The director of the federal government’s top agency on drugs and health says ending harsh penalties around use would reduce harm and facilitate access to treatment.

“Societal norms surrounding drug use and addiction continue to be informed by myths and misconceptions,” Nora Volkow, director of the National Institute on Drug Abuse (NIDA), wrote in an opinion piece for the health news website STAT last week. “Among the most harmful of these is the scientifically unfounded belief that compulsive drug-taking by individuals with addiction reflects deliberate antisocial or deviant choices. This belief contributes to the continued criminalization of drug use and addiction.”

“Many people intersect with the criminal justice system as a direct or indirect result of their substance use disorders, and the experience may worsen their addiction and their physical and mental health,” Volkow writes. “Imprisonment itself not only increases the likelihood of dying prematurely but also negatively impacts mental health and social adjustment via the stigma of having been incarcerated. And it has radiating effects: Incarceration of a parent increases their children’s risk of drug use, for example.”

The NIDA official’s column further argues that stigma caused by criminalization and prejudice against drug users have “major negative impacts on health and well-being,” which “helps explain why only 18 percent of people with drug use disorders receive treatment for their addiction.”

“While attitudes around drug use, particularly use of substances like cannabis, have significantly changed in recent decades, the use and possession of most drugs continue to be penalized,” she writes. “Punitive policies around drugs mark people who use them as criminals, and so contribute to the overwhelming stigma against people contending with an often debilitating and sometimes fatal disorder—and even against the medical treatments that can effectively address it.”

“They are often treated in a demeaning and dehumanizing way.”

The fear of criminal consequences—or even the perception of stigma—”reduces the quality of care” people who need treatment can receive and leads to other health effects when they conceal their use from health care professionals, the top federal drug official wrote. Those same factors also prevent people who use drugs from participating in public conversations about how to effectively address substance misuse problems.

“But while a growing number of people in recovery are speaking openly about their past use and their current struggles to keep sober, people who use drugs actively—either because of an untreated addiction or during a period of relapse or even simply as a matter of personal choice outside the context of a use disorder—are not free to do so without fear of legal consequences.”

“An effective public health response to substance use and substance use disorders must consider the policy landscape of criminalizing substance use,” she argues, “which constitutes a major socially sanctioned form of stigma.”

Volkow has expressed similar sentiments in the past, publishing another essay critical of the drug war in May in the journal Health Affairs. While she doesn’t explicitly endorse decriminalization or legalization of drugs in the new piece, titled “Punishing Drug Use Heightens the Stigma of Addiction,” it’s among among her sharpest indictments yet of the drug war—notable given that NIDA, part of the National Institutes of Health, is widely seen as a key piece of the nation’s drug-control apparatus.

Going forward, the official says that “research on the positive and possible negative outcomes associated with alternative policy models that move to prioritize treatment over punishment are also urgently needed, as such models could remove a major linchpin of the stigma around drug use and addiction and improve the health of millions of Americans.”

Volkow has received pressure from advocates to publicly discount the war on drugs as a failure, with the group NORML urging her last year to declare that criminalization causes more harm than marijuana itself.

But Volkow has also acknowledged that cannabis can carry risks. Last year, she told a congressional panel that legalization could bring benefits but also raise concerns. She described it as “an area where there’s been major changes in the perception of the American public that we have a drug that is benign and, as a result of that, we’re seeing a very dramatic increase in the number of people that are consuming marijuana.”

Last month, Volkow stressed to members of Congress that prohibition carries its own concerns, particularly around racial justice. “Abundant data show that Black people and other communities of color have been disproportionately harmed by decades of addressing drug use as a crime rather than as a matter of public health,” she said.

At last month’s hearing Volkow also responded to a question from Sen. John Cornyn (R-TX) on the need to investigate the impact of “high concentrations of THC on people with perhaps mental health challenges or on the developing juvenile brain.”

“Do you agree that it’s important before we legalize marijuana at the federal level—should Congress decide to do so that—we get this kind of research performed so we actually know what we’re doing?” he asked, implicitly recognizing that efforts to end federal cannabis prohibition are gaining momentum.

“I think it’s 100 percent necessary that we actually have an understanding of the consequences of legalizing marijuana are going to have into the children and adolescent brain and what are the consequences,” Volkow replied. “We owe it to the public to actually provide that information.”

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