CREMR: A Novel Drug Legalization Framework

In 2022, there were 107,941 deaths attributed to narcotic overdose in the United States alone, with 39.5 million people suffering from substance use disorder (SUD) worldwide in 2021 (National Institute on Drug Abuse, “Drug Overdose Deaths: Facts and Figures”; World Health Organization). Increasing drug dependency is a global phenomenon which has had a profound impact on the world economy. In the US, opioid use disorder and overdoses were estimated to cost $1.02 trillion in 2017 alone (Florence et al.). It is evident that drug abuse is a negative influence on both the population’s health and the economy. Hence, it is crucial that policy makers devise strategies to decrease drug use rates.

Traditionally, strong policing has been the favored solution to reduce drug abuse and hence mortality and economic loss. However, recent arguments have been made that legalizing drugs may be more effective. Proponents argue that drug legalization will decrease the violence and crime associated with illegal drug trafficking and allow for reallocation of resources towards rehabilitation, education, and treatment. Opponents predict that the increased availability of drugs due to legalization would cause more abuse and losses (National Center for Education Statistics). Both arguments have a degree of validity, and a regulated legalization model, focused on mortality reduction and dignified care through medicalized access, may be the most effective approach.

As such, I propose a novel framework for drug legalization and regulation, CREMR, focused primarily to mitigate the impact of fentanyl. CREMR stands for the five major elements: consumption centers, rehabilitation, employment, messaging, and research. Through this approach, mortality and lost productivity can be addressed while simultaneously providing dignity to SUD patients.

1. Setting the Stage

The illegal drug market is heterogeneous with a diverse range of drugs available from cannabis to opioids (Substance Abuse and Mental Health Services Administration, “Substance Use Disorders”). It is realistically difficult to combat all drugs at once, so I will be focusing on fentanyl because it is by far the most damaging to our society. 68.4% of 2022 drug overdose deaths in the US were caused by synthetic opioids, primarily fentanyl, making it almost twice as deadly as car accidents (National Institute on Drug Abuse, “Drug Overdose Deaths: Facts and Figures”; National Highway Traffic Safety Administration). 

That said, forcing SUD patients into sobriety through prison sentences will do little to actually decrease fentanyl use. Rather, specialized rehabilitation is necessary. Tomaz et al have found that rehabilitation treatment is more effective for addressing drug abuse than jail time, and this effect can be seen in real life examples as well (Tomaz et al.). Drug decriminalization in Portugal has led to a dramatic decrease in related deaths, seizures, and HIV infections (Félix et al. 1). It is evident that criminalization is not the solution when prioritizing the recovery of SUD patients. However, rehabilitation faces challenges, and success rates vary widely depending on the motivation of the individual (Substance Abuse and Mental Health Services Administration, “A New Look at Motivation”). This is because rehabilitation is often accompanied by extremely painful withdrawal symptoms, even with supporting medications such as buprenorphine (Weber et al. 59). Ultimately, the decision to go sober can only be made by the patient. It is important to remember that SUD patients are humans and have every right to be respected; regardless of whether or not they consume illegal drugs, they should be approached with empathy and the goal of decreasing mortality and creating an encouraging and fostering environment for rehabilitation.

In order to reduce the mortality of fentanyl, it is crucial to first understand its multifactorial dangers. There is no single way fentanyl takes lives, but there are trends. A 2020 meta-analysis conducted at the University of Birmingham collected worldwide scholarly reports on fentanyl-related deaths and sorted them by the cause of death. The vast majority of deaths were attributed to fentanyl overdose (56.4%) and mixed drug toxicity, including those who consumed contaminated fentanyl (34.5%) (Cheema et al. 3286-3287). The main reasons behind fentanyl mortality, therefore, are the failure of users to accurately dose themselves, the lack of pure fentanyl, and users using it in tandem with other dark addicts. 

2. C: Safe Consumption Centers

The most direct way to reduce mortality without treating the addiction itself is to provide a means for accurate dosing, ensure the purity of the fentanyl supply, and restrict potentially lethal doses and concurrent use with other drugs. In addition, availability of the opioid reversal medication naloxone, commonly known as Narcan, and CPR-trained personnel can help respond to any acute overdose (National Institute on Drug Abuse, “Naloxone DrugFacts”; Alqahtani et al. 10).

The establishment of ‘Safe Consumption Centers (SCCs),’ can provide an ideal location for such practices. These would be similar to Canada’s supervised consumption sites (SCSs) with one difference: they would sell fentanyl. The key is to allow legal fentanyl to outcompete illegal supplies and to control the demand, not the supply. Once demand for black-market fentanyl diminishes, so will supply, similarly to how light cannabis legalization in Italy displaced illegal forms. This would, in addition to ensuring purity, lead to a decrease in criminal activity related to illegal fentanyl production and distribution (Carrieri et al. 63).

The specific principles of SCCs would be the following:

1. Exclusively sell uncontaminated, certified drugs. Strictly prohibit third-party drugs. Provide clean needles, syringes, and alcohol swabs.
2. Restrict the quantity a customer can intake in a set amount of time and ensure that they only take one type of drug at a time. 
3. Be staffed at all times by personnel with CPR and resuscitation training. Naloxone should be ready on demand.
4. Prohibit intoxicated customers from leaving until they are deemed fit to leave to prevent driving under the influence and other drug-related crimes. 
5. Encourage rehabilitation through posters and adequate warning signs. When customers seek help, actively connect them with nearby rehabilitation centers.

The manufacture, distribution, sale, and consumption of fentanyl should be legalized only within the constraints of SCCs. These centers should be kept in a clinical yet warm atmosphere, similar to a typical family care clinic. A more hostile environment may force users out into less safe environments, while a more welcoming mood such as that of a bar may lure non-users. The purpose of SCCs is to serve as a temporary relief for previous users until they pursue rehabilitation. It should not, under any circumstance, appeal to non-users. 

A legitimate concern with legal drugs is their competitiveness against illegal counterparts. When marijuana was legalized in the US, illegal marijuana persisted thanks to the high prices of legal marijuana (Kerman et al.). The same may happen with fentanyl legalization in SCCs because abiding by all the stipulations would undoubtedly lead to high operating costs. However, there is a rather simple solution: subsidies. Alongside a base per-unit subsidy to all SCCs, lump-sum subsidies should be provided to SCCs in drug hotspots or impoverished neighborhoods in order to prevent concentration in wealthier areas. This could lead to strong public backlash as it may be seen as encouraging drugs. Even with Canada’s SCSs, there was strong public resistance (Taylor et al.). Still, subsidies, backed by political will, are necessary for successful implementation. Subsidies would drive prices down to a level comparable to illegal drugs. Users would then logically opt for using SCCs as they offer higher-quality, safer drugs at similar prices. 

Some may worry about legal supplies leaking into the black market, but this is unlikely as legal supplies would be too expensive without the subsidies given to SCCs. Others may argue that the legal supply of fentanyl may become contaminated to reduce costs. However, this can be combated by implementing routine testing using infrared fingerprinting, through which individual production batches of fentanyl can be scientifically serialized and tracked in a manner that is impossible to tamper with (Handzo and Peters 24). 

3. R: Rehabilitation Center Reforms and Funding

Currently, a major problem with rehabilitation centers is their steep cost and shady practices. This is especially true with for-profit programs, which require uninsured individuals to pay an average of $17,434 up front (Beetham et al. 317). Fraudulent centers that file unnecessary, marked-up, or even nonexistent tests with the intent of insurance fraud have also become prevalent (Pifher).

Governments should crack down on insurance fraud and set a price ceiling for rehabilitation-related procedures and medications. Facilities should be required to clearly declare their pricing and for-profit status in websites, advertisements, and other official materials. The decrease in availability of rehabilitation care resulting from this should be offset by increasing subsidies for and expanding not-for-profit facilities.

4. E: Employment Support

The end goal of rehabilitation is reintegration into society. Therefore, employment must be treated as a crucial part of rehabilitation. It not only ensures that recovered individuals contribute to the economy but also helps them stay sober (Hser et al.). 

An ideal model for supporting recovered individuals with their job search already exists in Individual Placement and Support (IPS) (Marsden et al.). IPS was originally developed in the US as a means to connect the mentally ill and disabled with personalized employment opportunities (Bond et al. 390). IPS’s multifaceted, comprehensive design ensures that individuals grow competitiveness, are not unfairly excluded, find jobs based on their individual preference, gain timely employment, and receive work-related training (Bond et al. 390). These aspects allow clients to find and retain jobs suited to their personal needs. A 2024 randomized control trial on the efficacy of IPS in SUD cases found that the method both provided for easier employment and was relatively cost effective (Marsden et al.). It is therefore suggested that IPS be implemented on a larger scale to benefit those recovering from SUD.

5. M: Messaging and Education

As important as rehabilitation is the prevention of new users, particularly in younger generations. A useful case study about preventing addiction in the new generation is the decline of adolescent tobacco smoking worldwide (Ball et al.). While there are many factors to this decline, a major reason is the change in public perception of smoking. Cigarettes are “no longer sexy, cool, or even normal” and social pressure discourages teenagers from even starting smoking (Cummings 5).

The same can be done with drugs such as fentanyl through effective public messaging. Public service announcements (PSAs) and other campaigns can be launched to change the public perception of illegal drugs. However, we should not blindly criticize substance use. A major barrier to solving the fentanyl crisis is the stigma and prejudices against SUD patients (Solberg and Nåden 480). A careful balance should be maintained between highlighting the dangers of SUD and showing empathy to those who suffer from it.

Granted, recent meta-analyses have brought into question the efficacy of mass-media campaigns in discouraging drug use (Allara et al.). Still, PSAs remain a cost-effective way to communicate with the public, as it can reach a large population with relatively little cost (European Monitoring Centre for Drugs and Drug Addiction). In addition to educating the public about SUD itself, authorities can utilize PSAs to communicate the societal benefits of SCCs in order to combat the public pushback they may face (Taylor et al.).

6. R: Funding Research

In order to facilitate rehabilitation, it is crucial to fund research on new treatments that reduce withdrawal symptoms and maximize success rates. Potential areas could be vaccines that prevent fentanyl toxicity and novel treatment regimens or strategies (Michael et al. 282). Through development in these areas, rehabilitation can be accelerated.

7. Investing for the Future

It is no secret that CREMR is an expensive proposal. Subsidizing and regulating SCCs, reforming and funding rehabilitation, organizing IPS, running public education campaigns, and funding research all cost money, and a lot of it at that. However, CREMR should be viewed as an investment for a brighter future. Given that the opioid crisis cost the US $1.02 trillion in 2017, or 5.3% of the national GDP, no amount of money is too much when trying to address fentanyl addiction (Florence et al.; “Gross Domestic Product, 4th quarter and annual 2017 (second estimate)”).

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