteer worker in connection with what they say is a case of rape and murder at Kolkata’s 138-year-old RG Kar Medical College.

Tens of thousands of women in Kolkata and across West Bengal state are expected to participate in a 'Reclaim the Night' march at midnight on Wednesday, demanding the "independence to live in freedom and without fear". The march takes place just before India's Independence Day on Thursday. Outraged doctors have struck work both in the city and across India, demanding a strict federal law to protect them.

The tragic incident has again cast a spotlight on the violence against doctors and nurses in the country. Reports of doctors, regardless of gender, being assaulted by patients and their relatives have gained widespread attention. Women - who make up nearly 30% of India’s doctors and 80% of the nursing staff - are more vulnerable than their male colleagues.

The crime in the Kolkata hospital last week exposed the alarming security risks faced by the medical staff in many of India's state-run health facilities.

At RG Kar Hospital, which sees over 3,500 patients daily, the overworked trainee doctors - some working up to 36 hours straight - had no designated rest rooms, forcing them to seek rest in a third-floor seminar room.

Reports indicate that the arrested suspect, a volunteer worker with a troubled past, had unrestricted access to the ward and was captured on CCTV. Police allege that no background checks were conducted on the volunteer.

"The hospital has always been our first home; we only go home to rest. We never imagined it could be this unsafe. Now, after this incident, we're terrified," says Madhuparna Nandi, a junior doctor at Kolkata’s 76-year-old National Medical College.

Dr Nandi’s own journey highlights how female doctors in India's government hospitals have become resigned to working in conditions that compromise their security.

At her hospital, where she is a resident in gynaecology and obstetrics, there are no designated rest rooms and separate toilets for female doctors.

“I use the patients’ or the nurses' toilets if they allow me. When I work late, I sometimes sleep in an empty patient bed in the ward or in a cramped waiting room with a bed and basin,” Dr Nandi told me.

She says she feels insecure even in the room where she rests after 24-hour shifts that start with outpatient duty and continue through ward rounds and maternity rooms.

One night in 2021, during the peak of the Covid pandemic, some men barged into her room and woke her by touching her, demanding, “Get up, get up. See our patient.”

“I was completely shaken by the incident. But we never imagined it would come to a point where a doctor could be raped and murdered in the hospital,” Dr Nandi says.

What happened on Friday was not an isolated incident. The most shocking case remains that of Aruna Shanbaug , a nurse at a prominent Mumbai hospital, who was left in a persistent vegetative state after being raped and strangled by a ward attendant in 1973. She died in 2015, after 42 years of severe brain damage and paralysis. More recently, in Kerala, Vandana Das, a 23-year-old medical intern, was fatally stabbed with surgical scissors by a drunken patient last year.

In overcrowded government hospitals with unrestricted access, doctors often face mob fury from patients' relatives after a death or over demands for immediate treatment. Kamna Kakkar, an anaesthetist, remembers a harrowing incident during a night shift in an intensive care unit (ICU) during the pandemic in 2021 at her hospital in Haryana in northern India.

“I was the lone doctor in the ICU when three men, flaunting a politician’s name, forced their way in, demanding a much in-demand controlled drug. I gave in to protect myself, knowing the safety of my patients was at stake," Dr Kakkar told me.

Namrata Mitra, a Kolkata-based pathologist who studied at the RG Kar Medical College, says her doctor father would often accompany her to work because she felt unsafe.

“During my on-call duty, I took my father with me. Everyone laughed, but I had to sleep in a room tucked away in a long, dark corridor with a locked iron gate that only the nurse could open if a patient arrived,” Dr Mitra wrote in a Facebook post over the weekend.

“I’m not ashamed to admit I was scared. What if someone from the ward - an attendant, or even a patient - tried something? I took advantage of the fact that my father was a doctor, but not everyone has that privilege.”

When she was working in a public health centre in a district in West Bengal, Dr Mitra spent nights in a dilapidated one-storey building that served as the doctor’s hostel.

“From dusk, a group of boys would gather around the house, making lewd comments as we went in and out for emergencies. They would ask us to check their blood pressure as an excuse to touch us and they would peek through the broken bathroom windows,” she wrote.

Years later, during an emergency shift at a government hospital, “a group of drunk men passed by me, creating a ruckus, and one of them even groped me”, Dr Mitra said. “When I tried to complain, I found the police officers dozing off with their guns in hand.”

Things have worsened over the years, says Saraswati Datta Bodhak, a pharmacologist at a government hospital in West Bengal's Bankura district. "Both my daughters are young doctors and they tell me that hospital campuses in the state are overrun by anti-social elements, drunks and touts," she says. Dr Bodhak recalls seeing a man with a gun roaming around a top government hospital in Kolkata during a visit.

India lacks a stringent federal law to protect healthcare workers. Although 25 states have some laws to prevent violence against them, convictions are “almost non-existent”, RV Asokan, president of the Indian Medical Association (IMA), an organisation of doctors, told me. A 2015 survey by IMA found that 75% of doctors in India have faced some form of violence at work. “Security in hospitals is almost absent,” he says. “One reason is that nobody thinks of hospitals as conflict zones.”

Some states like Haryana have deployed private bouncers to strengthen security at government hospitals. In 2022, the federal government asked the states to deploy trained security forces for sensitive hospitals, install CCTV cameras, set up quick reaction teams, restrict entry to "undesirable individuals" and file complaints against offenders. Nothing much has happened, clearly.

Even the protesting doctors don't seem to be very hopeful. “Nothing will change... The expectation will be that doctors should work round the clock and endure abuse as a norm,” says Dr Mitra. It is a disheartening thought.

Inside India's first heat stroke emergency room

India's covid doctors demand action after attacks.

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Details emerge after doctor raped and murdered in India as thousands protest

August 15, 2024 / 6:32 AM EDT / CBS/AFP

Thousands took to the streets of Kolkata early Thursday to condemn the rape and murder of a local doctor , demanding justice for the victim and an end to the chronic issue of violence against women in Indian society.

The discovery of the 31-year-old's brutalized body last week at a state-run hospital has sparked nationwide protests, with Prime Minister Narendra Modi demanding swift punishment for those who commit "monstrous" deeds against women.

Large crowds marched through the streets of Kolkata in West Bengal to condemn the killing, with a candlelight rally at midnight coinciding with the start of India's independence day celebrations on Thursday.

The protesters in Kolkata, who marched under the slogan "reclaim the night", called for a wider tackling of violence against women and held up handwritten signs demanding action.

"We want justice," read one sign at the rally. "Hang the rapist, save the women," read another.

"The atrocities against women do not stop," midnight marcher Monalisa Guha told Kolkata's The Telegraph newspaper.

"We face harassment almost on a daily basis," another marcher, Sangeeta Halder, told the daily. "But not stepping out because of fear is not the solution."

"Monstrous behavior against women"

Modi, speaking in New Delhi on Thursday morning at independence day celebrations, did not specifically reference the Kolkata murder, but expressed his "pain" at violence against women.

"There is anger for atrocities committed against our mothers and sisters, there is anger in the nation about that," he said.

"Crimes against women should be quickly investigated; monstrous behavior against women should be severely and quickly punished," he added. "That is essential for creating deterrence and confidence in the society."

Doctors are also demanding swift justice and better workplace security in the wake of the killing, with those in government hospitals across several states on Monday halting elective services "indefinitely" in protest.

Protests have since occurred in several other hospitals across the country, including in the capital.

"Doctors nationwide are questioning what is so difficult about enacting a law for our security," Dhruv Chauhan, from the Indian Medical Association's Junior Doctors' Network, told the Press Trust of India news agency. "The strike will continue until all demands are formally met."

The Telegraph on Thursday praised the "spirited public protests" across India.

"Hearteningly, doctors and medical organizations are not the only ones involved," it said in an editorial. "The ranks of the protesters have been swelled by people from all walks of life."

Police accused of mishandling case

Indian media have reported the murdered doctor was found in the teaching hospital's seminar hall, suggesting she had gone there for a brief rest during a long shift.

An autopsy has confirmed sexual assault, and in a petition to the court, the victim's parents have said that they suspected their daughter was gang-raped, according to Indian broadcaster NDTV.  

Though police have detained a man who worked at the hospital helping people navigate busy queues, officers have been accused of mishandling the case.

Kolkata's High Court on Tuesday transferred the case to the elite Central Bureau of Investigation (CBI) to "inspire public confidence."

In the early hours of Thursday, a mob of some 40 people angry at authorities' handling of the case stormed the grounds of the R.G. Kar Medical College and Hospital, the site of the murder.

The men smashed property and hurled stones at police, who fired tear gas in response, authorities said.

West Bengal lawmaker Abhishek Banerjee, from the Trinamool Congress party, condemned the "hooliganism and vandalism," but said "the demands of the protesting doctors are fair and justified."

History of sexual violence in India

Sexual violence against women is a widespread problem in India. An average of nearly 90 rapes a day were reported in India in 2022, according to  data  from the National Crime Records Bureau.

That year, police  arrested 11 people  after the alleged brutal gang rape and torture of a young woman that included her being paraded through the streets of Dehli. Also in 2022, a police officer in India was arrested after being  accused of raping  a 13-year-old girl who went to his station to report she had been gang-raped.

In March 2024, multiple Indian men were arrested after the  gang rape of a Spanish tourist  on a motorbike trip with her husband.

For many, the gruesome nature of the attack has invoked comparisons with the horrific 2012 gang rape and murder  of a young woman on a Delhi bus.

The woman became a symbol of the socially conservative country's failure to tackle sexual violence against women.

Her death sparked huge, and at times violent, demonstrations in Delhi and elsewhere.

Under pressure, the government introduced harsher penalties for rapists, and the death penalty for repeat offenders.

Several new sexual offences were also introduced, including stalking and jail sentences for officials who failed to register rape complaints.

• Sexual Violence

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For more audio journalism and storytelling, download New York Times Audio , a new iOS app available for news subscribers.

How Air-Conditioning Conquered America

Indoor cooling has transformed american life, reshaping homes, skylines and where people choose to live. as the planet warms, is that sustainable.

This transcript was created using speech recognition software. While it has been reviewed by human transcribers, it may contain errors. Please review the episode audio before quoting from this transcript and email [email protected] with any questions.

From “The New York Times,” I’m Michael Barbaro. This is “The Daily.”

[MUSIC PLAYING]

Today, the story of how air conditioning has become both our answer to a warming planet and a major obstacle to actually confronting it. My colleague, Emily Badger, on the increasingly dangerous paradox of trying to control the temperature.

It’s Friday, August 16.

Emily, I want to start with a very personal question for you. What is your relationship to air conditioning?

So, at this exact moment, I am sitting in no air conditioning and it is kind of uncomfortable. And I’ve turned it off because it’s loud and it’s not very conducive to recording a podcast.

[CHUCKLES]: I didn’t mean right now, I meant in the larger arc of your life. But thank you for turning it off for the purposes of this episode.

Yeah. So I grew up in Chicago in this brick three flat apartment building, this very classic Chicago architecture, you know, built in the early 1900s. And it didn’t have air conditioning, so I didn’t have air conditioning growing up. Hardly anybody I knew had air conditioning growing up because we all lived in buildings like this.

Not even window units, just didn’t happen.

Nope, we didn’t even have a window unit in my family. And it wasn’t that big of a deal, in retrospect. We had, in this apartment, these big open windows that you could open and you’d generate a cross breeze through them. And there’s this kind of lovely breeze that comes off of Lake Michigan in the summer. And when it gets really, really hot, you know, you take a cold shower at night before you get in bed. You eat a lot of ice cream.

I can’t even remember if we had air conditioning in the schools that I went to. But it just wasn’t something that I thought very much about or really even experienced very much.

Right. You didn’t miss it. You didn’t even know it could be.

Yeah, exactly.

And then, the first job that I got out of college, I moved to Orlando, and totally different environment. I mean, living in Florida is the story of moving from one air conditioned box into another. You’re in your air conditioned apartment. You get in your air conditioned car. You don’t walk anywhere. You drive everywhere you go. You drive to your air conditioned office. You go to air conditioned bars. And it’s a really, really integral to life there in a way that was very foreign to me as someone growing up in the North.

So you went from a dearth of air conditioning to suddenly being saturated by it. And was that a happy development?

You know, I don’t think that I really gave it that much thought. I mean, living in Orlando surrounded by air conditioning, it’s just sort of that’s the air that you breathe. That’s the way everyone lives. And I think this is probably true for lots of people. We don’t really give it a lot of thought. It’s just sort of a background part of our environment.

But as I have written for years now about urban policy in cities, and how we live, and how we develop cities, it’s sort of become increasingly clear to me that air conditioning is this incredibly important thing that is shaping everything around us. You know, it’s shaping where Americans live, where they choose to move to. It shapes how our houses look. It shapes what our skylines look like. It’s responsible for saving lives and heat waves. In many ways, it’s really improved our quality of life.

But it’s increasingly clear to us that there are some downsides to this. And one of those downsides is that while we’re all sitting in our air conditioned homes, and offices, and cars, and we’ve set the thermostat to exactly 72 degrees, we’re becoming increasingly detached from what’s happening in the environment outside. It is a lot easier to ignore that it’s 100 degrees outside when you’re sitting inside air conditioning.

And, in some ways, I think we have forgotten how to live with heat. We have forgotten how to live with the climate as it existed before air conditioning. And having forgotten that, it’s probably going to cause some problems for us going forward.

Well, Emily, what did the American landscape look like when people did have to contend with the heat in the days before air conditioning?

So I think about two big things in particular. One is that the buildings that we spend time in looked different. We designed houses and other kinds of buildings in ways that were really sort of thoughtfully trying to contend with the temperature outside.

And so you’ve got these buildings in the Southwest in the United States that have these thick Adobe walls that do a really good job of keeping the sun and its heat out. You’ve got these cottages and bungalows in the Southeast that are raised up off the ground so that they’re not receiving the heat that’s absorbed by the Earth.

They’ve got big windows. They’re thinking a lot about cross ventilation. They’ve got high ceilings so that, as heat rises inside your home, you’re not marinating in it while you’re sitting in your living room. They’ve got front porches where people sit at the end of the day in order to try to cool off.

And then you’ve got the building like the one I grew up in, in Chicago, which I mentioned — these sort of thick brick masonry buildings, which are also designed in a way that is making it possible for me to grow up in the 1980s and ‘90s and be OK with the fact that I don’t have air conditioning.

Because brick kind of retains cool air.

Right. Right. And so part of what results from all of this is that the buildings in Georgia look different from the buildings in Arizona, look different from the buildings in Chicago. Because in each of those places, we’re designing buildings that react to the particular climate in those environments. And so this is the first big change.

Think of a time when you have to design a building to interact with what’s going on outside, with how humid it is, with how hot it gets. But the other thing that was very different in the pre-air conditioning environment is that there were just a lot fewer people living in the parts of the United States that were really hot and swampy. So it’s kind of incredible to think about it, but 1940, there are fewer people living in the state of Florida than living in the state of Arkansas.

There are about 8,000 people total living in the city of Las Vegas. Dallas and Houston are nowhere to be found on the list of the largest cities in America. So fundamentally, before air conditioning, there just aren’t a lot of people living in places where it is uncomfortable if you’re not controlling the temperature in some way.

Right. If it’s too hot, then you just don’t live there.

Right. So climate shapes your decisions about where to live. It shapes your decisions about how to build housing. It shapes your decisions about where to spend your time and your house. Maybe you go onto your front porch in the evening when it’s cooling down. You know, in many ways, our behavior is shaped by the climate. And then air conditioning comes along and it totally changes everything that I’ve been talking about. Because now the outdoor climate doesn’t really affect what your life is like indoors.

Just tell us about that moment, because I don’t think any of us really know the story.

Yeah. So there have been contraptions invented in the 1900s that were trying to do things like blow forced air over big blocks of ice in order to cool it. But the thing that we really think of as air conditioning is just totally a 20th century story.

It starts at the very beginning of the 20th century in 1902, when Willis Carrier invents this machine that’s kind of controlling the temperature, and the humidity, and the purity of air, particularly in an industrial context. The very first use of this in 1902 is in a printing plant, and fundamentally the problem that it’s solving is that the moisture content in the air is really becoming a problem for printing documents.

You’re saying basically, publishing, journalism is responsible for air conditioning.

Yes, everybody can thank us and then later they can blame us.

And so, in the beginning, what air conditioning is doing is it’s solving an industrial problem. The machines are hot, or maybe it’s a textile mill and too much humidity is sort of destroying your textiles. And also, you want your workers to be productive in these manufacturing spaces.

Lots of people in a small space with hot machines. Right.

Yeah. And so in the very beginning of the 20th century, it’s not about providing comfort for people. It’s about conditioning the environments that manufacturing and industry is having. And then it is this very sort of long story that plays out over several decades, where this invention moves from these industrial spaces into these other kinds of spaces.

Yes, you lucky people. Just sit back for a moment, relax, and notice the delightfully clean, cool, and refreshing atmosphere of this scientifically air conditioned theater. Great, isn’t it?

So then it comes into theaters and becomes almost this marketing tool to attract people inside.

You can enjoy great motion picture entertainment all summer long in cool comfort.

Go see a movie and enjoy air conditioning while you’re in there.

Yes, low-cost all-season air conditioning is the right kind for you. And you’re so right to choose a ‘55 Rambler Cross Country, now at all dealers.

And then, at the same time, cars in America that have air conditioning in them — the share of those cars is rising and rising. It moves into office buildings.

Instead of traveling away from business and home to seek relief, you can obtain this same comfort right in your own home or office through air conditioning.

And then, eventually, after decades of refining this technology, and it gets smaller, and it gets more affordable, and it becomes more advanced —

This lucky baby will sleep quietly through the night.

— it reaches the American home and we get the window unit.

This baby’s RCA air conditioner will keep his room filled with cool, dry, fresh air.

And the window unit is this much more affordable, portable, easy to pick up at the store, bring to your house. You don’t need to get a special installer. You stick it in your window, and now all of a sudden you’re getting all of these benefits of humidity controlled, temperature controlled air inside of your home.

Humidity, controlled, dust and pollen filtered. My indoor climate is always perfect.

At that point it’s off to the races. It takes over the American home. And we can see in census data, for instance, that by about the start of the 1970s, about half of all new single family homes that are built in America have air conditioning in them.

And the other thing that we see in census data at this time is that Americans themselves are starting to move to places that are really hot, like Florida, like Texas, like Arizona, like Nevada, places that are kind of uninhabitable before air conditioning. Now they’re booming in population.

And there was this wonderful editorial that was actually published in “The Times” in 1970 about the census that year, and how 1970 was like, the air conditioning census. And it refers to how air conditioning had become this really powerful influence for circulating people as well as air in this country.

And this is a story that continues right up until this day, where air conditioning is sort of extending its reach into every corner of the country, every sort of housing type. And today, about 2/3 of American households in this country have central air, and about 90 percent, so 9 in 10 of them, have some kind of error conditioning if we include things like window units. And if we look just at New housing that’s built in America today, looking back in 2023, about 98 percent of new single family homes in America had air conditioning.

What you’re talking about is basically 200 or so million air conditioning units, condensers, boxes. That’s a lot.

Yeah. And as air conditioning has extended its reach into every corner of the country, into so many of the buildings where we spend time, I think it becomes clear that we’ve really kind of engineered our modern lives entirely around it.

And our reliance on this technology going forward is both unsustainable, and in fact, it’s put a lot of people in a very vulnerable position.

We’ll be right back.

Emily, walk us through how our reliance on air conditioning is both, as you just said, unsustainable and perhaps even kind of dangerous to us.

So the first obvious thing that it does is it just requires an enormous amount of energy for so many people to be air conditioning so many spaces all the time. And so to think about this in a larger sense, our buildings in the United States are responsible for about 30 percent of the greenhouse gas emissions. And that refers to the fossil fuels that we burn directly to heat and cool buildings, and to cook in them, but also to generate the electricity that then allows us to do things plug in our window units.

So there’s a ton of energy use happening here. But part of what’s also happening is that all of these buildings have been fundamentally designed to consume lots of energy. A lot of these buildings were built during a time, you know, in the ‘50s and the ‘60s and in more recent years, where energy was cheap. The idea that you’re designing a building that demands lots of energy — who cares? We’re not paying a ton of money for the energy.

And in the ‘60s and in the ‘50s, we weren’t particularly thinking about whether or not using energy is going to cause climate change. So because of this, we get this glut of inefficient houses. And this happens not just with houses, but with everything in the built environment.

Think about strip malls, shopping centers, workplaces, even offices — the sort of ubiquitous, tall, boxy, glass-covered office building that we think about in cities all over the country, all over the world — this is a building that is born out of the air conditioning age. That glassy box is designed around air conditioning such that without air conditioning, those kinds of offices don’t make sense.

Right. I’m thinking about the office that you and I call home, the “New York Times” high-rise building in Midtown. That does not feel, for all its virtues, like a building, you’d want to be in without air conditioning.

It’s glass, and tall, and I think it’d be very hot.

Yeah. When you think about tall glass office buildings, they’re basically greenhouses if you’re not controlling the air inside. They’re designed such that not only do you not have to open a window in order to cool off, you couldn’t open a window even if you wanted to. These buildings don’t have windows that open, because they’re designed to be these hermetically sealed environments where we’re going to keep the outside climate out and we’re going to control the climate on the inside. And this idea that the outside doesn’t matter is true in the design of so many of our buildings, our offices, even our homes. And that actually puts people into an incredibly vulnerable situation.

And vulnerable how, exactly?

So let’s assume a storm comes through and the power goes out, or your air conditioning stops working because you’ve been running it all the time, all summer long, or when we have these extreme heat conditions and the electric utility tells you, please try to preserve the amount of air conditioning that you’re using. What happens when, all of a sudden, millions of people who have been living in an environment designed entirely around air conditioning can’t have that air conditioning? We start to see real problems.

And this is an abstract. We have actually seen this happen in the United States even this year, in other recent years, where terrible storms have ripped through the state of Texas and millions of people have been left without power. And when this happens in the middle of a heat wave, people die.

Right. And that seems an example of the multiple ways that air conditioning conspires to make us avoid contending with the realities of heat to return to this idea you introduced earlier on. AC allows more people to go to a place like Texas than they’d ever go if there weren’t AC making them comfortable, and to design and live in homes and offices that become a cauldron without air conditioning when it fails.

Exactly. Air conditioning makes it possible for people to believe that you could be comfortable in Texas in the summer, in Arizona in the summer. And so people move to these places in large numbers. And then, when the air conditioning fails, they’re sort of suddenly thrust into a world where they’re living in the middle of the Arizona desert or they’re living in the middle of Texas on a 110 degree day. And that could be life threatening.

Especially with climate change making it even hotter in these places, it doesn’t really seem sustainable for a lot of people to live in those places without air conditioning, without some kind of artificial tempering of the environment.

Yeah. And it’s not just because of the heat. I mean, is it sustainable for a Metropolitan area of 5 million people to exist in Phoenix in the middle of the desert when there’s also not enough water there for everyone? So air conditioning sort of lulls people into moving to these places, which might be problematic for lots of other reasons, as well. But we’ve sort of convinced ourselves that the climate doesn’t matter. We’re going to control it. We’re going to engineer our way into living with it.

You’re reminding me, Emily, of an episode we did on the show about this very idea. It focused on the water shortage in Arizona and the plans to pipe in — and, as I recall, desalinate ocean water — to deal with the problem of not enough water in Arizona. And it doesn’t really seem fathomable that proposition would ever occur to people if they weren’t living there in the comfort of air conditioning in the first place.

Yeah. So there have been people living in the region of Phoenix for centuries, so it’s not that nobody can ever live there. But what air conditioning does is it enables millions of people to live there who don’t actually want to contend with 100 degree temperatures all summer long. So a place like Phoenix then becomes this perfect example where we now have 5 million people living in the middle of the Arizona desert, and they all have this expectation of comfort there, that any environment that I move into — in my home, in my office, in my car — I should be encased in this cooling, calm, 72 degree humidity controlled environment. And that sense of comfort becomes so deeply entrenched kind of culturally. And this isn’t just about Phoenix. This is about all of us. I think we have set up an expectation or even an entitlement around comfort such that it makes it really difficult to start to ask people, do you really need to turn up your air conditioning today?

So that makes me wonder how people are ever going to get off the air conditioning hamster wheel that we’re describing here. I mean, why would anyone?

Well, we have to figure out how to do something if we want to address climate change. So there are a number of different things that are going to happen here. Air conditioning is going to become more efficient. We’re going to have more renewable energy sources to power it in the future. And I think we’re increasingly going to see architects and builders trying to rediscover these lost ideas that we used to have about how to design buildings with the climate in mind, how to shade them, how to ventilate them in a more natural way.

But I also have talked to some people who say that all of that is not going to be enough. One of them is Daniel Barber, who’s an architectural historian who has thought a lot about life after air conditioning or, as he puts it, after comfort — life in a world where we’re not depending on air conditioning so much. And the point that he makes is that there are difficult things and changes that we would have to do going forward if we know that our buildings are responsible for a lot of greenhouse gas emissions.

Our dependence on air conditioning is responsible for a large share of that, and we have to reduce it in some way. What we all need to do is change our own behavior. We need to think anew about our relationship to comfort. And are we willing to be uncomfortable some of the time? Am I willing to wait until July to turn my air conditioning on? Am I willing to turn it off at night when it’s not really necessary to use it? Am I willing to sleep at 80 degrees instead of 72 degrees?

Or 68 or 65. And he’s talking about asking people to do something really difficult. He is asking people to be uncomfortable.

You are, of course, by conveying this message, putting this problem on individuals, not governments, not states. And lots of people might hear this and think the real solutions have to come from regulators, have to come from institutions, have to come from the people who have a lot more control over how this all works.

I think that there are some ways in which that will happen, too. When we think about new buildings that are being designed or renovated today that are trying to adopt some of these techniques to be less reliant on indoor air conditioning. They’re often institutional buildings you will see cities commit to when we rebuild our schools, when we build a new library, when we build a new civic center, we are going to embody these things that we are asking other people to do, too.

And, obviously, there are government incentives in the United states, for instance, to better insulate your home, to do things that would make your home greener. So there’s certainly a role for government. But what Daniel Barber at least would argue is that we all bear some responsibility. And air conditioning has lulled us into thinking that we’re not impacted by how hot it is outside. But it’s also maybe lulled us into thinking like, I’m not the one who needs to particularly change my behavior in any way.

But, fundamentally, what we’re talking about is people embracing a kind of different cultural idea about what it means to be comfortable. The idea that existing in a room that is artificially cooled to 68 to 72 degrees fahrenheit, that that’s the ideal temperature — that’s not some true fact about the human body. It’s a cultural idea that’s been created over decades by the air conditioning industry, by architects, and builders, and culture, and shopping malls, and movie theaters. And the idea that comfort means this one particular thing is an idea that we have constructed ourselves. And so what if we culturally came up with a different idea about comfort?

What if more people came to accept the idea that going and sitting out on my front porch in the evening is where I get comfort from? And it’s also, by the way, how I interact with my neighbors. And I had stopped doing that when we were all retreating inside to air conditioning. What if we revived the idea that it’s actually quite lovely in the summertime to sleep with an open window and to have fresh air? It’s not impossible to change ideas about this because we created these ideas in the first place.

Well, Emily, thank you very much. We really appreciate it.

Yeah. Thanks, Michael.

Here’s what else you need to know today. On Thursday, the White House said that its newfound authority to use the Medicare program to negotiate prices of prescription drugs with pharmaceutical companies is likely to save taxpayers about $6 billion a year. That power came from President Biden’s Inflation Reduction Act, which became law two years ago. Under it, regulators have now lowered the price of widely used treatments, including blood thinners and medications for arthritis and diabetes, some by up to 79 percent.

And both vice presidential nominees, Minnesota Governor Tim Walz and Ohio Senator JD Vance, have agreed to debate each other on October 1 during a televised face-off hosted by CBS News. That means there will be three debates before election day — one vice presidential debate and two presidential debates between Donald Trump and Kamala Harris.

Finally, remember to catch a new episode of “The Interview” right here tomorrow. This week, David Marchese speaks with the singer Jelly Roll about addiction recovery and putting his whole self into his music.

I think of everything as a going out of business sale, and I give everything I got everything I do every time I do it right now.

Today’s episode was produced by Shannon Lin and Diana Nguyen with help from Michael Simon Johnson. It was edited by Devon Taylor, contains research help from Susan Lee, original music by Marion Lozano, Dan Powell, Rowen Niemisto, and Will Reid, and was engineered by Alyssa Moxley. Our theme music is by Jim Brunberg and Ben Landsverk of Wonderly.

That’s it for “The Daily.” I’m Michael Barbaro. See you on Monday.

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Hosted by Michael Barbaro

Featuring Emily Badger

Produced by Shannon M. Lin and Diana Nguyen

With Michael Simon Johnson

Edited by Devon Taylor

Original music by Marion Lozano Dan Powell Rowan Niemisto and Will Reid

Engineered by Alyssa Moxley

Listen and follow ‘The Daily’ Apple Podcasts | Spotify | Amazon Music | YouTube | iHeartRadio

Air-conditioning has become both our answer to a warming planet and a major obstacle to actually confronting it.

Emily Badger, who covers cities and urban policy for The Times, explains the increasingly dangerous paradox of trying to control the temperature.

On today’s episode

Emily Badger , who covers cities and urban policy for The New York Times.

Background reading

From 2017: How air-conditioning conquered America .

Air-conditioning use will surge in a warming world , the U.N. has warned.

There are a lot of ways to listen to The Daily. Here’s how.

We aim to make transcripts available the next workday after an episode’s publication. You can find them at the top of the page.

Research help by Susan Lee .

The Daily is made by Rachel Quester, Lynsea Garrison, Clare Toeniskoetter, Paige Cowett, Michael Simon Johnson, Brad Fisher, Chris Wood, Jessica Cheung, Stella Tan, Alexandra Leigh Young, Lisa Chow, Eric Krupke, Marc Georges, Luke Vander Ploeg, M.J. Davis Lin, Dan Powell, Sydney Harper, Michael Benoist, Liz O. Baylen, Asthaa Chaturvedi, Rachelle Bonja, Diana Nguyen, Marion Lozano, Corey Schreppel, Rob Szypko, Elisheba Ittoop, Mooj Zadie, Patricia Willens, Rowan Niemisto, Jody Becker, Rikki Novetsky, Nina Feldman, Will Reid, Carlos Prieto, Ben Calhoun, Susan Lee, Lexie Diao, Mary Wilson, Alex Stern, Sophia Lanman, Shannon Lin, Diane Wong, Devon Taylor, Alyssa Moxley, Olivia Natt, Daniel Ramirez and Brendan Klinkenberg.

Our theme music is by Jim Brunberg and Ben Landsverk of Wonderly. Special thanks to Sam Dolnick, Paula Szuchman, Lisa Tobin, Larissa Anderson, Julia Simon, Sofia Milan, Mahima Chablani, Elizabeth Davis-Moorer, Jeffrey Miranda, Maddy Masiello, Isabella Anderson, Nina Lassam and Nick Pitman.

Emily Badger writes about cities and urban policy for The Times from Washington. She’s particularly interested in housing, transportation and inequality — and how they’re all connected. More about Emily Badger

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