Oregon withdraws bold plan to help drug addicts

This month, a brief, ambitious and, many would say, disastrous experiment came to an end: Oregon repealed Measure 110, which decriminalized possession of small amounts of illegal drugs. Instead of issuing small fines with an incentive to seek treatment, police are again issuing misdemeanor charges against people caught with opioids or meth.

What can we learn from this first experiment of its kind in the United States? Many would argue that it taught us what not to do. But an honest look at what happened in Oregon paints a more complex picture.

Let's start with what almost everyone agrees on. Decriminalization hasn't been a game-changer in Oregon. The state entered the policy transition, which was approved by voters in late 2020 and signed into law in mid-2021, with one of the highest addiction rates in the country. It also had one of the worst records on access to treatment. And while Measure 110 included funding for mental health and substance use services, training a workforce and building efficient infrastructure takes time. Four years later, the state still doesn't have nearly enough clinics or staff to meet its goals.

As one drug policy expert told me, without near-perfect implementation, the experiment seemed doomed to fail. And many would call it a failure. Homelessness, crime and addiction increased and burdened public spaces. Social services, including treatment and housing assistance, were not expanded quickly enough.

And there has been a sharp increase in drug overdose deaths. Fatal overdoses rose 50% in 2021 compared to the previous year, another 30% in 2022 and another 45% in 2023, preliminary data from the Oregon Health Authority show.

The core message of Measure 110 was that “a health-based approach to combating addiction and overdose is more effective, humane, and cost-effective than criminal punishment.” The fact that decriminalization not only failed to save lives, but appeared to cost many more, was seen as the most damning proof of its folly.

Those grim numbers are undeniable. But decriminalization wasn't the only big change in the state in 2020. A recent article in JAMA Open Network points to another culprit behind this rise in deaths: fentanyl. The potent opioid permeated Oregon's drug supply just as restrictions on possession were being lifted.

The insidious effects of fentanyl on a community are now well known. As the drug spread from the East Coast, through the Southeast and Midwest, and finally to the West Coast, it left a horrifying death toll in its wake. As of 2021, more than 100,000 people have died of overdoses each year in the United States.

The researchers wanted to find out how much of Oregon's rising death toll was due to the policy shift and how much was due to the introduction of fentanyl. The results of their analysis, which compared Oregon to states without decriminalization, stunned even the study's authors, says Brandon del Pozo, an assistant professor at Brown University who led the work. The increase in deaths was entirely due to fentanyl. And entirely.

“The hidden headline of this article is that drug reformers are plotting and fentanyl is laughing,” del Pozo said. “The spike in overdoses in Oregon was tragic and boringly typical.”

In other words, the most important lesson from Oregon's experiment is not that a public health approach to drug control can't work. It's that fentanyl makes drug use more difficult and complicated to manage. Even if the state's decriminalization experiment had been conducted under the best circumstances and with the best of intentions (which it wasn't), saving lives would have been a challenge if fentanyl had emerged at the same time.

This should serve as a reminder for others analyzing other drug reform efforts, del Pozo says. Researchers need to model the effects of fentanyl to capture the true effectiveness of harm reduction interventions like naloxone to reverse overdoses or safe injection sites.

It is likely that the impact of the Oregon measure has dampened acceptance of any effort aimed at curbing addiction by shifting the focus from punishment to public health.

That's a shame. Oregon has gotten a lot of things wrong, and Measure 110 should not be seen as the final word on decriminalization. And the U.S. urgently needs to find new ways to fight addiction. Early data from the Centers for Disease Control and Prevention suggests that overdose deaths recently declined for the first time since 2018 – a trend that health experts are still trying to understand but that may be due in part to increased access to the opioid antidote naloxone.

While this is good news, approximately 100,000 people will die from a fentanyl overdose this year. We still have a long way to go before we get things right.