Opinion | This Is a Very Weird Moment in the History of Drug Laws

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From New York Times Opinion, this is “The Ezra Klein Show.”

In 2020, voters in Oregon passed a ballot measure, a drug reform policy, that was beyond what I ever thought would pass in any state in America.

I’ve been involved in drug policy reform for a long time. I got into it in high school. And this was not a politics that seemed possible back then. In that era, the idea that you would have a state decriminalize heroin possession, I mean, it was unthinkable. But in the coming decades, there would be a real turn on the war on drugs — the overpolicing, the mass incarceration, the racism, the broken families. It was not achieving, as far as anybody could tell, anybody’s policy goals.

So we began to move in this other direction. Oregon was at the vanguard of this, but it wasn’t alone. In Washington state, you saw the Supreme Court overturn the law that had made a lot of drug possessions and felonies. In a bunch of different cities, you had these very liberal district attorneys who instead of running on tough on crime platforms were running against overpolicing, against mass incarceration.

Something that had really never been tried before in America was all of a sudden being tried. We were moving towards a radically different equilibrium than anybody had imagined even just a few years before on drugs. I mean, you could walk down the streets — you can right now in many states — and buy all kinds of cannabis products from shops. It was, again, unthinkable.

But this politics and these policies are not working out the way people had hoped. Chesa Boudin, who was the district attorney in San Francisco, one of these very liberal set of reformers, he was recalled. Legislation was passed rebuilding an enforcement structure around drugs in Washington state. There are a lot of concerns and, I think, quite bright ones about how cannabis legalization and particularly cannabis commercialization is working out in a bunch of places.

And in Oregon, Measure 110 was gutted. The results of it had not been what many of the advocates had hoped for. Drug policy feels very unsettled to me right now. The war on drugs was a failure, often a cruel one. The war on the war on drugs has not been the success its advocates had hoped. So what comes next?

Keith Humphreys is a professor at Stanford University who specializes in addiction and drug policy. He’s advised the White House, California, the UK. I always find that he balances compassion and rigor unusually well. So I wanted to have him walk me through what he has seen and where he’s landed. As always, my email for guest suggestions, for reflections, ezrakleinshow@nytimes.com.

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Keith Humphreys, welcome to the show.

Thanks, Ezra. Good to talk to you.

There’s a tendency to just use this term “drugs.” And that tendency just belies a huge amount of variation, I think, in how people think about different drugs, how they think about opioids, how they think about stimulants, how they think about psychedelics, how they think about cannabis, alcohol, caffeine. Is this a useful term?

So “drug” is an incredibly vague term that covers an enormous number of drugs that have very different properties. The biggest one, I think, is the capacity to instill addiction. People don’t get addicted to LSD, for example. But they do get addicted to heroin. That’s really important. They do get addicted to nicotine. That’s really important. So you would think about those drugs differently, the ones that have the ability to generate an illness with obsessive compulsion to use in the face of destructive consequences over and over and over again. Those belong in their own class, I think.

The second thing is that we should stop pretending that legal and illegal drugs are so different for lots of reasons. We could learn much more about what to do with illegal drugs if we looked at legal drugs. When I talk to policymakers, they say, well, I know what I don’t want. And that’s a carceral, racist war on drugs. I say, OK, I’m glad that option is off the table. That, of course, leaves millions and millions of other options to choose from.

And how some people have framed that is there’s really only two choices here. You can have that, that horrible thing. Or you can throw the switch the other way — tolerance, acceptance, public sale. And that’s going to be better.

And the problem with that argument, even before we get into what happened in places like Oregon, is the number one drug that kills people on the planet is cigarettes. The number one drug associated with arrests, violence, and incarceration is alcohol. Those drugs are legal. It’s not that drugs suddenly become easy to deal with once they’re legal.

You get to pick the set of problems you have, as our mutual friend Mark Kleiman used to say. But you don’t get to get rid of those problems. So people are right to identify substantial costs to prohibition of drugs or for that matter of everything. But that is different than saying there is some other framework that doesn’t also include pretty substantial costs.

So this major drug policy reform went into effect in Oregon in 2021, Measure 110. It passes. What happens next?

Part of what happens is exactly what the reformers hoped would happen, which is that there’s a dramatic drop in arrests — arrests for drug possession and arrests for drug dealing. So they say, wow, that’s a victory. On the other hand, some of the other aspects of it didn’t work out the way people planned.

So there was a system that they thought would encourage people to enter treatment in replacement of criminal penalties. You’d be written a ticket, let’s say, if you were using fentanyl on a park bench. And it said there’s $100 fine for doing this, but you don’t have to pay the fine. All you have to do is call this toll free number, and you can get a health assessment and a potential referral to treatment. Well, it turned out that over 95 percent of the people got those tickets simply threw them away, which, keeping with the spirit of the law, there was no consequence for doing that. Hardly anybody called. The new body they set up to distribute the new funds had very serious management problems because the people — they may have been terrific human beings, but they weren’t actually experienced in how do you run a government bureaucracy.

So there was no real improvement in the availability of treatment, no real improvement in the number of people interested in seeking it. And those things may well have contributed to Oregon having a very high overdose rate. So currently going up about 40 percent per year, 4-0. Of course, some of that is due to fentanyl, which is raising — I’m here in California. Our rate’s up 5 percent, but it’s certainly not up 40 percent.

And the last thing is the intangible. And I say this as someone who goes to Oregon a lot and talks to people there almost every week, which is just the change in neighborhoods was really palpable of what it was like to go out in the street or try to go to a park, how much visible drug use you saw, how much disorder connected to it. And this was accentuated even further by the pandemic. There were fewer people on the street who had the choice. So the experience became more frightening as people were perhaps outnumbered in their neighborhood by people who had clearly visible problems were using drugs. And that generated significant and, I think, understandable upset as to how things were going in Oregon.

So not everybody agrees that Measure 110 was a failure, certainly not as a policy. I mean, it definitely failed politically. The Drug Policy Alliance says that it failed because of disinformation because there was a concerted effort to undermine it. And they cite data from the Oregon Health Authority saying that, look, health needs screenings increased by almost 300 percent. Substance use disorder treatment increased by 143 percent. Is there some argument to this that we’re looking at the wrong measures and, judged according to its goals, 110 was actually kind of working?

If what you care about the most was a drop in drug arrests and involvement of people who use drugs and deal drugs in the criminal justice system, then it was a success clearly because there was very little contact anymore between law enforcement and people who sell and deal drugs. But on the health side, no, I don’t think that. And those statistics on treatment I believe count a lot of one time consultations. I think what most people, particularly people who love someone who has an addiction, are looking for is evidence on people getting better, people getting into recovery, not just at some point having some transitory contact with the system.

There’s another argument that’s made in the Drug Policy Alliance document and other things I’ve seen and that has occurred to me, too, because when I think about Oregon, when I think about San Francisco, when I think about Washington State, I mean, you’re talking about places with very broken housing markets. We’ll talk I’m sure more about the Tenderloin.

But the Tenderloin is dystopic in the way the Tenderloin is dystopic because it is a giant homeless encampment. And that was true well before the current wave of drug policy liberalization. And so one argument here is that the drug system is being blamed for policymakers’ inability to solve these other problems. Is there something to that?

There’s an intense argument out here in the Bay Area between people who say, look, the homeless crisis is just a side effect of addiction. And people say, look, the addiction crisis is just a side effect of homelessness. And I would say they’re both wrong in that, even within my personal group of acquaintances, I know people who lost their home because of an addiction. And it’s not that the housing market discharged them, they had an empty property. But they were out on the streets. And then there are people who lost their housing and then were living next to drug markets on the streets and developed an addiction there.

So I don’t think we can separate that Gordian knot. And I don’t know if in policy terms we have to. I mean, I think we should be able to pursue policies that increase the access to housing and still work on policies that reduce the damage from addiction.

So to go back to Oregon and one of the theories that was operating there was that we’re going to move more money into treatment. We’re going to make it easier and safer in the sense that you will not be arrested for seeking treatment. We’re going to make it easier and safer for you to seek treatment. We’re going to make it cheap to seek treatment. Why didn’t more people seek treatment?

That theory reflects a misunderstanding about the nature of addiction, which is that it is like, say, chronic pain or depression, conditions that feel lousy for the person who has them all day long, and they will do anything to get rid of them. Drug addiction is not like that. It has many painful experiences. It destroys people’s lives.

But drug use feels in the short term incredibly good. That is why people do it. They’re getting intense reward. So they are ambivalent about giving that up in a way no one with chronic pain is ambivalent about giving up chronic pain and no one with depression is ambivalent about giving up depression.

The other point about it is a huge number of the problems from drug use and addiction fall on other people rather than the person concerned. And so people like me who work in this field, we get calls and calls and calls from mothers, fathers, brothers, sisters, children concerned about their loved ones. But it’s very rare we get a call from somebody concerned about their own use.

Take the law out of it and look at a drug that is legal and widely accepted. Studies of people who seek treatment for an alcohol problem, slightly over 9 in 10 of those people say they were pressured to come. And the pressure might be family pressure, mom and dad said or my spouse said, this keeps up, I’m moving out. The boss said, one more day drunk at work, and you’re fired. Doctor said, you keep doing this, you will be dead in six months. It could be this is your fourth or fifth arrest for drunk driving, and your lawyer says, you better get into treatment because the judge otherwise might throw you in the penitentiary. That is overwhelmingly the situation of people seeking treatment — pressure from outside.

So let’s just remove all pressure. No legal pressure, no disapproval. Then people will spontaneously say, OK, I really want to make a change, and I’ll come in. Look, those of us who do this for a living, we pray for patients like that. It’s great when they come in, but that is just a very rare person.

Let me ask about this from the other direction, which is maybe this all just wasn’t nearly liberal enough because one of the arguments made — and I do think there’s evidence behind it — is people are getting stuff they don’t know. And the reason people die from fentanyl laced heroin or simply fentanyl that they thought was heroin is because they don’t have a source they can trust. Part of the difficulty here is, yes, people end up addicted. We don’t have really good treatments for addiction that we can come back to whether you think that is a true claim.

And then we also make it very difficult for people and dangerous for people to get what they need to avoid withdrawal to keep feeling normal. And if we made that easier on them, if we made it so they didn’t have to go to a place like the Tenderloin and instead get something safe, they would not die from overdose. They would not die from fentanyl laced heroin. Is there validity to that?

Yeah, well, certainly using fentanyl in an illicit market is extraordinarily dangerous. And my colleagues and I are trying to figure out the death rate per year of a regular user. It might be as high as 5 percent. So that is an extraordinarily dangerous thing to do.

And the arguments you’re making have been influential in this region to the point that if you go up slightly even further in the Pacific Northwest into Canada and British Columbia, they’ve gone so far to say it’s the government’s job to supply these drugs because prohibition makes things more dangerous, so we have a positive obligation to do this. But the problem with that reasoning is we did flood communities with legally made, consistent quality, clearly labeled opioids for years. And the net effect was millions of people getting addicted and hundreds of thousands of people dying.

That’s, in fact, how we got here. I think everyone knows what OxyContin is, all the other opioids that were really pushed out there. So it’s just really hard to sustain that argument that at a population level, huge access to addictive drugs is not going to cause a lot of addiction and overdose as long as they’re clearly labeled and of consistent quality. If that were true, we would never had an opioid crisis.

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So Measure 110 passes in 2020. It goes into effect in 2021. What happens to it in 2023?

At that point, overdoses were way up. And popular sentiment has shifted pretty dramatically. I think quite a few people felt burned. They hadn’t gotten what they’d been promised. And that included people who, for example, had relatives who were addicted who they assume would be getting into treatment and recovery and then weren’t able to get services.

Neighborhoods are decaying. Polling showed that about two thirds of the Oregon population wanted Measure 110 repealed in part or in whole. And interestingly, those sentiments were even stronger among Black and Hispanic Oregon residents.

In response to all this, both Houses by very large margins replaced Measure 110 with a different approach to drug policy. It restored the ability to impose criminal penalties, to use those penalties particularly to leverage people to change their behavior — for example, by restoring drug courts and other kinds of diversion and monitoring programs. It is definitely not correct to say they reinstated the war on drugs because, it has to be remembered, Oregon never really had a war on drugs policy. They were the first state in the nation to decriminalize marijuana over 50 years ago, in fact. They decriminalized marijuana. They had a very low rate of putting nonviolent criminals into prisons.

So it was more a restoration of that progressive, liberty loving approach that they’d had before but supplemented with a lot more funding for treatment, which is something they’ve had a lot of problems standing up for years, which had nothing to do with Measure 110. The treatment system was in very bad shape before Measure 110. And it still is.

If you’ve been around drug policy conversations for a long time, you’ll have heard a lot, I have heard a lot, about Portugal. And Portugal is a place where they decriminalized drugs. And it has been a much more sustainable, solid policy. So what is different about Portugal?

Portugal is different in policy and different in culture. So they definitely don’t throw people in prison, and it’s decriminalized. But they do have what are called dissuasion commissions that do assessments of people, say, who arrested in the street for using drugs. And you have to show up to this assessment. And they can push and nudge people to seek care.

And they can also apply penalties if they want to. They can say, you’re a cab driver. You’ve been caught using cocaine. And we’re going to take your cab license away until you seek treatment and stop using cocaine. Things like that. It is not a war on drugs approach, but it is a push in the policy. And that has never been taken on seriously by American advocates who cite Portugal.

Portugal also has a universal health care. We do not have that. We are the only developed Western country that doesn’t have that. So that makes it easier to get help irrespective of what the laws are. And Portugal had at least at the time of their decriminalization a very nice network of treatment services and harm reduction services for people. And all that together worked in the policy mix.

The other point is the culture of Portugal is much more family oriented. It’s much more communitarian than American general and certainly much more true than our freedom loving Libertarian Pacific Coast. If you spend time in Lisbon, you have a common experience of running into people and say, where are you born? And they’ll say, well, Lisbon. And where were your parents born? Lisbon. And they still live in my neighborhood. And my grandparents live in my neighborhood, too. You never hear this in San Francisco or Portland. Everybody is from somewhere else. And many people actually moved to the West to get away from everybody else, to get away from social constraints. I want to be my own person. Well, Portugal is the opposite of that.

So there’s a lot of constraint on behavior. It’s loving constraint, but it is constraint, those boundaries around people’s behavior that don’t exist out in the West with the exception of recent immigrant communities, which, by the way, have very low rates of drug problems.

This is something that I always think people underestimate at least about San Francisco, which is one of these cities under the best, which is that it is a culture of enormous tolerance. And that is a lot of what makes San Francisco remarkable, what has made it a home for L.G.B.T.Q. people when that was a very rare thing to be, what has made it open to all these weird ideas from computer scientists and strange nerds who came around with their thoughts about AI and their thoughts about visual operating systems.

And people don’t like necessarily the dark side of this open, tolerant, nonjudgmental way of looking at the world. There’s a bit of a divided soul, a difficulty judging, a discomfort with paternalism, and a kind of optimism that if you let subcultures have their freedom and grapple their way forward, they’ll find their way to an equilibrium and that we should be very, very, very skeptical of heavy handed particularly law enforcement as a way of changing culture.

That is a very nice description of the city we both love. And we’d be much poorer without San Francisco’s embrace of individual freedom and all the great things that it gives, which you just articulated. To me, the resolution here is taking addiction seriously as a problem.

So if you look at somebody who is using methamphetamine five times a day, you could say, well, that is really an expression of their individual freedom. I need to respect that. But if you recognize the likelihood that they are not particularly free because they are addicted, the inconsistency disappears. And so I feel personally no contradiction between saying the state should intervene with pressure — for example, mandating people into treatment. For me, that doesn’t conflict with individual freedom at all. So when I talked to somebody who said, look, you need to just let people do what they want, I say, look. I volunteer in the Tenderloin. And I carry naloxone, the overdose rescue medication, with me. If someone were in front of me in overdose and dying, should I administer naloxone even though the person can’t consent, they’re unconscious?

And I’ve never had anyone say, you’re right. You should just respect their right to die. They say, well, no, of course, you should do that, conceding the principle that there are times that the thing we can do the most to help other people is take care of them when they were not in a fit state to take care of themselves.

Is that a straw man, though? I can’t really think of people at least that I have heard arguing that somebody under the throes of heroin addiction is free and is choosing the life they live, that they’re likely to be happy with the world they now exist in.

One of the really striking things about this new rhetoric about drug policy out here is how rarely addiction is even mentioned. The fact that there’s so much focus on drug overdose, which is, of course, terrible, but that is treated as the only index and not addiction reflects a viewpoint that that’s not either an important thing or not that real a thing. Because if it were, you would note that in the heyday of wild opioid prescribing, there were fewer overdoses, but there were far more people who were addicted to those substances. And that made their lives dramatically worse.

I also see the lack of attention to addiction in the investment in harm reduction without the idea of using it as a springboard into treatment, which to me is a very novel idea that’s only become more powerful in the last couple of years where people feel like that in itself is the goal versus trying to eliminate addiction and get somebody into recovery.

So this is complicated, I think, because there’s this interaction in this period between what you might call elite and mass drug culture. In this period, you have the rise of a lot of super popular podcasters like Joe Rogan and Tim Ferriss, who are very open about their psychedelic use. You have Michael Pollan’s great book on psychedelics, “How to Change Your Mind.” I do a bunch of podcasts about psychedelics. You have a book by Carl Hart, who’s a well-known drug researcher at Columbia, called “Drug Use for Grownups” where he talks openly about using heroin to relax at the end of the day. Ketamine use rises in a very public way.

And so you have this change in drug culture among elites. It becomes much more acceptable to talk about how you use drugs to improve your life that I think also makes it look hypocritical to have a punitive approach not just legally but culturally towards other kinds of drug use. Do you think there’s something to that?

Yeah. I’ve seen that very much, too. And people with a platform, they’ve got a hearing. One of the most important things to understand about Measure 110, for example, is it passed easily. It was not that controversial as people thought it would be. And that elite change, I think, was part of the dynamic.

And definitely, you could see that in psychedelics in Oregon, which, as you know, has set up an entire system to administer psychedelics as a healing force. At least that’s the theory. These are transformative medicines often, by the way, in advance of evidence. But put that aside for a minute. And that is a remarkable change.

I think the criticism you could make of people who are well off and well resourced and have a lot of social capital and have access to treatment and health care whenever they need it is that they could be overgeneralizing what it’s like to use drugs in that situation versus the situation most people find themselves in with a lot less resources and a lot fewer things to catch them if they develop a problem. Now, some would say, well, the real problem is the law, and it’s the punishment you get and all that. And that can absolutely ruin people’s lives. There’s no question to that.

But there’s also quite a few people whose lives are ruined by drugs, including cannabis. There’s some people whose lives have been ruined by psychedelics and certainly people’s lives ruined by cocaine and fentanyl and so on. You don’t think about that much maybe when you are in a really comfy, well-resourced environment. But the average person who lives in a more typical environment does think about it, does have to worry about it. And that gives them a different understanding of what drugs are, how risky they are, and what they want their government to do about them.

That all makes sense to me. But something else I would say was here was that I would have described the consensus for a very long time as drug use is bad, and policing is good. And to some degree, by the time of 110 and some other reforms we were seeing in other states, I think that there was — and you can tell me if this tracks for you — a belief that drug use is somewhere between neutral and good depending on the drug, and policing is bad.

Yeah. There’s no way to separate what happened in Oregon from the murder of George Floyd and from Black Lives Matter. I mean, the protests against police were as intense in Oregon as anywhere they were in the United States and indeed throughout the region and a lot of concern — and it’s got to be said — a lot of justifiable concern about racism and policing. And a huge portion of that was focused on drug enforcement. And that flip was clearly part of why the bill passed.

In terms of drug use, I think there’s a split. I mean, so there are people who accept it’s a health matter. So let’s move to that part of the population, some of whom will say, it’s not a good idea, but we should add health services, and I certainly wouldn’t punish anybody for it, to people would say, no, it is good. In fact, it is actively good. Drug use is good. Drug use should be accepted and maybe even promoted or celebrated. And the debate has been, I think, between those two strands, whereas in the ‘80s, it was more between “drugs are bad — period” and “they should be legal even if they’re good or bad.”

You’ve written about billboards that I used to see and always thought were somewhat strange around fentanyl use and showing happy people — and these were in San Francisco — showing happy people and suggesting if you’re going to use this stuff, use it with friends. Use it around others. Make sure you’re not doing it alone.

One way of looking at them was as a destigmatization of this. It’s totally fine. Just be safe. And another way of looking at it was a total last gasp, but we don’t know what to do. We’re going to try this approach to everything else is failing. Maybe if we completely turn around our approach and just try to change the social dynamics in which people use, that might have an effect on the margin.

So several things there you’re saying, I think they’re important. One is, absolutely. In the face of all this death and all this suffering, we’re all desperate for solutions. And I think it is good that we are thinking in very fundamental ways about what the solutions are. That should be the case when you have this much suffering.

I think it is not irrelevant that these changes have unfolded during a pandemic where, let’s face it, we all went a little crazy. It was very stressful. It was emotional. Many policy debates took on a very personal cast. And we did rock between different extremes in our politics.

With the billboards — and just to describe these billboards, what to me is interesting about them is that the public health department signed off on these. And if they had been promoting beer, they would’ve been outraged by them because they would’ve said, well, you’re making it look like this is something young, attractive, successful people do. And it’s a lot of fun. And you’re understanding all the risk. And you’re going to be tempting kids. You’re basically giving people really bad information. But it wasn’t alcohol. It was fentanyl.

And so I guess they felt it was reasonable on the idea that this will destigmatize. And then people will be comfortable talking about it and using fentanyl together. And they would show people in the apartment having a nice party. Then they could take care of each other in the event of an overdose. It would be a social event, and then you could be there. To me, it’s an extraordinary chain of reasoning. But that’s where San Francisco got in 2021.

I lived in San Francisco during this period. It also had a highly liberalizing attitude on drugs. It had significant open air drug markets, particularly in the Tenderloin.

But what I always saw as the core thing that was infuriating people because I lived in places like D.C. that had a much higher murder rate but where crime was much less of an angry political issue was a feeling that the government was tolerating disorder, that it wasn’t fighting it and failing or fighting it and failing to triumph over what’s a very hard problem, but that the government was allowing it, that they were allowing these open air drug markets, that they were allowing people to shoot up on the street, and that it turned out the politics of permitting disorder were really, really, really bad.

Yes, they are. And I volunteer in the Tenderloin. So I’ve spent a lot of time in those neighborhoods and definitely pick up that sense. And, say, for a number of people would express it in an even harsher way, which is the government is tolerating it where I live in a way they would never tolerate it in a wealthier neighborhood. That could be coupled also with a sense of some of those people in the wealthier neighborhoods say this should be tolerated, but they’re not having to tolerate it. I am. And that generates understandable anger.

And this has had an interesting racial dimension in my observation of it is that a lot of this tolerance has been pushed in the name of racial justice often by white college educated progressives but is unpopular with many, many people of color who live in low income neighborhoods because they’re paying the cost of it while it’s being advocated for for people who they don’t even know who live in neighborhoods that don’t have these kinds of problems.

I was reading recently a lawsuit filed by residents of the Tenderloin against San Francisco. And it was saying in a way that is illegal and unconstitutional, it was alleging that San Francisco — and everybody knows this to be true — was not enforcing laws in the Tenderloin the way it was in other parts of the city, that it had settled on a containment strategy in the Tenderloin. And the Tenderloin is really rough for people who have not walked around there. I mean, the disorder, the despair, the difficulty’s incredibly visible. And one of the things that was noted in the lawsuit was that the Tenderloin has a much higher ratio of children than most parts of San Francisco. It has a lot of immigrant families, a lot of poor families. And so this is being tolerated where really a lot of kids were.

And the argument was that this was not allowed where richer people lived in San Francisco, and it was where these poorer people lived. And even knowing that, it was striking to see it laid out and to see these experiences of people who were living amidst it laid out and their fury that containment was being done on their backs.

Why are there hundreds of dealers standing on street corners in the Tenderloin and in the south of Market? They are not there to service the neighborhood. Because if you live in a neighborhood and your dealer lives in the neighborhood, your dealer doesn’t have to stand on a corner. You know each other. You can text. You can just stop by and make your transactions.

Open air markets are there to service strangers. They’re so that buyers and sellers can find each other really fast. And in an open air market, it’s serving people who don’t live in the neighborhood. There’s no reason there’d be that many dealers. The Tenderloin doesn’t need that many dealers to pay for its own drug use.

So it’s a legitimate gripe if you live in a neighborhood and you’re trying to raise a family in a neighborhood that is taken over by an open air market to say, we’re taking all the harms of all the drug use of the other neighborhoods where they don’t allow open air dealing. But people know they can just drive from there to here pick up their drugs and then go off about their way. And that’s unfair. And so I sympathize with the residents of the Tenderloin who are raising that very legitimate gripe about not getting equal protection under the law.

One question I’ve had about all this is how much of it is a set of policies that might’ve worked or certainly worked better than they did, but fentanyl rolled a grenade underneath this? I mean, a lot of this thinking was happening years before fentanyl just completely invaded America.

The emergence and dominance of powerful synthetic drugs like fentanyl among the opioids or super strong methamphetamine that is now a larger share of the market than cocaine has, I think, undermined basic assumptions about drug policy across the world. When a kind of person who might come into, say, a methadone clinic addicted to heroin, their heroin use might be once a day or maybe twice a day, including people who were holding jobs, people who still were in touch with their families. Not that life was going well, but there was some level of manageability. We now have people with fentanyl using 10, 20, 30 times a day. Their entire existence is — because fentanyl has a very short cycle of action.

So you wake up. You’re in withdrawal. Withdrawal is incredibly unpleasant. You may smoke fentanyl, smoke, smoke, smoke. Maybe it takes 10 minutes, 20 minutes, 30 minutes. Your withdrawal finally stops. You smoke some more till you get high. You fall asleep. You wake up, and you’re in withdrawal. And you’re just really stuck like that.

And I see people like that. I mean, I’m very optimistic about the potential of recovery for addiction. Those are what I’ve seen. And those are also my values. I try to approach everybody that way.

And I also sometimes am frightened that it’s just much, much harder to help people in this state when their life is that consumed by drugs even relative to how consumed their lives were by drugs like heroin and OxyContin. It’s really pretty frightening. And we are getting it first. The United States and Canada too are being exposed to these drugs.

It’s interesting to note in Europe, they’re just starting to get these drugs. And whether they’ll keep with their same policy mix is a really interesting question. It isn’t entirely sure. I have a colleague who says fentanyl is like an antibiotic resistant infection. The stuff we always done that used to work doesn’t work anymore. And that’s terrifying.

How good now is our best gold standard addiction treatment?

So this varies a lot by drug. I’m going to start with the bad news first, which is the stimulants. So the biggest disappointment of my career is about cocaine and methamphetamine. I started my career in the late 1980s. And the care that people got for those drugs then is almost the same as what they get now. There’s been very little progress.

Billions have been spent. Brilliant people have tried to develop, for example, pharmacological treatments for them. Nothing has panned out yet. Most of the behavioral treatments don’t work. We have one thing that seems to work, which is contingency management, a particular way of structuring and giving rewards to help people make changes in their behavior. But we’ve had that for a very long time. So the news there is kind of disappointing.

For alcohol, funnily enough, one of the best things we have has been around forever, which is Alcoholics Anonymous. And for a long time, people in my field looked down on it as too folky and not medical enough. And yet there’s now tremendous evidence that myself and some colleagues assembled in what’s called a Cochrane Collaboration showing that does work, that people do, in fact, as well or better in Alcoholics Anonymous as they do coming to see people like myself.

There’s also some medications available. Acamprosate is one. Naltrexone is another. Some people benefit from those.

On the opioids, we have multiple approved FDA medications. Methadone has been around a very long time. It’s a substitute medication. It is effective for many people. Buprenorphine is another substitute medication, slightly different pharmacologically, but also effective for a great many people. And we have naltrexone, which is it works differently. It’s a blocking agent. And there are people who do very well on that.

So those things are all good. That’s considered the front line. You offer people medication first. And people also can benefit from other kinds of things — therapies and from residential care. And if somebody is out on the street with an addiction, it’s not believable that they are going to check in once a week for an hour with a therapist because their lives aren’t that organized. They usually need a safe substance free environment in which to stay. And those are often in short supply. So we sometimes don’t have success there not because we don’t know what to do, but because we haven’t allocated the resources to do it.

But how good are any of these? I mean, let’s zoom in on alcohol for a minute. I’ve known a lot of people — people I’ve loved — who have had very severe alcohol addictions. And you can’t be near that and not realize how differently different drugs act on different people. If I am drinking, just at some point, my body is like, that’s good. We’re done.

And there are people I know who they have burnt their life down around them. And they’ve been in and out of residential treatment. They’ve gone to A.A. Some people recover. Often they really don’t. How likely is it if you go into A.A. or some of these other things that you’ll recover?

People who seek for alcohol treatment or Alcoholics Anonymous can fall into three bins. If you look at them about 6 or 12 months later, somewhere between 40 percent, 50 percent are dramatically better off. Their lives are dramatically better. And that could be the completely abstinent, or they’re much more abstinent, but their lives are dramatically better.

Then there’s another group of people who seem to be somewhat better. That might be 20 percent, 25 percent. They’re still having significant problems. But maybe they make some things like, at least I’m not drinking and driving at the same time, or at least my spouse and I are making some progress in our marital communication. And then the remaining people unfortunately look exactly the same as the day they came into treatment. They either made no progress, or they made some slight progress and then relapsed.

The perception that we have of it tends to be driven by that last group. That’s because when people get better, they disappear into the woodwork. So when I worked in the White House, I used to think when I walked by somebody getting out of the metro who’s actively using drugs or alcohol, I’m very aware. That’s so visible to me.

And yet I know every day people walk by me in suits or in recovery, and I don’t notice them at all. Just looks like another Washington lawyer or civil servant or politician. So the cognitive effects of people who are doing the worst or the most vivid give us, I think, a more despairing view than we ought to have.

How much is the risk of developing an addiction genetic?

Genes affect us a lot. Studies across addictions show a genetic contribution. It varies by the substance, but at least 30 percent, sometimes even 50 percent. How much control people have just in general — some people are more impulsive than others, have a harder time thinking about the future than others from their first day on this Earth. And that will increase your risk for addiction.

If you’re very, very risk averse person who thinks a lot about the future, drug use looks differently to you than if you’re someone who wants to feel good today and is a happy go lucky person. Some of why we get addicted has to do with things that nobody can really control. And those can be things like liking. Even for the first time we use them, we like drugs differently.

When my boys were little, they were in the backyard, and they were climbing a tree. And I said, ah, that’s not how to climb a tree. I’ll show you how to climb a tree. So when I got to the emergency room, I said, this bone is broken. And I know it because I can see the way it’s knocked off my wrist.

And they nicely patched it for me. And they sent me home with Vicodin, the opioid Vicodin, bottle of 30, and said, it’s going to hurt. So you’re going to want to take these.

I take one. And I feel terrible. Stomach all feels bound up. I feel just really groggy. I don’t like this. For me, it was very easy to say pain is better than taking even one more of these pills. Meanwhile, I’ve treated people who say, the first time I had an opioid, it was like a hole that had been in my heart my whole life filled up for the first time.

Now, both those experiences are real. You cannot attribute them to, well, Keith must be a real solid and moral person, and that’s an immoral person, or Keith must have made good choices, and that person made bad choices, because we had no learning history at all. It was just the kismet of genetics that drugs feel differently to different people from the very first time, not just learning history.

And so I find it very easy to be sympathetic to someone who’s addicted to opioids because I think the reason I’m not going to do that is not because I’m a better person. It’s because they just don’t feel good to me. And to you, they felt fantastic. And so you were willing to keep on using them.

It’s not just that I find it easy to be sympathetic. But I find it hard to know how to think about it because, to be blunt, I’ve had very positive personal experiences with certain drugs. And at the same time, I’m somebody who is extremely nonaddictive in this area of my life. I have never wanted more puffs on a cigarette than I had. I’ve never smoked a cigarette and been like, I need another one. Obviously, other people I knew when I was in college, that was not how that went for them.

There is something here where, on the one hand, I worry that a fair amount of the discourse around drugs comes from people for whom maybe it actually is positive for them. There are people who have real positive relationships with different kinds of substances both legal and illegal. Adderall can be amazing for somebody with A.D.H.D., and it can be very destructive for somebody who ends up using it recreationally. I mean, you were talking about methamphetamines. And it’s not all that different.

And it becomes, I think, almost philosophically hard to know how to think about these substances that really can range. How to think about something where for some people it can be a very good part of their life, either pleasurable or even very profound. For other people, it can be a complete disaster that will actually ruin their life. And who are you making policy for and how feels like something that this conversation gets caught on a lot.

I agree, yeah, because drugs aren’t good, and drugs aren’t bad. They are good and bad. And sometimes I envy colleagues who work in areas like cholera prevention. If there’s a cholera outbreak, and you get rid of it, you’re a hero. Everybody loves you. Nobody says, but I was having a party. I need a little cholera. Can’t you keep a little cholera for special occasions? It’s like, no, everyone just hates cholera. Drugs are absolutely not like that. People have great experiences with drugs. I drink wine, by the way. That’s a drug. Or ethanol is a drug.

So we can’t resolve it that simply. And so we have to get into these questions of, well, when is it good? And when is it bad? And for whom is it good? And for whom is it bad?

And then there’s a question that is to me a philosophical question, in fact, religions grapple with, which is should I give something up for the benefit of others? Perhaps I can use fentanyl freely and enjoy it. But should I still say it shouldn’t be in recreational market because I’m aware enough of my fellow people would find it life ruining? And so the moral thing is for me to give it up so the sense that all of us can live together in a spirit of common humanity. And there’s always going to be tougher discussions, things that are good and bad versus things that are just clearly good, and we should just embrace them, and clearly bad and just reject them.

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I wonder about this with the rollout of legal cannabis across a lot of the country. So this is something that I occasionally take. I’ll sometimes have a 5 milligram edible to help me sleep or to relax at the end of the night. It isn’t something I want all that often. And when I go into these stores, and I look in them, and I see the way they’re popping up in New York the way they popped up in California, it’s pretty clear this market is not catering to me.

And I think a lot about something that, as you mentioned, our mutual late friend Mark Kleiman, who was one of the great drug researchers and crime researchers, used to say to me, which is that alcohol companies do not make their money on people who drink a beer or two a week. They make their money on people who drink a case. And when I go into these stores, what I see are the rise of super high potency products that I wouldn’t touch. And clearly the money is being made given how many of the stores there are on people taking a lot more than I am a lot more often. When you look at what is going on with legal cannabis, how do you feel about it?

So start at the question of should we ever throw people in a cell for cannabis? Oh, so that was a terrible idea. So let’s take that off the table and just say if we’re going to have a legal industry, have we regulated it well? And I think it’s absolutely clear we have not.

And this is something we’re generally I’d say bad at relative to other countries of constraining profit when the profit damages public health. And so we have an industry with hardly any constraints on their products, not a very good record with even labeling their products accurately, very poor enforcement of even keeping the legal regime in place. And the pot shops in New York are a good example of that. A huge number of them are unlicensed and just doing whatever they want. And they’re being allowed to do that.

So I think we’ve done a really bad job with cannabis and in part driven by this phenomenon of not being willing to admit that cannabis isn’t good or bad, but it is both. And so when Mark Kleiman and I worked with Washington state, who was one of the first states to legalize, and we said, you still need to have some enforcement to make a licensing system work, I remember people literally either laughing or getting angry at us saying, the war on drugs is over. No more enforcement ever.

It’s like, actually, no. Why would you have a license and do the right thing and not hire minors? And why would you be sure to card? And why would you sell clean and safe products when you do that because you get a market advantage in a licensed market? And so if we just allow anybody to do anything, well, then there’s really no point in getting licensed, no point in paying your taxes, no point in being a good citizen, no point in not in hawking dangerous products.

And that’s the situation that we have. And we’re going to be really sorry for it. The distribution of consumption is also really important to think about. It’s not quite half, but it’s certainly a plurality of cannabis users today are using it every single day, usually a high strength product.

Wow, really? Almost half?

Yeah. I’d say about 40 percent are daily or near daily users. And so that’s where the money is if you’re running an industry. And so you want to produce cheap high-strength product that that population will use and use and use and use. And I just think we’re really going to regret that.

My friends over at “Search Engine,” which is a great podcast, just did this two part series on the New York cannabis market. And I had not really understood that while New York is now completely full of what appeared to me to be legal cannabis stores, virtually none of them are legal cannabis stores. There’s a very small number of legal ones and then a huge number of illegal ones.

And you might say, well, how are there all these illegal stores? And the answer is that nobody wants to send the police to bust people for cannabis. And so much of the theory of legalization as I understood it for years was that we will legalize and then be able to regulate the market. But if what we’ve done is legalized, but we’re not willing to use law enforcement, and so we cannot regulate the market, that’s actually a dramatically different policy equilibrium than I feel like I was promised.

Yeah, the experience you’re having — I think people have had across a lot of drug policy — is expecting one thing and then getting another and underestimating the ideological commitments of the people who designed it. So there are people who say, we’re going to have this legal market, and we’ll get rid of the illegal sellers and all that. But that isn’t what necessarily they wanted. They just thought, look, this should not be restricted at all. And you should just be able to deal with it and sell it and have a classic Libertarian understanding of it as opposed to a more progressive understanding of what we expect from industries. And this problem is replicated all over the country.

There’s also something that’s happened in policing, which is there’s always more to do for police than they have to do. So they’re not super interested in getting involved. Even with some of the massive problems we have, for example, here in California, we have huge illicit groves, some of them staffed by people who have literally been human trafficked. But it hasn’t really risen up as an enforcement priority because, cannabis, we don’t do that anymore.

You said this about cannabis, and I found it really striking. Quote, “The newly legal industry looks a lot like the tobacco industry — an under-regulated, under-taxed, politically connected, white dominated corporate entity that generates its profits mainly by addicting lower income people to a drug. 85 percent of Colorado’s cannabis, for example, is consumed by people who did not graduate from college.” Can you say a bit more about that socioeconomic breakdown?

Yeah. So I think that in middle upper class society, that figure’s really shocking. And the idea is, oh, cannabis user is, oh, someone like you, someone who has a good job, went to college, and maybe uses occasionally. No. I say if you want to think of the typical user, think of somebody who works in a gas station who gets high on all their breaks. That’s much more the sociodemographic breakdown of it.

And by the way, that’s what you see with tobacco as well. In my professional middle class life, it is so rare for me to see somebody smoking a cigarette. But if you go into a poor neighborhood, there’s still a lot of people who smoke cigarettes.

And so we’ve won the war on smoking I guess, middle class and well off. But it’s far less the case as you move into people who have much more challenging lives. And this comes back to the point that you raised and I think is really important one is that since that professional class makes the policies, it’s really important for them to remember that their lives are different than the people whose lives will be most profoundly affected by those policies.

One thing that a lot of drugs, cannabis being one of them, do is allow you to escape from a life that doesn’t feel good to you. If I had a job that bored the hell out of me, it might be more appealing to use something like cannabis more often. I really like my job. And I definitely cannot do it high, so I don’t. But there’s both a question of how does this affect you as a person but also how much might you want it, need it, need the escape?

I think this gets down to one of the most important questions to ask, which is, why don’t more people use drugs? People say, why does anybody use drugs? And it’s like, well, do you ask me why anybody has sex? That’s a really strange question. It feels good. We don’t need an explanation why people use them.

It’s actually far more interesting to think, why aren’t we all using them? Why aren’t you and I using drugs right now? And big reasons why are, well, we have other rewards in our lives. And we have a lot of other stuff that we want to do that is rewarding.

So in the absence of those things, the why not question, the answer seems to be, well, I can’t think of a reason why not. I might as well. Well, you won’t live as long. Well, I don’t expect to live that long. You won’t do well in your brilliant career. I don’t have a brilliant career. You won’t enjoy your fabulous house. I don’t have a fabulous house.

And that’s a reason I think it’s easy or it should be easy to have some sympathy. We all don’t have the same set of rewards to choose from. Rewards any neuroscientists would tell you are judged relative to each other. We don’t just make judgments over good, bad, but we do a lot of this is better than that. So as you pull rewards out of an environment, yeah, drugs become relatively more appealing.

It feels to me across this conversation that we’re talking about two eras that didn’t really work. I think a lot of people are worried about just a pendulum swinging between extremes. I’m curious if to you there is a synthesis out there either in a place or in a theory that feels like it balances these different realities, that people will use drugs? They are good for some people and terrible for others, that we don’t want to be throwing adults constantly into jail because they did something with their own bodies. We don’t want tons of people to get addicted because we decided not to throw anybody in jail. Is there something that feels to you like it strikes a balance here?

So years ago, when I worked for President Obama, we cited Washington’s example because they had taken a couple of hundred million dollars, spent it on mental health and substance use treatment, and showed within 12 months they’d actually made all their money back because of less crime, because of less disability, because of less trips to the emergency room. And importantly, they had gathered data to show that. And that was one of the things we used when the Affordable Care Act was being done to explain why covering substance use in that package would be a good deal for the taxpayer in addition to, of course, being a good deal to any person who had that problem.

There’s also certain issues where people with very different views and feelings about drugs can agree. So I’ve been working with a lot of people around the country on building Medicaid into the correctional system starting in California. It was pushed by a fabulous assembly member named Marie Waldron. We turn Medicaid on before people leave. And that gets them typically on some type of medication. And that can pull people together because it makes it far less likely for them to die of an overdose or to have other health problems. And it also makes them much less likely to commit crimes. And so you can get people like, well, I’m not very sympathetic. I don’t want to spend money on the health of some drug user. But if it makes them less likely to commit more crime, I like that. And other people say, well, this is a health matter. It’s like, well, then they like it too.

And that approach, which now multiple states have been approved for and the Biden administration C.M.S. has said, you can all have this Medicaid waiver — I don’t know the current number. I think it’s about 14 or 15 other states are applying. And as an example of something where you don’t necessarily have to resolve all the disagreements, but you can find a policy that maximizes multiple outcomes that a broad section of people care about.

Something I’ve seen you talk about and write about is this idea that the way that policing should work here is it should be very, very predictable, very certain you will get picked up, and very modest. It’s sort of almost like it operates as a constant annoyance. You end up in jail for 24 hours and are let loose. And there was some evidence that definitely did decrease repeat offending not among everybody but among enough people to really matter in the study. Do you still think that’s a good idea?

Absolutely. It’s a good principle for enforcement and for deterrence to have it be predictable, responsive, and fair. There’s been a lot of success with drink driving and alcohol through the program 24/7 Sobriety, which started in South Dakota and has now spread to about 15, 20 states and is also now in other countries.

It’s all across England, all across Wales where I was just last week actually working on that, which is a model whereby people are sentenced after their second, third, fourth, fifth alcohol related arrest to not be allowed to drink. They aren’t sent to jail. They aren’t fine. Their cars aren’t taken away. But their alcohol use is monitored literally every single day with swift and certain but modest consequences if they drink.

And that program has reduced incarceration. It has reduced crime. It has reduced domestic violence. And it strikes a good balance between using the criminal justice system to protect and put some constraints on people but not in a way that ends up being carceral.

And the place where we can really make a huge impact on that in the United States is the million people we’re already supervising on probation and parole who have substance use problems. And we need to roll those out more broadly. For example, Oregon’s new policy mix if implemented properly, which will be a challenge, I think it would be a very good one. They do put pressure on people to seek treatment. But they say literally, no one is going to be put into a prison in Oregon simply because they used a drug. And now they’re building up the other part you got to have, which is have to have the health system and the services that keep people alive while they use and then help them get into recovery. That, I think, is a very appealing mix of things.

We have a really hard time, I think, in the U.S. and lots of policy issues of realizing that it’s not a series of on/off switches. It’s a series of dials. And you can adjust things and find sensible, nuanced approaches that are more effective than what fits on a bumper sticker.

And I feel like that’s what my job is. And people like me who do not have to take the great risk to stand up and people and say, please vote for me. And then that means I have to explain something simply. It can’t be any other way but are next to it and are very fortunate to have the time to sift through evidence in a calm environment before they venture out with some suggestions about what we might do better.

I think that’s a good place to end. So then as a final question, what are three books you would recommend to the audience?

So there’s so many good books written about in this area. It’s hard to pick. So I decided to prioritize personal relationship starting with your late friend of mine Mark Kleiman, who wrote a book called “Drugs and Drug Policy: What Everyone Needs to Know,” coauthored with Jonathan Caulkins and Angela Hawken.

And it is exactly what the title promises. It’s accessible. It’s something you can dip into and out of and answer any question you want. And I also point to it as just a model of how academics in any area can write in such a fashion that a broad audience can engage their work and learn from it.

The second book I would suggest, again, from a friend who’s someone I’ve known since she was a psychiatric resident and I was an assistant professor. And that’s Dr. Anna Lembke here at Stanford. And the book is called “Dopamine Nation,” which was a deserved bestseller around the world.

But that gives you much more of the human experience describing, what is it like to be addicted, to not be able to stop doing something even though you know it’s destructive? How does it feel? How do you try to overcome it? And what is going on in that person neurologically that makes it so hard? And then the book also talks about just the seeking of reward in a reward saturated society and how we all are chasing all these things, whether it’s on our cell phones or with drugs and so on.

And then the last one — maybe a more eccentric choice, but it’s such a good book — is by Thomas De Quincey. And it’s called “Confessions of an English Opium Eater.” So De Quincey was a hangers on of the romantic poet set about 200 years ago in England. And he wrote at the time a very scandalous account. But, of course, also scandalous things in Britain are often very popular things.

So it became a bestseller about his experience of long time opium use. And he talks about the pains of opium and the pleasures of opium and a bit about how it affects social relationships, how it affects human psychology. And what I like about is, first off, it has a wonderfully florid over the top poetic style. And the other thing is almost everything you and I have talked about today is touched on in that book. And that shows that while we do learn things and we go forward with science, with policy, it is also true that the human relationship with drugs has had the same benefits and challenges in it for time immemorial. And so that’s a reminder of that when you read a book written that long ago and can resonate with so much of what’s going on today.

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Keith Humphreys, thank you very much.

Thank you.

This episode of “The Ezra Klein Show” was produced by Annie Galvin. Fact-checking by Michelle Harris, with Kate Sinclair and Mary Marge Locker. Our senior engineer is Jeff Geld, with additional mixing by Aman Sahota. Our senior editor is Claire Gordon.

The show’s production team also includes Rollin Hu and Kristin Lin. Original music by Isaac Jones. Audience strategy by Kristina Samulewski and Shannon Busta. The executive producer of New York Times Opinion Audio is Annie-Rose Strasser. Special thanks to Sonia Herrero.