Opinion | The World’s View on Drugs Is Changing. Which Side Are You On?

jane coaston

Today on “The Argument,” is it time to legalize all drugs?

archived recording

Last November, an overwhelming majority of Oregonians voted to decriminalize most drugs via referendum. Medical marijuana is now legal in Alabama. And in a matter of months, cannabis products could be available to those who qualify.

^archived recording^ (joe biden)

Truth of the matter is, there’s not nearly been enough evidence that has been acquired as to whether or not it is a gateway drug. And I want a lot more before I legalize it nationally.

jane coaston

President Biden may not be ready for legalized, recreational marijuana, but many states are way ahead of him. Connecticut just became the 18th state to legalize recreational marijuana. And it’s not just weed. Several cities have recently decriminalized magic mushrooms, and Oregon just decriminalized possession of small amounts of all drugs, including heroin, methamphetamines, and cocaine. It seems like the War on Drugs is over and drugs won big. I’m Jane Coaston, and there seems to be more and more consensus that jailing our way out of the addiction crisis in the United States is not working. But even hardcore drug policy reformers have vastly different takes on how we get to a better place with drugs, like our guests today. Ismail Ali is the Policy and Advocacy Director at the Multidisciplinary Association for Psychedelic Studies, and Jonathan P. Caulkins is the H. Guyford Stever University Professor of Operations, Research, and Public Policy at Carnegie Mellon University’s Heinz College, and a member of the National Academy of Engineering. I started out by asking Ismail to define the difference between drug decriminalization and legalization.

ismail ali

So when people think of decriminalization, they’re usually thinking of the reduction or elimination of criminal penalties, sometimes including civil penalties. And legalization tends to be when the law actually is fully recognizing, regulating activity from point A to point Z. So you can decriminalize, for example, personal use and possession. But if every behavior up to that point is still illegal, you have an island of maybe legal or decriminalized behavior in a sea of illegal behavior. So they get through all this illegal behavior to get to the legal behavior. And I think legalization implies a full spectrum, regulated approach to the whole piece.

jane coaston

Ismail, you do think that ultimately the goal would be to legalize all drugs. Why?

ismail ali

I do think that legal, regulated access is likely the best environment for a number of drugs, but I think it’s going to depend very much on the substance itself, and factors that have to do with the supply and demand questions with respect to where and how it’s produced. Not having a legally regulated system puts us in a position where the very, very large and lucrative drug trade, which exists, whether or not there’s a regulated industry, entirely is captured by underground actors with various levels of ethics and morals. And I think that that whole conversation around legal access must also look at — and has looked at, historically — the uptake of all substances in illegal markets, and then the effects of those behaviors. My mother’s family is Colombian, and they left Colombia in the 1980s as a result in part of the massive increase in cocaine violence and cartel use. And that continued underground. Engagement has not really ceased — not just with cocaine, but with a number of other drugs. And even Colombia now is having a very serious conversation at the governmental level about what it would look like to legally regulate cocaine, because — despite pressure from the U.S. and other actors, they have realized that, actually, having some sort of legally regulated system could be the way to reduce the violence in the country. So while I do think that legalizing drugs, which sounds like such a scary thing to a lot of people, really means bringing them under more regulatory control. It’s hard, I think, to really think through what an effective addiction response strategy at the social level would be while we’re under an environment of prohibition, because prohibition does exacerbate some of those secondary effects of drugs, like, for example, addiction independence.

jane coaston

I’m curious as to your thoughts, Jonathan, on decriminalization versus legalization.

jonathan caulkins

These have to be decided drug by drug. Drugs are different. For a long time, we’ve had caffeine be legal. That was probably fine. I don’t think that it’s — one should be cavalier about other substances. Opioids make the point. The prescription opioid crisis was a crisis that killed tens of thousands of people every year for a drug that was highly regulated, much more so than the typical recreational drug. Opioids are intrinsically dangerous, much more so than caffeine or cannabis. It has to be decided on a case by case basis.

jane coaston

I think that that’s something that’s also important to note here, is that, for instance, in Oregon — Oregon just passed Measure 110, which makes possession of small amounts of LSD, methamphetamines, cocaine, and heroin punishable by a civil citation. That is not legalization. That is decriminalization. So I’m interested, Jonathan, can you talk about — when we’re talking about decriminalization, it sounds to me that it is still a civil penalty in Oregon to possess these — crimes. It’s like a traffic ticket, but that’s still a crime-ish.

jonathan caulkins

Yeah, with the ish. The other thing it’s important to say is that, usually, when people talk decriminalization, they’re talking about decriminalizing or changing the consequences for people possessing amounts suitable for personal use. Whereas if you just say legalize, without any qualification, the presumption is you’re legalizing supply. So there is a big difference there. And sometimes it helps to keep them straight by remembering a third term, which is legalizing use. So decriminalization is usually reducing penalties for use so that you don’t have people getting a criminal record for use. Then you can go a step farther, as Ismail was saying, and legalize use, meaning you don’t even get the equivalent of a fine or a traffic ticket. Both of those are very different than legalizing supply.

jane coaston

Jonathan, you made a really fascinating argument in a piece called “The Drug Policy Roulette,” and I’d like you to explain more about this, because it actually was counterintuitive for me, which is — my view was that legalizing drugs would do what the end of Prohibition did for alcohol, which is when you aren’t legally allowed to drink, you can drink all the time. But with the end of Prohibition and with a regulated alcohol market, you have places — you have counties that are dry. You have a liquor store that can only be open from this time to this time. There are prohibitions on drunk driving, and societal prohibitions against when you can — like, drinking in the morning, drinking by yourself, this is looked down on. And I think societal prohibitions play into how we think about using drugs and alcohol anyway. But in the case of drugs, you made the point in this piece that one of the issues that would be unexpected from this is that prohibition makes drugs expensive, and that drugs like heroin and cocaine would actually be pretty cheap to obtain if they were legalized, because a part of what makes them expensive is what’s called compensating wage differentials. Namely, it’s really hard to bring cocaine into the United States. You are paying for the cost of how hard it is to bring cocaine into the United States. But with that price collapse, the taxes required to make it so that you weren’t just having cheap cocaine everywhere would be incredibly high, which would then contribute to the kind of gray market smuggling that we see with cigarette smuggling in the United States and in other countries. This is a financial issue I had never thought about.

jonathan caulkins

Sure. The first point is that prohibition prevents one from producing these things in straightforward ways. None of the drugs are hard to produce. If it was legal and you could allow a regular company to do it, then they become very cheap. You can see that, for instance, just in the price of cocaine in Colombia is about 1 percent or 2 percent what it is in the streets in the United States. And the illegal distribution system effectively charges $15,000 to move a kilogram from Bogota to New York City that would cost $70 on FedEx. So prohibition makes things far more expensive than it would be if they were legal. As a practical matter, there’s no way that we will have taxes high enough to prevent prices from declining substantially. And that is in part because there probably wouldn’t be the political will, but also in part because of practicalities. Drugs are very potent in the sense that it doesn’t take very much material. A daily cannabis user using one and a half grams a day consumes only a little more than a pound over a year, about the same weight as one 20 ounce can of beer. So we just can’t effectively collect very high taxes on these easy to smuggle commodities.

ismail ali

Yeah, and many people have talked now for some years about this concept, the Iron Law of Prohibition, which maybe it would be good to bring in here, which is essentially the idea that because smuggling is such a lucrative activity, and because smuggling smaller things, more concentrated substances is easier, it actually incentivizes higher concentrations of substances to be taken across borders. So for example, if you want to take enough heroin for 500 people, you need a trunk of a car. If you want to take enough fentanyl for 500 people, you need something about the size of your phone or maybe much, much, much smaller. So there might be the case where as smuggling gets more difficult, it’s actually incentivizing higher concentrations of drugs, because it’s easier to smuggle those drugs as opposed to ones that take up more physical space.

jonathan caulkins

Well, we should unpack this, though. I mean, the movement from heroin to fentanyl is not a response to a change in the legal status of either substance. But the Iron Law of Prohibition has been completely refuted by the experience with cannabis legalization. It’s the iron law that holds no water. Cannabis did not exceed average potency of 5 percent until 2000, and now it’s — typical flower potency in a legal stores is over 20 percent. And we now have common use of vapes and dabs, which are much more potent than that. So the Iron Law of Prohibition has just been disproved by experience with cannabis legalization.

ismail ali

I’d probably push back on that a bit, because cannabis is also produced in state. We’re not talking as much about taking things across borders, but the big difference is that with a lot of cannabis products, they’re being produced at the place or near the place they’re being used, which is different from things that are crossing international borders.

jonathan caulkins

The weight of drugs doesn’t matter much at all after they are legal, because the weight is so small. Again, I make reference this —

ismail ali

Yeah, no. I agree after they are legal, for sure.

jonathan caulkins

So it doesn’t matter that at the moment we’re in this weird situation where we have a bunch of state specific markets. That’s a temporary artifact of the fact that there’s not yet national legalization. Once there’s national legalization, we can no longer have these state specific markets because of the Interstate Commerce Clause in the Constitution.

jane coaston

Jonathan, you brought up the opioid crisis. And I think that there have been a host of people who’ve written on how they used to support drug legalization. And the opioid epidemic and how it took place changed their minds. And I want to point to a great piece — my former colleague at Vox, German Lopez, wrote about this, where he said that essentially with opioids, you had companies that got a hold of a product. They marketed it irresponsibly and lobbied for lax rules in influencing government, and people died. As he points out, the United States historically is very bad at regulating drugs. Ismail, does the experience of the opioid epidemic — has that changed your viewpoint on what legalization would look like?

ismail ali

No, because I don’t see legalization as only a question of the regulations that have to do with the drug. I think that there are factors beyond just the way opioids are regulated and are regulated that has to do with why there’s a crisis today. And I actually personally tend to frame it as an overdose crisis. I do think opioids are a big part of that. But if you’ve been following the numbers for the last couple of years, it’s absolutely the case that overdoses with methamphetamine and other drugs are also extremely intensely increasing. And the way that, as you said, a certain framework of pharmaceutical regulation has operated with certain opioids is such a good example of what I imagine legalization to be. Like, I think if I were putting together a thinking through with people — what would be an ideal legalization scheme? And I really agree with what Jonathan said, where it’s a case by case basis. And there may be drugs that don’t need or shouldn’t have fully legally regulated systems, and maybe decriminalization is the appropriate environment for that. And maybe decriminalization of certain kinds of behaviors — and I think one really good example that feels like it’s at the center of this is this question about advertising and marketing. I think that what companies are allowed to say, what claims they’re allowed to make, how they’re allowed to advertise, what expectations are setting with consumers — those factors are pretty significant. That’s not to say that if there wasn’t the aggressive marketing campaign with some of these opioids that we’d be in the same or a different position today. It’s really difficult to tell. It’s a system that has been highly affected by interests that are not in that of the consumer, not in the interest of the public. When society was flooded with cigarette ads, a lot of people started smoking more cigarettes. That’s not — and of course, there’s a risk to smoking cigarettes. But to me, that’s an artificial pressure that comes from the market and its incentives. And I think that once you take out some of those things to the extent that that’s possible in a legal market, you might actually be able to adjust some of those outcomes.

jonathan caulkins

But I think that’s the point. It’s easy to imagine an ideal legalization, but that’s not what we’re going to get. We’re going to get the legalization that comes out of our political process and institutions. And marketing is the concrete example. Once a product is legalized, the companies that produce it will enjoy First Amendment commercial free speech protections that will allow them to market.

ismail ali

Should they?

jonathan caulkins

It doesn’t matter whether they should or should not. In the United States, under our Constitution, which protects commercial free speech, they will. In another country, with a different constitution, the government would have greater power to restrict advertising. Many of the current restrictions on cannabis advertising only are constitutional because it is still illegal under federal law.

jane coaston

Yeah, I spent a brief time looking at some of the ads that were made for OxyContin. And there’s one that says that, when you know acetaminophen won’t be enough, OxyContin 12 Hour — which is, like, acetaminophen is Tylenol. And going from Tylenol to OxyContin is a real — it’s a real leap. But I think that gets to something I’m curious about — because the United States has been a leader in determining the control of drug trade and practice, Jonathan, how do you think hypothetically that a legalization or decriminalization would impact international markets? Do you think that there would be a collapse in the price, internationally, of cocaine or heroin? What would that even look like?

jonathan caulkins

Yeah, it’s a great question. And sort of the short answer is that in any place that legalizes and allows for profit industry, you’re going to see a price collapse. And because these things are so easy to smuggle, that would put downward pressure on other countries that are connected commercially to the country that legalized. And in an interconnected world, that’s a lot of places. You’re seeing some of this already, even without legalization, from the switch to synthetics which can be produced anywhere and are easier to produce surreptitiously than with crop based products. And legalization would be a little bit like the innovation of fentanyl coming into the market. It would greatly reduce the cost of production. And over time, that puts downward pressure on prices.

jane coaston

Ismail, I know that your organization has been thinking a lot about this with regard to psychedelics, so whether that’s LSD, whether that’s the use with MDMA in Oregon and other places, psychedelics and the use of psychedelics is getting increasing state support. The California State Senate in June of this year passed a bill that would legalize the social sharing and possession and use of psychedelics. It’s something that’s coming around. What does that look like, and how has your organization participated in that conversation?

ismail ali

Yeah, a couple of things. So I work for the Multidisciplinary Association for Psychedelic Studies, which was founded in 1986 after MDMA was criminalized in an emergency scheduling decision by the D.E.A. MDMA — best known as the active ingredient in ecstasy. It’s now— through MAPS and the Public Benefit Corporation, which we work with — in that entity is taking MDMA through the F.D.A. process, with the intention of having it recognized as a prescription medicine. But while we’re focusing primarily on MDMA, it’s absolutely the case that one of the large goals and kind of value systems that MAPS has utilized over the last 35 years is toward legal, regulated access for psychedelic substances, and specifically, in a legal, medical, or cultural context. And while my personal perspective on this does have to do with really shifting drug laws for all of the substances involved, it is absolutely true that psychedelics are experiencing a kind of like zeitgeist, or some sort of like resurgence in society, now that we have a couple of decades of solid clinical and observational data, you know, depending on the substance, depending on the environment, that show that they may have benefits for certain people in certain mental health contexts. That’s happening simultaneously to this renewed awareness of the spiritual use of some of these substances in certain contexts, which regulatory and structurally speaking, looks very different from like a medicalized, or like, a medical adjacent system. So you mentioned Measure 110 in Oregon. At the same time, Oregon also passed Measure 109, which is a legal psilocybin services system, and psilocybin being the active ingredient in what people call magic mushrooms. And that’s relevant, because it’s actually the first legalized, or attempt at a legalized regulated system for access to one of these substances aside from cannabis. And I’ll just say — to kind of close this thought — that psychedelics are an interesting bridge, because while I think some people want them to be the silver bullet for mental health. And they have all these benefits, and it’s certainly true that for certain people and in certain contexts, they do have tremendous benefit. But they do come with risks. And the thing about psychedelics is that they’re actually more known for their psychological risks as opposed to their physical risks.

jane coaston

Right.

ismail ali

And that’s a really interesting thing, because it brings up how we actually navigate and handle mental health in the United States.

jane coaston

I want to push back very lightly on that, because I think that when — in D.C., the language around the decriminalization of mushrooms, which I supported, it very much implied that not only should mushrooms be decriminalized, but that you should do them.

ismail ali

Yeah.

jane coaston

I think that this gets into the question of — we don’t necessarily exist in the ideal regulatory and cultural marketplace for legalized psychedelics or legalized drugs in general. And I’m curious as to how you’re thinking about how, yes, it would be fantastic if these drugs would be used in these safe contexts, in these — whether secular or religious ceremonies, or with the right groups of people. But they won’t be. And I’m curious how you’re thinking about this.

ismail ali

Well, this brings me to the question of education, which we haven’t touched on too much in this conversation yet. I think that the current legal status of psychedelics has — and all drugs – has significantly warped the education that people receive about them. I was part of the DARE generation, and when I learned that —

jane coaston

Oh, I was too.

ismail ali

Right.

jane coaston

I was too. Some would say it did not prove effective.

ismail ali

Totally. Do you remember the doobies with the big googly eyes, like, they’re going to come get you. Like, when I learned that methamphetamine and marijuana were not the same, that were they were not equally dangerous, which is what I was taught in sixth grade, I experienced a big rupture where I actually — it was probably the beginning for me of beginning to really doubt what education I was receiving, not just about drugs, but about other things in general. And I would say now, especially looking back at what feels like propaganda for the drug war, it makes it really difficult to trust what kind of education and information people are getting. So to answer your question, you’re right. There’s absolutely no way to control the way people use drugs. Like, there’s no guarantee that even with the best regulatory system and the best policy in every way, people will use them the way that we want every time. However, I do think that stigma and misinformation and drug hysteria contributes to people using drugs in less educated ways. And that’s not to say that more information would fix the overdose crisis. It would not fix a lot of these issues with addiction. But I do think that with psychedelics specifically and especially, better education about the environment would make quite a big difference. One of the most persuasive things I can say when I’m doing advocacy work around psychedelics is that psychedelic therapy is not that fun. I mean, it is true that people can have super ecstatic and joyous experiences with psychedelics, but psychedelic therapy as a treatment modality is actually quite challenging. And dealing with one’s own internalized trauma is not a particularly fun process. It’s not something you want to do at a festival surrounded by your friends. You want to do it in a safe place, maybe with a blanket and some chill music going on, in a room where you can do that with people who you can trust. So it’s — a lot of that has to do with the environment that people are in. And because all psychedelics are equally illegal and you can’t do them anywhere, then that means you can do them anywhere, you know.

jane coaston

Yeah, when you’re surrounded by 90,000 people, it’s maybe not the best time to maybe encounter God.

jonathan caulkins

On the psychedelics, the people who are optimistic about legalization are often very optimistic about the potential of education. My caution is when you allow a for profit industry, a lot of the education, quote unquote, is going to be provided by the industry. You referred earlier to — I may get the details wrong, but I think it might have been a Purdue advertisement that said when Tylenol is not enough, take Oxy. I mean, I don’t have the details right, but that is them trying to educate you about the right — in their mind — set and setting for drug use, not for your benefit, but for their profits’ benefit. Legalizing supply is night and day different than just decriminalizing. The power of the market that is unleashed when you create corporations that make money by inducing greater use of their product, coupled with — intrinsically, some of these products are appealing or addictive — that’s a potent combination we need to be very careful about.

blake

Hi, Jane. My name is Blake and I live in Boston. One thought that’s been occupying my mind, and something I talked to my dad and family about, is on cryptocurrency — in particular, Bitcoin. And I guess one thing that I’ve been struggling with is trying to determine whether I believe it’s something that’s going to stick around or if it’s just a fad. It’s been really hard for me to find sources that are objective and look at both sides of the coin, no pun intended there. Thanks so much. Take care.

jane coaston

Hi Blake. Well, I have a lot of thoughts on cryptocurrency, but I think the question isn’t it a fad, or is it something that’s going to stick around forever, because the answer to both of those can be yes. I don’t think cryptocurrency is going to save the world. I also think that it’s going to be around for a long time. And it’s something that I’d like to learn more about. But I have a feeling that both sides tend to overstate either the importance or the lack of importance of cryptocurrency. That seems to be how this kind of thing goes.

What are you arguing about with your family, your friends, your frenemies? Tell me about the big debate you’re having in a voicemail by calling 347-915-4324, and we might play an excerpt of it on a future episode. Jonathan, can you talk a little bit about overdoses and the potential health impacts?

jonathan caulkins

Opioids are particularly dangerous in terms of overdose risk, but what makes them less problematic because we do have pharmacological therapies for them, methadone being the original and most famous — perhaps buprenorphine. We do not have anything like that in terms of pharmacotherapies for the common stimulants. And it makes a difference, because if you’re going to legalize — particularly legalize supply, allow for profit companies to promote the use, you’re going to get more use. You’ll get more dependence. And it’s a very different thing. If you are choosing policies that promote dependence to something for which there is no real effective treatment, as opposed to opioids — it’s not that opioids are gentle, but we do at least have a treatment.

jane coaston

Ismail, how do we think about recovery, and how do we think about the aftershocks of legalization? I’m just curious how you think about addiction in this conversation.

ismail ali

Yeah, I have what might be a slightly unpopular opinion, especially in today’s time. Like, addiction itself — let’s say, like, drug dependency, to be a little more specific — itself, I don’t necessarily see as a social harm or a social bad. I think that a lot of people manage a lot of addictions totally fine, regularly, because it’s not disruptive to them, because they have access to a safe supply of what it is that they’re addicted to. Of course, the effects of a caffeine addiction or caffeine dependency are significantly less dramatic and less likely to cause some sort of antisocial behavior than a withdrawal from a different substance. But I think that what both Jonathan and you have mentioned, Jane, that I think is more relevant, has to do with the consequences and the secondary effects — of course, on the individual, but especially on society. Alcohol is a great example, because we do have what people would consider a safe supply of alcohol. It’s a regulated product with tons and tons of social externalities that are still there. The difference is that the purchase, the manufacture, the use of alcohol — if criminalized, I believe, would make our current alcohol related issues worse. But I do think that the big difference with other substances is that because they’re criminalized, you have all of those effects, those secondary antisocial effects of dependence or antisocial use, et cetera. And you have the additional layer of criminalization for the use itself. I’m curious about — especially Jonathan’s perspective on this, because there are examples where certain countries like Switzerland are using heroin to manage heroin addiction. Right, they’re actually allowing people to have a safe, consistent supply of heroin. In places like Portugal and Spain, you have a huge percentage of people who were on heroin in the ‘80s and ‘90s who’ve transitioned onto methadone, and are still on methadone decades later. But they’re able to have jobs. They’re able to have families. They’re able to do x, y, z — so.

jonathan caulkins

I think this gets right to the heart of where you and I differ, if I may. I mean, on the last — we had legal supply of prescription opioids and still had a lot of overdoses. There’s no question that an inconsistent supply exacerbates the problem. But I don’t think legal supply of opioids would eliminate overdoses. But to be more fundamental about it, you and I differ on whether or not legal supply necessarily can stabilize a person who is dependent on the substance. To me, that’s substance specific. Caffeine and nicotine are two drugs for which if you have legal supply that is not adulterated and so on, the person can function in everyday life just fine, even if they are dependent. But for the stimulants — crack, methamphetamine, and for alcohol, just providing abundant amounts of unadulterated, free supply does not let those people stabilize their lives. And that has terrible repercussions for them and their families.

ismail ali

Yeah and I would just — to clarify, I don’t necessarily think that an uninterrupted, as much as you want, supply of any drug is going to be good for everyone. Like, I —

jonathan caulkins

Well, that’s what for profit companies are going to want to supply if we legalize.

ismail ali

But there is nuance there. But my question — actually, back to you is — I wonder about your thoughts about why there hasn’t been the same — because while there is a tremendous amount of methamphetamine use, it’s not the case as far as I understand that the increase in methamphetamine use is a result of increased, for example, prescribing of dexamphetamine or other amphetamine analogs that are legal for various treatments, whereas you do see a little bit more of that shift from prescription opioids to underground use of opiates with that market. So I hear what you’re saying. And it seems to be the case that a regulated, safe supply of something like Adderall actually doesn’t have the same effect as in bringing people into a super unregulated, dangerous, unadulterated market in the same way you see with opioids. And it’s true that we also don’t have the pharmaceutical interventions for stimulants as we do with opioids, but I wonder what makes that different. Why are people going to meth in that way versus the other?

jonathan caulkins

Yes, stimulants is a broad category. And some of them are tougher than others. I mean, at some level caffeine is a stimulant, but it’s not a very powerful one, to speak informally, whereas methamphetamine definitely is. Adderall is more on the caffeine end of the spectrum, blessedly, although there is actually some diversion of Adderall. But it’s a different feel. This is like somebody with access to Adderall selling it or giving it to their friend in college to help them study, because they think it’s going to be a performance enhancing smart drug. But on the whole —

jane coaston

I’ve never I’ve never heard of that happening, ever — definitely don’t know anything about that.

jonathan caulkins

Adderall’s worth talking about for a minute here, because it does illustrate the phenomenon that — the trick with providing generous supply to some people is, in part, can they make money by diverting it to other people — money, or do favors for friends. The prescription opioids got out of control for a whole bunch of reasons, many reasons. But one of them was the fact that there was already this value in the illegal market. And you also could seek a prescription based on symptoms that could not be objectively assessed by the clinician. And that combination was a problem. You could show up and say, oh, my back hurts a lot. Give me these things for the cost of a co-pay, and I can turn around and sell them for a lot of money. We’re going to always be vulnerable if you, through the medical system, provide subsidized access to anything for which there is demand in the illegal market. And Adderall does have that character. It just fortunately is nowhere near as bad for you, or risk of overdose, as the opioids were.

ismail ali

Yeah, or meth. I hear that. That makes a lot of sense, and I appreciate that answer. And also I think that the other factor, especially with regulated stimulants — and this is, I think also one of the questions with respect to regulations in general, which is method of administration. Because I do think that the fact that you don’t have smokable amphetamines or injectable amphetamines through regulated system also means that people who are accessing it through a regulated market tend to be doing it in a way that’s not going to have the same super rapid onset, and then related withdrawal, et cetera that you might have with methamphetamine use or other related things.

jonathan caulkins

Yeah, I’ll agree with that. And then it’s also location of administration. So cocaine is available as a medicine. It turns out to be a vasoconstrictor and topical anesthetic that’s useful in minor surgeries. We have no problem with Dirty Roulette diversion of medical cocaine to illegal markets, because it’s only used inside the medical facility, administered by the clinician. So if we were to talk about, like, psychedelics used by a psychiatrist, on site, under supervision, that sort of medical use would have next to no risk of diversion to a market. But if we were ever to say to somebody, here are two pills a day for the next month. Take them home, do what you want with them. Then, there’s much greater risk of some of those being diverted into the market.

ismail ali

Yeah, and just to clarify — the way that psychedelics are being incorporated into health care now, it’s more like a procedure or a surgery than it is like other psychiatric interventions, where it actually is in the presence of a therapist or a psychiatrist or someone who has specific training to work with both these altered states of consciousness as well with the substances themselves.

jane coaston

Jonathan, I’m curious. Are we asking some of the wrong questions about consumption and distribution if we’re thinking about something as big as what decriminalization or legalization of substances beyond marijuana would look like?

jonathan caulkins

Well, first of all, the bigness of decriminalize and legalize are very, very different. Decriminalization would be a big change, but it’s not a change the world. Legalization of supply, that’s totally different. You said that’s a big shake up. It’s a once in a century event. I would just stress — it’s a once and for all time event. Once you create a legal industry, it’s going to be really hard to get rid of it. When you create a legal industry, you create a powerful lobbying force. One of the challenges we have is regulatory capture. It’s already starting with cannabis. We haven’t even gotten to national legalization yet. But you just presume- – if you’re going to legalize supply of something, presume that there will be regulatory capture, presume you will never go back. And presume that a lot of the regulations are actually going to be shaped by what’s in the industry interests much more so than public health. Public health doesn’t tend to win in the lobbying battles against industry.

ismail ali

I totally agree that legalizing drugs, legalizing supply would be a generational event. It would be a massive, massive shift in the way things are done — even though, as I like to remind people, drugs were legal and traded until about 100 years ago. And it was US pressure on international actors that really brought us into the realm of prohibition that we have now — among others, because even large colonial powers, the Dutch and the English and others, were very happily trading a lot of these drugs for a long time before prohibition in its current form existed. So I also think that we are in a new paradigm in the sense that people have much more awareness and a willingness to talk through the stigma around the dependency and addiction and so on. And that does give me hope, that as we look at these questions around advertising and marketing and so on, that maybe it is possible that these public health perspectives could be better considered. I hope that our experience with tobacco and with opioids could lead to a more rational drug policy with respect to legal access of other substances. That could be naively optimistic, but I feel like as a policy reform advocate, if I’m not somewhat optimistic, then there’s really no point to going forward. And I think it’s really good to have some level of possibility for what there could be beyond where — we currently are.

jonathan caulkins

I admire that optimism. I’m usually the one who’s accused of being optimistic. Compared to you, I guess I’m the jaded, cynical one. We’ll see.

jane coaston

Jonathan, Ismail, thank you so much for joining me. And I really appreciated this conversation.

jonathan caulkins

Good. It was a joy to be here.

ismail ali

Thanks so much, Jonathan. Thank you so much, Jane.

jane coaston

Ismail Ali is a Policy and Advocacy Director at the Multidisciplinary Association for Psychedelic Studies. Jonathan P. Caulkins is the H. Guyford Stever University Professor of Operations, Research, and Public Policy at Carnegie Mellon University’s Heinz College, and a member of the National Academy of Engineering. If you want to learn more about drug policy of the United States, I recommend “Is There A Case For Legalizing Heroin” by Benjamin Wallace-Wells in The New Yorker, published in April of 2021. For the other side, you can read “The Drug Policy Roulette” by Jonathan P. Caulkins and Michael A.C. Lee in the National Affairs Summer 2012 edition. And listen to “Michael Pollan’s ‘Trip Report,’” an episode on The New York Times opinion podcast “Sway.” You can find links to all of these in our episode notes.

“The Argument” is a production of New York Times opinion. It’s produced by Phoebe Lett, Elisa Gutierrez, and Vishakha Darbha, edited by Alison Bruzek and Sarah Geis, with original music and sound design by Isaac Jones. Additional engineering by Carole Sabouraud, and additional mixing by Sonia Herrero. Fact checking by Kate Sinclair, and audience strategy by Shannon Busta. Special thanks this week to Kristin Lin.

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