Chronic opioid misuse puts people at significant risk for developing multiple health problems, caused either by decreased access to preventative care, exposure to blood-borne or sexually transmitted diseases or as a direct result of chronically elevated levels of exogenous opioids. People with opioid use disorder often suffer from chronic pain and mental illness at rates much higher than in the general population and are at significant risk for financial ruin, homelessness, overdose, and death. While it may not be possible to make opioid use completely safe, if we can, we should make it less dangerous. Illicit opioids are often impure and adulterated after production. They must be procured illegally and are often injected with unsterile equipment in an unsafe and unsupervised environment. All of these factors can and should be addressed as part of a comprehensive strategy to fight the opioid epidemic. Only by challenging the beliefs that underlie the stigma surrounding opioid use disorder and directly addressing the factors that contribute to the increased morbidity and mortality associated with chronic opioid misuse can we turn the tide of the epidemic.

Harm reduction refers to a set of strategies aimed to limit the negative consequences associated with drug use, but without requiring complete abstinence. Some harm-reduction strategies aim to reduce the risk of overdose, such as the use of naloxone rescue kits, fentanyl testing strips, and implementation of Good Samaritan laws. Other strategies lower the risk of overdose but also the likelihood of contracting infectious diseases such as HIV and hepatitis. Syringe services programs, also referred to as needle exchange programs, and supervised consumption facilities all fall under this category. Medications for opioid use disorder (MOUD), which include methadone, buprenorphine, and naltrexone, have been proven to lower the risk of overdose, improve the likelihood of maintaining sobriety, and therefore lower rates of disease transmission. Finally, harm reduction is utilized in criminal justice system through the use of drug decriminalization, police diversion programs, and drug treatment courts.

The war on drug users developed in tandem with neoliberalism. By examining the way that society polices and treat people who use drugs, Lenhard and Meng offer a perspective on how neoliberal governance individualizes responsibility and abstains from any kind of collective support. Lenhard and Meng make use of narratives drawn from their fieldwork to illustrate both what criminalized drug use looks like, and how people’s lives change when criminalization goes away. The chapter shows that it’s not necessarily the drugs that make people’s lives difficult and painful but rather the approach that is taken to their behavior. In one model of treatment – exemplified by the war on drugs and the use of methadone programs – a responsibility to change lies solely with the individual, and drug users are criminalized, surveilled, and disciplined primarily by law enforcement. Lenhard and Meng contrast this model with one where society is conceived as collectively responsible to provide support for whomever requires it (e.g., in the form of safe injection facilities) and addiction is understood as something to be managed both medically and holistically. What is interesting in the first model is the way that individual autonomy and responsibility is taken for granted as a preexisting, self-standing capacity that needs only to surveilled, incentivized, and disciplined from the side of the authorities. In the second model, on the contrary, autonomy and responsibility are conceived as capacities that needs to be nourished and cultivated within collective structures of trust and support.

In an era that is often characterized as one of a growing convergence of the laws governing criminal activities in different countries, the issue-area of cannabis policy undergoes processes of fragmentation and polarization. Some countries continue to criminalize all forms of medical and recreational uses of cannabis. Others have sought to “separate the market” for cannabis from that of other drugs by decriminalizing the possession of small amounts of marijuana, authorizing its use for medical purposes, and establishing administrative measures for taxing and regulating the commercial sale of the drug. This chapter explores the causes and consequences of the decline of the transnational legal order of cannabis prohibition. It shows how the erosion of the regulatory capacities of this transnational legal order reflects deep-seated political conflicts over the legitimacy of prohibition norms in this field. It analyzes the ways in which conflicting regulatory approaches become institutionalized as a consequence of the structural mismatch between the actors framing the meaning of cannabis prohibition norms at the international level and the actors implementing these norms in national and local contexts. Finally, the chapter shows how this transnational legal order has created path-dependent trajectories of legal change that continue to shape domestic drug policies in various countries.

The War on Drugs failed and public opinion is turning against punishing marijuana users in much of the world and within the US. Individual states have become the “laboratories of democracy”, beginning with California’s legalization of medical marijuana in 1996. Latin American countries have become less likely to accept US military assistance to combat drug production. Portugal decriminalized all drugs in 2001 without experiencing increased rates of use and Uruguay legalized marijuana in 2013. In 2016 the UN declared the War on Drugs a failure while calling for “an end to the criminalization and incarceration of users….” In 2011 the California Medical Association (CMA) proposed a regulated legal marijuana market and the California Society of Addiction Medicine (CSAM) proposed a public health framework emphasizing directing tax revenue to services for adolescent substance users. Colorado and Washington state legalized marijuana in 2012, Oregon in 2014 and California in 2016. Implementation of the new industry is currently having difficulty suppressing the previously existing underground market. It still remains to be seen whether a legal marijuana industry that pays for whatever damage its products produce in vulnerable populations can successfully replace an illegal market already in place for years.