In a recent post, David Henderson commented on how people view the horrors of drugs:
But what so few people seem to understand is that virtually all their horror stories about drugs occurred during a time when drugs were illegal….But if all these horror stories occurred during the drug war, it is hard to see how people can so easily think that these horror stories are an argument for the drug war.
His post reminded me of something that I learned while researching the heroin chapter of my book The Seven Deadly Sins: in certain ways, heroin prohibition makes an intrinsically deadly activity even deadlier.
To help understand why this is the case, let’s consider what one paper called the main risk factors for heroin overdose:
injecting heroin, using opioids together with benzodiazepines or alcohol, not being in methadone treatment, and using opioids after a period of abstinence, generally due to having been in prison or drug-dependency treatment. (emphasis mine)
At least some people who currently inject heroin would ingest the drug through a safer method if the government made no attempt to discourage heroin use. Justifying this claim is a two-step process. Step 1: the free market, untaxed price of heroin would be a small fraction of the current street price. How cheap would unregulated heroin be? Jeffrey Miron compared the price of street heroin to the price of heroin legally produced for scientific research. This comparison suggested that interdiction increased the price of street heroin by a factor of 19. Step 2: one reason why heroin users inject is its cost effectiveness. As a heroin user’s tolerance increases, getting high without injecting becomes cost prohibitive. If heroin was much cheaper, cost would make injecting less financially imperative. As one initiate to injecting described:
I already had a habit going on because I snorted. I was already at a three bag tolerance each time to get high, and I wanted to get high, and I thought it was a waste of dope. It’s more efficient if you shoot up, it’s supposed to be like one of the most euphoric feelings you ever feel, and it costs less.
The second highlighted risk factor (having been in prison) is obviously connected to drug prohibition. The most dangerous time to be a heroin user is probably the first few weeks after getting out of prison. The primary cause of heroin overdose is respiratory depression: the user’s breathing slows down and over time body tissues suffer from a lack of oxygen. Users take more and more heroin as they develop a tolerance for its euphoric effects. These large doses of heroin would dangerously depress respiration except for the fact that the body develops a tolerance for heroin’s respiratory effects at the same time that it develops a tolerance for its euphoric effects. Abstinence lowers tolerance and makes the user more susceptible to respiratory depression, which explains why binging after a period of abstinence is so deadly. Putting heroin addicts in prison is the perfect trigger for this. As soon as they’re released, most users are eager to get back to heroin. It goes without saying that a heroin user would be less likely to face imprisonment if heroin was legal.
Prohibition might also make heroin use more dangerous by causing the purity of a user’s supply to fluctuate. Safety would recommend ingesting heroin of known purity (especially for injectors). An addict who is used to consuming low-purity heroin and then unknowingly consumes high-purity heroin might ingest more of the drug than expected. The fact that a user’s supply is continually being interrupted by law enforcement causes fluctuations in purity. (The evidence for this risk factor is weaker than for the two highlighted factors above.)
Prohibition also causes quality fluctuations due to the adulterants that black-market dealers add to heroin. Proponents of heroin legalization and many heroin users themselves often cite this as a significant cause of overdose. However, the medical literature generally views this as an insignificant risk factor. Fortunately for the prospects of safely finishing my book, reading medical research is a better way to understand the dangers of overdose than acquiring firsthand experience.
P.S. I am not suggesting that overall heroin overdoses would decrease if heroin became unregulated. Even without new heroin users, lots of financially constrained injectors would use cheap heroin to increase their heroin consumption instead of transitioning to a safer ingestion method.
P.P.S. One of the saddest facts about heroin is that seeking treatment for addiction is itself a risk factor for overdose (at least in the short term). Treatment reduces how much heroin people use, which reduces tolerance, which makes it very dangerous to fall off the wagon.
READER COMMENTS
Greg Heslop
Mar 30 2014 at 8:52am
It is interesting that purity fluctuations and the possibility of adulterants seem, respectively, less strong and insignificant factors in causing addicts to die, compared to what is often claimed. These findings would fit well with black-market dealers’ being concerned with reputation, no? Even absent government-imposed quality controls, reputation concerns seem to be sufficient incentive to maintain a reliable product.
David R. Henderson
Mar 30 2014 at 9:25am
Good post.
GregS
Mar 30 2014 at 10:17am
Great post. I often argue to people that prohibition INCREASES the number of overdoses, and this post fleshes out the exact mechanisms by which it does so. I didn’t know that adulteration was not a significant risk factor in heroin overdoses. Pretty clearly it was a factor in many of the fatal poisonings during alcohol prohibition.
You will definitely have a buyer for The Seven Deadly Sins. I will be eagerly awaiting it.
Tom West
Mar 30 2014 at 10:29am
Interesting that in a more Libertarian society, the heroin could be legal, safer and cheap, but given the absence of any form of government support, the lives of many addicts might still be more perilous than now, with no money for food, shelter or drugs.
James Schneider
Mar 30 2014 at 11:20am
@ David and GregS. Thanks for the kind words.
@ Greg Heslop I discuss reputation in the heroin chapter, but I hadn’t considered your point before. Seems correct to me.
NZ
Mar 31 2014 at 2:46pm
This is essentially a long list of reasons why the artificially high costs (monetary and non-monetary) of heroin use would be drastically lowered if heroin was legalized.
Lower cost, of course, leads to increased consumption.
So, in the event of legalization, would the lowered rate of overdoses be cancelled out by the increase in absolute volume of them?
I am a proponent of drug legalization, but I usually don’t see libertarians making any of the good arguments for it.
sourcreamus
Mar 31 2014 at 3:28pm
The purity argument is belied by the fact that prescription drugs kill more people than street drugs.
NZ
Mar 31 2014 at 3:37pm
@sourcreamus:
Maybe. I have some problems with that comparison though:
-Prescription drugs have the medical-sounding word “prescription” in them, and often a smart guy in a white lab coat as well as countless TV commercials have told you to use them, so people have an artificially lowered concept of the risks.
-I’m skeptical that a higher percentage of prescription drug users vs. illicit drug users OD.
-Do the numbers on people dying from prescription drug use include people who mixed drugs they weren’t supposed to, or mixed the drugs with alcohol? Like other so-called “drug related deaths,” are prescription drugs considered a factor any time they are present in the system of someone who dies? I’d bet a great many people die with prescription drugs in their systems but without having necessarily abused the drugs, since these drugs are often used to, you know, combat illness.
Artur_500
Apr 1 2014 at 5:04pm
It reminds me of the interaction between Senator Ted Kennedy and Timothy Leary regarding the idea of LSD being legal or not. Timothy Leary stated that having a legal drug company manufacture the product would ensure a quality, safe product with consistent doses.
Senator Kennedy then declared that obviously it must be dangerous if it needed quality control such as this.
Imagine making any drug illegal that needed quality control.
Never mind, we pretty much have done that with most of our pharmaceuticals and driven up the cost not only to purchase them but to get the prescription to obtain them.
Hmmm, I wonder why healthcare in the United States is so expensive…
Mike Rulle
Apr 1 2014 at 7:39pm
Your argument reminds me so much of John Stuart Mill, who everyone seems to have forgotten for some reason. His ideas seemed just too easy, mechanical and somehow wrong. Not literally wrong, merely incomplete and shallow.
The legal heroin question is a red herring. It will never be legalized—at least in the sense of alcohol being legal. The evidence for this are all the legal drugs which currently require prescriptions.
We do not know the unintended consequences of full blown heroin legalization. Lets finish our pot experiment, which I agree with, and see how that goes before we start making super clean heroin available for all. If it is not made available for all the crime will continue. So what is the point? I think society can live without freely available heroin. Not one of my priorities.
NZ
Apr 2 2014 at 9:34am
…and before everyone piles on Mike Rulle’s statement that “We do not know the unintended consequences of full blown heroin legalization” with the reminder that we in fact had full blown heroin legalization before the Harrison Act, I would point out several things:
-the consequences back then were actually quite bad, with very high rates of use and addiction;
-but these stemmed from a lot of misunderstandings about the properties of heroin (for instance, it was believed that heroin would cure addiction to opium, and that it was a suitable remedy for children’s toothaches);
-though, we still do not have a solid understanding of what exactly causes addiction and how exactly it works.
So in sum, Mike Rulle is correct that we don’t really know the unintended consequences of full-blown legalized heroin in any context similar to our own. He’s also correct that it’s extremely unlikely heroin would ever be legal in the same sense as alcohol.
My short-term recommendation would be to ease up on supply-side enforcement while continuing to crack down on use, since the vast majority of drug war violence is on the supply side and I don’t see a large moral obligation to protecting junkies.
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