Introduction

Over a hundred thousand Americans - many of them children - died of drug overdoses in 2023, more than double the number in 2015.1 And although some regions of the United States are finally beginning to see a reduction in deaths, more than 1 million Americans have succumbed to drug overdoses since 2000. We are expected to lose another million-plus people over the next decade, according to a Stanford University study.2 The numbers go deeper: More than 48 million Americans have a substance use disorder.3 The toll in human life and suffering is unfathomable. Never before have opioids, methamphetamine, cocaine, and other drugs affected so many people.

These aren't just statistics. People are dying, or just barely hanging onto life. Drugs have broken families. No community has been left untouched.

Nearly as many Americans have died from the drug epidemic as have died from the Covid-19 pandemic. And yet, while scientists were able to react to the pandemic and develop vaccines in record time, the drug epidemic has continued to rage on largely unchecked. The pandemic was accompanied by minute-by-minute media coverage, while the drug epidemic garners only the occasional middle-page article when, for example, a public figure dies from an overdose.

The problem has left parents, users, social workers, and policymakers exasperated.

Cheryl Juaire of Boston, for one, is more than just exasperated. She has felt it in her own family. Cheryl lost not one, but two of her three sons to fatal drug overdoses.

Two.

"There are no words," she says. Her youngest, Corey, died on February 24, 2011. The cause: heroin. He was 23. Corey left behind a four-and-a-half-month-old daughter, Faith.

Cheryl's second son, Sean, died on June 25, 2021. The cause: cocaine laced with fentanyl. He was 42. Sean left behind a son, a daughter, and two grandchildren.

How did this happen?

"I didn't raise my kids to be like this," says Cheryl, a former dental assistant and church secretary. But she looks back, seeking answers, and sees a lethal combination of debilitating factors - genetics, family trauma, and the unyielding grip of addiction.

Her oldest son, Robert, is a police sergeant in Hudson, Massachusetts, outside Worcester, who regularly sees drug users break into storefronts and steal cars - and yet, "Bobby doesn't understand the disease of addiction," Cheryl says. "He gets very angry."

Mother and son have a hard time talking about the searing losses they have experienced due to drugs.

For Cheryl, all she could do was not put up a Christmas tree. When people heard about this on Facebook, hundreds of other grieving moms sent her ornaments - angel wings.

So, she put up the tree after all.

"It turned into my angel tree," Cheryl says.

She has also channeled her unfathomable grief into setting up a nonprofit to help other families who have lost and suffered from drug addiction. It's called Support After a Death by Overdose, or SADOD. "So that our children didn't die in vain," explains Cheryl, now in her mid-sixties.

The tragedy that befell Cheryl is unfolding all over the country, from California to New York, and spanning the heartland from Nebraska to West Virginia. So too is the dissolution and decay that drug use has brought to places like San Francisco. There are, of course, many causes. But one stands out: the misguided policies and practices that have inadvertently unleashed the worst drug crisis in American history.

"The crisis is national," former President Joe Biden said in an address. Drawing on his son's highly publicized experience with addiction, he continued: "A lot of families have loved ones who have overcome addiction and know what we mean."4

What about the impact of the drug epidemic in financial terms? About 1.5 trillion - with a T - dollars a year, by some estimates.5 Meanwhile, the size of the illicit drug market in the United States is estimated at $150 billion, as synthetic drugs smuggled from countries like China and Mexico have become increasingly common and lethal.6

Though it's a connection largely not talked about, one might argue the legalization of marijuana opened Pandora's Box. Now, "drug policy reform" proponents seek to commercialize psychedelics and legalize virtually all other illicit substances, including fentanyl and heroin. They use euphemisms like "harm reduction" - a well-intentioned idea originating from the AIDS movement of the 1980s to reduce the consequences of drug use, like infectious disease - and "decriminalization" - rallying the popular notion that those whose only crime is using drugs should get help rather than jail - to get their way. They've set up "supervised consumption sites" - places where drug use is tolerated, staffed by harm reduction activists - in communities of color, like Harlem, New York, despite misgivings from residents there. And they argue that we can give addicts a "safe supply" of drugs in the form of pharmaceutical pills, since they are "known" and "controlled."

Everyone from illegal underground players to multinational corporations to deep-pocketed nonprofit organizations are among the chief beneficiaries of the push to normalize drug use. "Traditional" drug dealers ply their deadly trade with impunity, with many using the dark web and social media to sell illicit substances, such as fentanyl. On the popular platform Snapchat, some dealers have sold marijuana, offering to throw a couple of fentanyl pills into the bargain. Indeed, many unsuspecting teenagers have died of fentanyl poisoning because they took a pill without realizing what was in it. Meta is now facing a huge lawsuit that contends its platforms - including Facebook and Instagram - have served as virtual marketplaces for drugs like opioids, cocaine, and methamphetamine.7 Surveys show that an alarming number of teenagers still do not realize the dangers posed by fentanyl.8 Lost in the debate is the massive and growing number of people in the grips of addiction who have become homeless. You can see the staggering camps of homeless people in nearly every major American city, from Los Angeles to New York.

So, what do we need to do to address the crisis?

A further legal crackdown? A renewed war on drugs?

Or should we simply learn to live with drugs, an age-old vice?

Or is that a false dichotomy? Can we find common ground?

Even more importantly, is there an effective path forward to save lives?

Given the fatal implications of the drug epidemic for the future well-being of our country, there is an urgent need for a dispassionate and in-depth examination of this crisis. That is why I have written this book, which will look at different places, and our own history, for answers. San Francisco, for example, known for its "free drugs" mantra of the 1960s, was actually one of the first cities in the country to ban drug use a couple of hundred years ago - and is now starting to come around full course and reverse its libertarian drug policies in the wake of extraordinary destruction.

* * *

Why has addiction defied a clear explanation for its causes and a viable course for its treatment while many other health-care problems have benefited from the miracles of scientific research and innovation?

"In search of answers," writes Carl Erik Fisher, an addiction physician and bioethicist, "I immersed myself in the field, studying the psychology and neuroscience of addiction . The field seemed to be in chaos. Scientists and other scholars seemed bitterly divided, always talking past one another. Some insisted that addiction was primarily a brain disease. Others claimed that this brain-centric view blinded us to the psychological, cultural, and social dimensions, including trauma and systems of oppression."9

Not only are the experts unable to agree on the causes of addiction, they are engaged in a fierce debate over its treatment and, in some cases, whether treatment is necessary at all. Numerous approaches to treatment range from the traditional twelve-step model to a medical approach that favors biological alternatives such as buprenorphine and other medications, to therapeutic communities that stress long-term residential behavior modification. These should not be seen as mutually exclusive. They are all useful and effective.

If you read authors like Carl Hart, a professor at Columbia University and author of Drug Use for Grown-Ups: Chasing Liberty in the Land of Fear, you may believe drug use is a safe, truly recreational activity. "I am now entering my fifth year as a regular heroin user," he writes. "I am better for my drug use."10

Hart argues that drug use isn't only not harmful, it is helpful. Lost in his personal experience are the horrors drug addiction can afflict on others, even as he speaks with young people around the world about what he describes as the joys of heroin and hallucinogens. Hart is not some fringe figure. His work is praised regularly in mainstream media outlets, papers like The New York Times, and by witty TV entertainment programs like The Daily Show. He's a popular professor at an Ivy...