An estimated 107,543 people died of drug overdoses in the US in 2023, a shocking figure that obscures a glimmer of hope – this is the first annual decline in drug overdose deaths since 2018. The grim toll represents Americans’ struggle with powerful synthetic drugs, in particular the synthetic opioid fentanyl, known to be up to 100 times stronger than morphine. More than 1 million people have died of a drug overdose [since 2001](https://www.cdc.gov/drugoverdose/deaths/index.html#:~:text=Drug%20Overdose%20Deaths%20Remained%20High,1999%20from%20a%20drug%20overdose.&text=In%202021%2C%20106%2C699%20drug%20overdose,2021%20(32.4%20per%20100%2C000).), according to the Centers for Disease Control and Prevention. The National Center for Health Statistics (NCHS), which [tracks overdose deaths](https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm), attributed more than 74,000 deaths to fentanyl, followed by more than 36,000 deaths from methamphetamine. Often, overdose deaths involve more than one drug. Drug overdoses declined 3% in 2023. “We are encouraged to see the preliminary data that shows a decrease in the overdose death rate for the first time in five years, especially following the period of rapid double-digit increases from 2019-2021,” said the White House Drug Control Policy director, Dr Rahul Gupta. The west was hit particularly hard by drug overdoses, according to the data from the NCHS. Alaska, Oregon and Washington all saw increases in drug overdose deaths of more than 27%. The increases may reflect how illicit drugs have moved across the US, after primarily emerging in states east of the Mississippi in the early 2010s. Other states saw notable declines: Nebraska, Kansas, Indiana and Maine all saw declines of 15% or more. Recent reports by the Drug Enforcement Agency (DEA) and a study supported by the National Institutes of [Health](https://www.theguardian.com/society/health), both released this week, paint an increasingly complex picture of the US’s illicit drug supply, with fentanyl-laced pills appearing to make up an increasing proportion of the illicit drug market. “Pills are flooding the market,” said Joseph J Palamar, associate professor in the department of population health at New York University, and the lead author of the NIH-supported study released this week in the International Journal of Drug Policy. According to Palamar’s study, law enforcement seized more than 115m fentanyl pills in 2023, compared with about 49,000 in 2017, a 2,300% increase, while new synthetic drugs such as xylazine have posed new threats. Palamar also said he believes the arc of drug use has changed over time. In the early 2000s, a person might have developed substance use disorder by starting with a prescription opioid, such as Oxycontin, and moving to heroin. By the early 2010s, it was common for heroin to be laced with fentanyl. Today, fentanyl may be preferred by some people and appears as an adulterant in many different types of illicit drugs. It is also pressed to look like prescription benzodiazepines or opioids, raising the possibilities that people believe they are taking prescription drugs, or may begin using with fentanyl. “The most serious thing is you get these young people who think they’re going to take a Xanax or a Adderall or an Oxycontin and then they find out there’s fentanyl in it,” said Palamar. “You have some kid who thinks he’s getting an Adderall from Snapchat or whatever – that kid could overdose and die.” [skip past newsletter promotion](https://www.theguardian.com/us-news/article/2024/may/15/drug-overdose-deaths-2023#EmailSignup-skip-link-12) Sign up to First Thing Our US morning briefing breaks down the key stories of the day, telling you what’s happening and why it matters **Privacy Notice:** Newsletters may contain info about charities, online ads, and content funded by outside parties. For more information see our [Privacy Policy](https://www.theguardian.com/help/privacy-policy). We use Google reCaptcha to protect our website and the Google [Privacy Policy](https://policies.google.com/privacy) and [Terms of Service](https://policies.google.com/terms) apply. after newsletter promotion The illicit drug supply is primarily controlled by Mexican cartels, according to the DEA’s [National Drug Threat Assessment](https://www.dea.gov/sites/default/files/2024-05/NDTA_2024.pdf). Cartels ship fentanyl, methamphetamine and synthetic drugs into the US through expansive networks, often with the backing of illicit Chinese chemical suppliers, pill presses and bankers. The toll also reflects broader struggles within American society. An estimated [2.5 million people](https://nida.nih.gov/news-events/news-releases/2023/08/only-1-in-5-us-adults-with-opioid-use-disorder-received-medications-to-treat-it-in-2021) suffer with opioid use disorder, but only one in five are in treatment, even though the disease has increasingly come into [public view](https://www.theguardian.com/us-news/2024/feb/21/oregon-drug-law-measure-110-backlash) because of a [housing affordability crisis](https://www.theguardian.com/us-news/2024/feb/22/los-angeles-unhoused-deaths-increase-housing-crisis-fentanyl-overdoses). Experts attribute the low number of Americans in treatment to [systemic barriers](https://www.statnews.com/2024/03/05/opioid-addiction-treatment-methadone-buprenorphine-restrictions/#:~:text=The%20evidence%20supporting%20the%20use,to%20those%20not%20receiving%20medication.), including a focus on abstinence, [insurance company policies](https://www.theguardian.com/us-news/2024/feb/03/opioid-treatment-prior-authorization-health-insurance-edited-) and laws out of step with science and those of peer western nations. At the same time, addiction and the overdose crisis have become a new front in the culture war. Republicans have criticized Joe Biden for failing to focus on [interdiction of illicit fentanyl](https://www.presidency.ucsb.edu/documents/op-ed-nikki-haley-ending-the-fentanyl-crisis-starts-securing-the-border) at the border, even as many [Republican policies](https://www.theguardian.com/us-news/2024/feb/03/opioid-treatment-prior-authorization-health-insurance-edited-#:~:text=In%20her%20analysis%2C%20Andrews%20said,harmful%20in%20one%20program%3A%20Medicaid.) make treatment harder to access.

Dave Yeager didn’t join the US army to become a pathological gambler. But after re-enlisting as a food inspection specialist in the wake of 9/11, Yeager arrived at his base hotel in Seoul, Korea, feeling overwhelmed and restless. “I’m walking around and find a casino-style slot machine room,” says the 57-year-old former sergeant. “As soon as I sat down, the first thing I noticed was that my shoulders started to relax. Then I won, and it was like a dopamine hit. In that moment, all of the fear and anger and stress that I was feeling just went away.” Suddenly and without warning, a night of gambling here and there became a seven-day-a-week addiction – one that had him phoning home for more money, pawning personal effects and stealing from his unit. When a demotion in rank failed to curb Yeager’s reckless behavior, his bosses threw up their hands. “My commander, a colonel I really respect, basically said in few words, ‘We have no idea what to do with you because you’re such a stellar performer,” he recalls of the come-to-Jesus meeting that preceded his transfer to a US duty station. “Nobody ever used the word _gambling_. It was ‘this problem you have’.” While the boom unleashed by the 2018 legalization of sports betting [raised fears of an emerging addiction crisis](https://www.theguardian.com/us-news/2023/dec/01/sports-betting-regulation-gambling-addiction), this institutional problem – at the heart of the US military – can be traced back decades, to the rooms like the one Yeager ventured into in Korea. In 1951, Congress banned slot machines from military bases in the US. In the 70s, the army and air force pulled them from foreign bases only to slowly bring them back in the 80s – with the idea that it would keep the troops from running into off-base trouble. Currently, the [US military](https://www.theguardian.com/us-news/us-military) operates more than 3,000 slot machines on bases in 12 countries – down from 8,000 slots in 94 countries in 1999, according to the Pentagon. That’s besides the other chance games the military sponsors on bases, with service members as young as 18 able to participate. The remaining slot machines alone rake in more than $100m annually, money that each branch steers into groups supporting “morale, welfare and recreation” initiatives on all bases such as movie theaters and golf courses. None of that money, Yeager notes, goes toward education, screening or prevention. “When you fall into a gambling problem,” he says, “it’s not treated as a mental health issue and an addiction. It’s treated as a money problem and a disciplinary issue.” All the while, service members spiral deeper down the hole. A [2003 patient chart analysis](https://www.psychiatrist.com/wp-content/uploads/2021/02/17991_suicide-attempts-among-veterans-seeking-treatment.pdf) at one Veterans Affairs (VA) medical center found that, of the patient population that had attempted suicide, 64% blamed gambling-related harms for pushing them to the brink. Three years later, the suicide death of a decorated army helicopter pilot forced the general public to [somewhat reckon with](https://www.cnn.com/2007/US/05/22/military.gambling/index.html) the military’s gambling problem. A [2016 survey of Iraq war veterans](https://pubmed.ncbi.nlm.nih.gov/27156377/) concluded that 4.2% had become at-risk gamblers subsequent to being deployed. According to the National Council on Problem Gambling, an estimated 56,000 active duty service members may meet the criteria for gambling disorder – which more generally affects [an estimated 1% of Americans](https://www.yalemedicine.org/conditions/gambling-disorder#:~:text=Gambling%20disorder%20affects%20about%201,includes%20daily%20fantasy%20sports%20leagues.) – roughly the same percentage of the adult population currently in active duty service. Both demographics skew heavily male. > You’re taught from day one, leave your problems at the door; you have a mission to do Dave Yeager In a 2021 Rutgers University study of gambling in the military, the researcher Mark van der Maas deduced that active and retired military service members were more than twice as likely to become problem gamblers than the general population – and even that may be underestimating the actual figures by quite a margin. “People tend not to think of the different things they’re doing as capital-G gambling because that’s such a morally loaded term,” van der Maas says. “A sports bettor, for example, might not think they’re gambling because they put so much time and research into it.” Van der Maas’s research suggests a connection between military service and poor mental outcomes for women, a less-studied gambling cohort relative to men. “Generally speaking, there are fewer women with gambling disorder compared with men,” he says. “But when we talk about the reasons why people gamble, women are more likely to say that they gamble to help deal with negative emotional state. “In both the US and Canada, women in military service or on police forces are exposed to sexual harassment and assault on the job. Understanding how being in that emotionally stressful environment potentially leads to gambling disorder for women is an area we need to pay more attention to.” Even though gambling has been recognized in the Diagnostic and Statistical Manual of Medical Disorders since 1980, the military is no better at confronting the problem than other American institutions that don’t see gambling on a par with drugs or alcohol addiction. (Some insurance carriers have only just begun covering problem gambling treatments.) It’s only since 2019 that the Department of Defense has mandated annual screenings for gambling disorder as part of service members’ general health assessment in addition to conducting random spot surveys of active duty soldiers. “Early detection and treatment of gambling disorder and other health-related behavioral issues is critical to maintaining the overall wellbeing and operational effectiveness of our forces,” a defense department spokesperson said. Before this statement, neither the defense department nor the VA had publicly commented on efforts to curb problem gambling within their ranks. > It’s only a matter of time before stories come out about the sergeant who committed treason because of their gambling addiction Dave Yeager Still, the military’s periodic checkups for gambling aren’t as rigorous as the ones used for substance abuse, or physical fitness. “It really would just take three quick questions to at least flag if someone needed more follow-up,” van der Maas says. This relaxed attitude makes military members especially vulnerable to gambling addiction. “When you think about military people, they’re very bonded,” says Heather Chapman, a psychologist who directs the gambling program at the Louis Stokes Cleveland VA, one of the few residential facilities in the country that focuses on the disorder. “It almost becomes like a family, and what you see is that behavior becomes integrated within the family structure, something to do when they have downtime – whether it’s slots or a Texas hold ’em tournament. It doesn’t have the immediate problematic issues that drugs and alcohol can have. There’s no obvious screen for gambling other than financial issues, which can affect a person’s clearance if they have considerable debt or declare bankruptcy.” Gambling can seem like an especially attractive escape in a high-stress environment that conditions workers to accept risk, bottle individual issues and finish the jobs they start. “You’re taught from day one, leave your problems at the door; you have a mission to do,” Yeager says. “The problem is that, even when they fall into addiction, the mentality is ‘I _have_ to fix this on my own. I _have_ to keep this to myself. I can’t leave until I _win._’ “One of the tenets of gambling addiction is chasing losses. You add the warrior mentality to that, and you’ve basically got gambling addiction on steroids.” Yeager’s addiction resulted in the breakup of his young family, the end of his military career and a debt in the high five figures. (“The only thing I didn’t do was borrow from my subordinates,” he says.) After a decade-long nosedive that included a two-week stay at a civilian psychiatric hospital, Yeager remembers the stumped counselor at his local VA handing him a packet for the VA gambling program in Cleveland. It was only after making that pilgrimage and communing with veterans in his same foxhole that Yeager turned his life around. Now remarried, reconciled with his family and out of debt, he raises awareness about problem gambling in the military, touring the country and promoting a book about his recovery all the while. He hopes to be a light to service members. In some ways, as gambling becomes more ubiquitous and accessible, they are even more vulnerable to addiction. “Just having gambling in your pocket now changes everything,” Chapman says. “We won’t really know what the true impact will be for another five or six years down the road when things really start to boil over.” Some federal lawmakers have shown a willingness to cooperate in the interest of heading off disaster. In 2017, the senators Elizabeth Warren and Steve Daines introduced a bipartisan bill that would force the Department of Defense to track gambling disorders in its health assessments and develop policies and programs around treatment and prevention. Earlier this year the congresswoman Andrea Salinas teamed up with the senator Richard Blumenthal on a bill that, among other things, would [funnel half of the federal taxes on gambling operators into national treatment and research programs](https://www.theguardian.com/us-news/2024/jan/27/gambling-addiction-bill-treatment-online-sport-betting-andrea-salinas). But both measures have struggled for traction within a divided Congress. The inaction just deepens the sense of dread within the precincts of the military on the frontlines of the gambling addiction problem – not least Yeager, who shudders to think of the potential risks to national security if the military’s gambling problem continues unchecked. “I’m telling you right now: it’s only a matter of time before you start seeing stories come out about the major who lost their commission, or the sergeant who committed treason because of their gambling addiction,” he says. “There’s so much more we need to do. And that’s why I don’t shut up.” * _In the US, call the National Council on Problem Gambling at 800-GAMBLER or text 800GAM. In the UK, support for problem gambling can be found via the NHS National Problem Gambling Clinic on 020 7381 7722, or GamCare on 0808 8020 133. In Australia, Gambling Help Online is available on 1800 858 858 and the National Debt Helpline is at 1800 007 007._

**2 Scrappy weapons startups are changing the face of war in Ukraine** They’re leaving the more established players in the dust. ([FT](https://www.ft.com/content/cf6ded0f-f595-4359-b8f7-273799f1149c) $) \+ _Inside the messy ethics of making war with machines._ ([MIT Technology Review](https://www.technologyreview.com/2023/08/16/1077386/war-machines/?truid=*%7CLINKID%7C*&utm_source=the_download&utm_medium=email&utm_campaign=the_download.unpaid.engagement&utm_term=*%7CSUBCLASS%7C*&utm_content=*%7CDATE:m-d-Y%7C*)) **3 How to scam a scammer** AI bots are the first line of defense against crooks on the phone. ([The Guardian](https://www.theguardian.com/technology/article/2024/jul/07/ai-chatbots-phone-scams)) \+ _Crypto hacking thefts are on the rise._ ([Reuters](https://www.reuters.com/technology/crypto-hacking-thefts-double-14-bln-first-half-researchers-say-2024-07-05/)) \+ _Watch out for card skimmers, too._ ([Insider](https://www.businessinsider.com/how-to-spot-card-skimmers-ebt-scam-2024-7) $) **4 Saudi Arabia is using esports to launder its reputation **It’s been accused of attempting to sportswash its human rights record. ([CNN](https://edition.cnn.com/2024/07/06/sport/esports-world-cup-saudi-arabia-spt-intl/)) **5 Here’s what would happen if Russia detonated a nuclear bomb in space **It would cause indiscriminate damage all over the world. ([WP](https://www.washingtonpost.com/technology/interactive/2024/nukes-space-explosion-nuclear-weapon-russia/?itid=sf_technology_article_list) $) \+ _How to fight a war in space (and get away with it)_ ([MIT Technology Review](https://www.technologyreview.com/2019/06/26/725/satellite-space-wars/?truid=*%7CLINKID%7C*&utm_source=the_download&utm_medium=email&utm_campaign=the_download.unpaid.engagement&utm_term=*%7CSUBCLASS%7C*&utm_content=*%7CDATE:m-d-Y%7C*)) **6 Ferrari is working on its first fully electric vehicle **Though other luxury automakers have struggled to make the switch. ([NYT](https://www.nytimes.com/2024/07/06/business/ferrari-electric-vehicles.html) $) \+ _Why the world’s biggest EV maker is getting into shipping._ ([MIT Technology Review](https://www.technologyreview.com/2024/01/30/1087393/byd-shipping-electric-cars-china/?truid=*%7CLINKID%7C*&utm_source=the_download&utm_medium=email&utm_campaign=the_download.unpaid.engagement&utm_term=*%7CSUBCLASS%7C*&utm_content=*%7CDATE:m-d-Y%7C*)) **7 How an Australian couple persuaded regulators to greenlight MDMA therapy **Despite lacking a medical or scientific background. ([Bloomberg](https://www.bloomberg.com/news/features/2024-07-08/australia-clears-medical-mdma-mushrooms-after-couple-s-drugs-campaign?srnd=phx-businessweek&sref=E9Urfma4) $) \+ _A person may have died after eating microdosing candies._ ([Ars Technica](https://arstechnica.com/science/2024/07/authorities-investigating-death-possibly-linked-to-toxic-microdosing-candies/)) \+ _US FDA advisors just said no to the use of MDMA as a therapy._ ([MIT Technology Review](https://www.technologyreview.com/2024/06/06/1093327/fda-advisors-just-said-no-to-the-use-of-mdma-as-a-therapy/?truid=*%7CLINKID%7C*&utm_source=the_download&utm_medium=email&utm_campaign=the_download.unpaid.engagement&utm_term=*%7CSUBCLASS%7C*&utm_content=*%7CDATE:m-d-Y%7C*)) **8 Google’s repairs policy is busted **Good luck trying to get that Pixelbook Go working again. ([Wired](https://www.wired.com/story/google-repair-policy-broken/) $) **9 This pill can help to treat alcoholism** But doctors appear reluctant to prescribe it. ([Slate](https://slate.com/technology/2024/07/alcoholism-pill-naltrexone-prescription-addiction-treatment.html) $)

NEW YORK -- It was a landmark moment for the [psychedelic movement](https://apnews.com/article/aaron-rodgers-psychedelics-conference-bae8c5ae3f221770fb84b123a92cf2d2): The Department of Veteran Affairs’ top doctor stood on stage, praising advocates who have spent decades promoting the [healing potential of mind-altering drugs](https://apnews.com/article/af93ce6f3daf4a8b97f21b9cde196cda). In an unannounced appearance at a New York psychedelic conference, the VA’s Dr. Shereef Elnahal said his agency was ready to start rolling out [MDMA-assisted therapy for post-traumatic stress disorder](https://apnews.com/article/mdma-fda-psychedelic-therapy-ptsd-treatment-drug-bc2d7495035a9532876c3dcaf52a9761) as soon as regulators approved it. “The VA has to be first, as we have been, with the mental health needs of our veterans,” Elnahal told attendees at the May meeting. He also highlighted the “awesome, groundbreaking” research on the drug by MAPS, or the Multidisciplinary Association for Psychedelic Studies, the leading nonprofit advocating for the medical and [legal use of hallucinogenic drugs](https://apnews.com/article/psychedelic-churches-ayahuasca-5101fe47fe9a6e28de686272ed96ff46). But expectations for MDMA’s first-of-a-kind approval unraveled a few weeks later when Food and Drug Administration advisers [voted overwhelmingly against the drug](https://apnews.com/article/mdma-psychedelics-fda-ptsd-ecstasy-molly-1f3753324fa7f91821c9ee6246fa18e1), citing flawed data, questionable research conduct, and potential safety and addiction risks. The panel's recommendation isn't binding, but the FDA is widely expected to delay or decline approval when it makes its decision by mid-August. The potential rejection has sent shockwaves through the psychedelic community, including [combat veterans](https://apnews.com/article/magic-mushrooms-therapy-conservative-states-3384fd864634204deba9fa8c21d4dcf8) who have spent years lobbying for the drug, which is also known as ecstasy or molly. The advocacy effort has long been intertwined with MAPS, which has funded or supported some of the most vocal veterans supporting psychedelic therapy. Dr. Harold Kudler of Duke University met with veterans and MAPS leaders while serving as the VA’s top consultant on mental health services. He believes FDA's experts are justifiably skeptical of the science behind the drug, which he says has been drowned out by messaging from MAPS and its leader, Rick Doblin, who began pursuing MDMA's approval in the mid-1980s. “Rick is the most persuasive advocate within the scientific community that I’ve ever seen. You want to believe him because he's offering you something you sorely need — an effective treatment for PTSD,” Kudler said. “But I think the FDA committee caught a glimpse of how much of this is Rick’s zeal and how much is real.” MAPS declined to make Doblin available for an interview. Instead the group pointed to a recent [statement](https://www.scientiststatementonptsd.com/) by two dozen scientists and pharmaceutical executives — many with backgrounds in psychedelic research — supporting MDMA's approval. Earlier this year, MAPS changed the name of its drug development arm to Lykos Therapeutics, allowing the new company to [raise funds from outside investors](https://apnews.com/article/psychedelic-drugs-mushrooms-startups-psilocybin-fda-e3f629f817781b096d72535e022d8b2f). In addition to shortcomings in Lykos' studies, FDA panelists voiced concern about separate allegations that some MAPS-affiliated researchers suppressed negative study results or coached patients to inflate positive results. The FDA says it's investigating those claims. Casey Tylek, an Army veteran, says he didn't experience any of that while [participating in the study](https://apnews.com/article/mdma-ecstasy-ptsd-study-molly-fda-1155a374305027567d5f41910022022d). When he asked researchers for guidance in evaluating the effect of the drug, Tylek says he was repeatedly rebuffed and told he had to rate the treatment without any outside influence. Tylek says he was “pessimistic” going into the trial, but credits MDMA-assisted therapy with resolving anger, anxiety and trauma stemming from a rocket attack in Iraq. “It basically rewrote that memory in my mind and how it functioned,” Tylek said. “I was able to just kind of let go of it and not be hung up on it.” Kudler and other researchers say they want to see the MDMA results confirmed in larger studies that have no links to the psychedelic community. That work would take years. Veterans who support the treatment say it would jeopardize patients suffering from PTSD who haven’t been helped by antidepressants and other existing therapies. The suicide rate among veterans is 70% higher than the general population, according to government figures, with 18 veteran suicides per day in 2021. Jon Lubecky, who served in both the Marines and the Army, says he tried to kill himself five times after returning from deployment to Iraq in 2006. After years of struggling with PTSD he enrolled in a MAPS trial in 2014. He credits MDMA-assisted therapy with curing his condition. Since then, Lubecky has told his story hundreds of times in media interviews, congressional hearings and private meetings with military officials and federal lawmakers, including conservatives like Sen. Rand Paul and Rep. Dan Crenshaw. Lubecky worked as a consultant for MAPS for more than five years. But he rejects the idea that he was merely advancing the agenda of psychedelic boosters who want to see the drugs outright legalized. “I’m not in this for ending the drug war or any of those other things," he said. "I’m in it for my friends.” Lubecky’s work helped secure $20 million in funding for the VA to conduct its own studies of psychedelics, including MDMA and ketamine. Part of the rationale for that research: Many veterans now leave the U.S. to undergo psychedelic therapy at clinics in Mexico, Peru and other countries where it is more accessible. A nonprofit group, Heroic Hearts Project, currently has a waiting list of over 1,000 veterans seeking financial and logistical support to travel abroad. A former Army Ranger, Jesse Gould, founded the group after returning from a weeklong retreat in Peru using ayahuasca, the psychedelic brew associated with indigenous cultures of the Amazon. After the experience, he said he was able to overcome anxiety, anger and depression that had burdened him after three deployments to Afghanistan. Gould says MAPS deserves credit for kickstarting research that could eventually help thousands of veterans. “I think MAPS has done more for the veteran community in this area than most politicians have done in the last 20 years,” said Gould, whose group has no financial ties to MAPS. “Time and time again our needs either go unheard or go to the back of the line.” Heroic Hearts hosted an event on Capitol Hill earlier this month where several House lawmakers and veterans called for MDMA's approval. Gould doesn’t expect the FDA to flatly reject MDMA. Instead he and others say the agency may ask Lykos to perform additional studies. Even if the company is unable to quickly conduct that research, experts say others could benefit by avoiding the pitfalls in Lykos' MDMA application, including a small patient population with little diversity and a high potential for bias. [Dozens of other drugmakers](https://apnews.com/article/filament-health-natural-psychedelics-psilocybin-aadee1fa4e84692d614888fa5ff66d18) are studying [psilocybin](https://apnews.com/article/mushroom-psychedelic-alcoholism-study-a3b6692ae7590de9fd09a7cac271a199), LSD and other psychedelics for depression, anxiety and addiction. Dr. John Krystal, a Yale University psychiatry professor, said Lykos' setback "will hopefully ensure that future studies are conducted in ways that give reviewers greater confidence about the effectiveness and the safety of these drugs.” \_\_\_ The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Science and Educational Media Group. The AP is solely responsible for all content.

 How do you fight HIV infections in the midst of a war? That’s a question that’s been bedeviling Ukraine since the Russian invasion of February 2022. It’s a critical issue for a country that, with an estimated [245,000 people living with HIV](https://www.thelancet.com/journals/lanhiv/article/PIIS2352-3018(22)00257-0/abstract), has the second highest incidence of the infectious disease in Europe after Russia, with the virus typically spreading through contaminated blood, sexual contact and shared needle usage. “After the fall of the Soviet Union, injectable drug use was very, very high across all former USSR countries,” says Dr. Ksenia Voronova, an infectious diseases doctor who works for [AIDS Healthcare Foundation Ukraine.](https://www.aidshealth.org/category/global/ukraine/) “There were a lot of cheap, high purity drugs, and people would gather together and share needles. It was one of the main reasons for the fast spread of HIV. “ ### A threat to past progress Ukraine turned the corner in its battle to control HIV in 2012, when the annual rates of new infections [declined](https://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2013/november/20131120report) for the very first time, from 17,300 people being newly infected with the virus in 2011 to 16,847 the following year. This reduction followed the implementation of contact tracing to rapidly identify newly infected individuals and provide them with access to antiretroviral drugs that suppress the virus. Injectable drug users were offered opioid substitution therapy such as methadone or buprenorphine, which provided them with a pathway to stabilize and eventually tackle their addiction. “Ukraine has always been, I believe, at the forefront of HIV prevention,” says [Tetyana Vasylyeva](https://publichealth.uci.edu/faculty/vasylyeva-tetyana/), a Ukrainian epidemiologist now based at UC Irvine. “These initiatives, which helped find undiagnosed people and link them to care, were tested in Ukraine and have since been adopted by many countries in Southeast Asia and Africa.” “Things were on a good trajectory,” she says. But when war came to Ukraine in early 2022, Vasylyeva was immediately concerned that much of this progress would be undone. By early 2024, the fighting had already displaced an estimated 3.7 million people within Ukraine and another 6.3 million fled the country. So far, Russian bombardments have completely destroyed 214 medical facilities and damaged more than 1,600, with the biggest losses in eastern Ukraine. National health-care spending declined from 12% of the budget to just 5% while defense expenditure soared from 9% to 55%. ### Coming up with solutions But despite limited resources, the groups leading the effort to address HIV have improvised solutions, from organizing medical missions in war-torn regions close to the front line, to rolling out new preventative medications that can protect people from the virus for weeks at a time. [The Alliance for Public Health](https://aph.org.ua/en/home/), a Ukrainian advocacy group working to fight HIV/AIDS, tuberculosis and other infectious diseases in the country, was able to procure emergency antiretroviral supplies through U.S. donors such the Global Fund and PEPFAR — treatments previously purchased in large quantities by the Ukrainian government. But the Alliance still faced challenges in administering care, as many trained health-care professionals with expertise in managing HIV left the country. “At the time, I was trying to establish a research project in Ukraine, and the lack of skilled professionals with experience of working in HIV services was pretty dramatic,” says Vasylyeva. “Of course some people stayed, but their workload tripled.” At the same time, Ukraine was experiencing a dramatic population displacement as millions fled from the east to the relative safety of western cities like Lviv. Andriy Klepikov, the Alliance’s executive director, says that as a result of this population movement, demands soared for so-called Pre-Exposure Prophylaxis (PrEP) drugs, which are 99% effective at preventing HIV transmission through sex and 74% efficient at preventing HIV infections through drug use.  But even as the Alliance and other organizations attempted to help the influx of people fleeing to the west, they worried about the health of those still in war-torn eastern Ukraine. Studies showed that the stresses of war were driving a sharp rise in the [use of injectable opioids](https://www.nyu.edu/about/news-publications/news/2024/february/war-opioid-crisis-ukraine.html). And with hundreds of hospitals and clinics razed, access to health care was extremely limited. Within a few months, the Alliance estimated that without intervention, this could ultimately lead to hundreds of new infections. ### Bringing help to the 'Red Zone' In December 2022, a small team of doctors, nurses and lab technicians embarked on their first mission into what the Ukrainian government calls the Red Zone, an area of roughly 6,000 square miles. It encompasses the rural towns and villages of eastern and central Ukraine which lie between five and 50 kilometers from the front line. This mission represented the first step in an ongoing project launched by the Alliance to restore some form of health care to Ukraine’s most vulnerable citizens. Pavlo Smyrnov, deputy executive director of the Alliance, recalls that the initial journey took them on icy roads winding through fields on the outskirts of Kupiansk, a city that had been captured by Russian forces in late February, and liberated seven months later in early September 2022. The crew travelled in vans equipped with a small lab, capable of analyzing rapid HIV tests, and stocks of vital medications. Smyrnov says the team could hear the rattle of gunfire just three or four miles away, but were still able to provide general medical care to around 70 people**.** Since then, similar missions have been undertaken to 230 towns across the Red Zone, administering just over 1,000 HIV tests and uncovering 12 previously undetected cases in the process. The team also carried out tests for tuberculosis, hepatitis C and syphilis. With battlefield lines continuously being redrawn, these missions come with their own risks. Phones must be switched off to avoid detection from the Russian army and low-flying military planes occasionally whizz through the treetops, just 30 feet or so from the ground, to avoid radar. Smyrnov says that at times the fighting has been so close that the van’s windows have been shaken by the rumble of incoming artillery. “Our team protocol is that when that happens, we pack up and leave immediately,” he says. “Because there is a possibility that the next shot will be on your position. It’s quite hair-raising.” Still, these mobile clinics may become more widespread. The Alliance says that Russia has continued to bombard Ukraine’s energy facilities to an extent that electricity blackouts last for much of the day, but the mobile clinics are powered by their own independent generators and can work through the disruptions. UC Irvine’s Vasylyeva recently traveled to Ukraine to help set up mobile testing across major cities. “It’s really hard to run HIV tests in a traditional laboratory when there’s no electricity for up to eight hours a day,” she says. “But with these mobile labs, we can still get testing done, even if the electricity goes down for a really long time.” Her project is in partnership with the [L.V. Gromashevsky Institute of Epidemiology and Infectious Diseases](https://ror.org/01t7qjd50), one of Ukraine’s leading scientific institutions studying HIV and other infections within the country. ### Reaching out to refugees Other efforts are working to help displaced Ukrainian refugees get HIV support in their new countries. The Alliance for Public Health says it has had success with telemedicine. MISSING TEXT? Over the last two years, the group introduced a digital service called the HelpNowHub, which runs on encrypted social media channels like WhatsApp and Telegram. It has addressed more than 50,000 requests from Ukrainians living with or affected by HIV, helping them access antiretrovirals and HIV prevention medications in their new country as well offering translation support to help them navigate their local health care services. ### A new generation of preventive drugs There is also hope in the form of a new generation of pharmaceuticals, which were the focus of considerable optimism at the AIDS 2024 conference in Munich last month. A longer-acting form of the preventative drugs taken before HIV exposure (PrEP) called cabotegravir is drawing particular attention. It prevents HIV from entering cells and could make it far easier to stop chains of new infections. While previous forms of PrEP had to be taken daily, cabotegravir only has to be injected once every two months. Clinical trials conducted in the U.S., Latin America and sub-Saharan Africa found that cabotegravir reduces the risk of contracting HIV by anywhere between 66 and 89%, and this month, a new trial of the drug has begun in 100 homosexual men in Kiev and Lviv. “Cabotegravir is the talk of the town everywhere right now, but particularly in a country like Ukraine where the situation is so volatile, you don’t know whether your health-care facility will still be standing next month, it can be crucial,” says Vasylyeva of UC Irvine. “So the longer you can go without needing contact with your care provider, the better.” But while Vasylyeva is optimistic about Ukraine’s ability to continue driving down infection rates, the situation in the Russian-occupied cities of eastern Ukraine remains uncertain. Here, the Ukrainian HIV charity, [100%Life](https://network.org.ua/en/), fears that the epidemic is being silently fueled by forced sex work. Vasylyeva admits that there is no data on HIV rates among these regions as testing has all but stopped, but she and others strongly suspect that rates are rising. “I’m scared to think about what’s happening in these territories and what’s going to happen when the war ends,” she says. “All of us are very hopeful it will end in Ukraine’s favor, but even then, there will need to be a lot of adjustment to make sure that HIV cases in these areas don’t seed outbreaks in the rest of the country when Ukraine is unified.” _David Cox is a freelance health journalist who has written for publications around the world including NPR,_ The New York Times, Wired _and_ The Guardian. _He has a Ph.D. in neuroscience._

 It should be easier to get the methadone today than it has been in decades. In April, 2024, the federal government relaxed some of the rules around the treatment for opioid addiction. But many patients are still not benefitting from those changes. Kellyann Kaiser, 30, is among those in recovery who had been waiting eagerly for greater access to methadone. She said she was addicted to opioids from the age of 13 into her late 20s. She tried several different addiction medications, including buprenorphine and naltrexone. “I think just methadone is what got me sober,” she said. “Without that, I think I would still be using.” But it hasn’t always been easy for her to get the sticky pink liquid — taken daily — that relieves her opioid cravings and withdrawal symptoms. At first, she had to drive an hour from her western Massachusetts home to a methadone clinic. “And I have three little children, so I would have to find a babysitter for them. Go out there and come back,” she said. “I used to have to go every single day.” Now, there’s a clinic closer to her home and Kaiser only has to go once a month. That’s because new federal rules allow her to take methadone bottles home, instead of taking each dose at the clinic. “(Under) the old rules you had to be in clinic for 90 days and you had to never miss a day to get one bottle. So that's a lot of perfection,” to expect from patients, says Dr. Ruth Potee who oversees Kaiser’s treatment at the nonprofit Behavioral Health Network, based in Springfield, Mass. Potee is also a national advocate for better addiction treatment. In contrast, newer anti-addiction drugs like buprenorphine and Vivitrol can be prescribed in a primary care office and picked up at a pharmacy. Since they have a different chemistry, those medications can’t be abused in the same way as methadone. But for many people, Potee said, methadone works better against the potent new street drugs like Fentanyl and Xylazine. She calls methadone a “miracle drug.” “It doesn't take any length of time to get on to it,” she said. “You get to a stable dose and then you stay there. You don't really develop tolerance to it.” ### A COVID-era experiment with methadone rules proves successful Methadone, which locks up opiate receptors in the brain, was first introduced to treat addiction in the 1960s, just as the Nixon administration’s War on Drugs was doubling down on a law-enforcement approach to drug abuse. At the time, methadone’s high street value and potential for abuse led the federal government to set up strict rules around how to get it, including daily visits to a high security methadone clinic and mandatory counseling. “They just built the rules in this one way that made it incredibly restrictive,” Potee said, “And they never went back to change it, despite decades of increasing addiction.” But this past spring, the federal agency that oversees substance abuse and mental health services — called SAMHSA — changed the methadone rules for the first time in decades. Under the new rules, patients still have to get methadone at clinics, but if they meet the criteria, they can take weeks’ worth of bottles home and get counseling via telehealth, and providers have more leeway in prescribing individual doses. Dr. Yngvild Olsen, who directs substance abuse treatment for SAMHSA, said regulators first tried out the new rules as a COVID measure and, as she put it, the sky didn’t fall. “This did not increase the rate of methadone-related mortality, for example, which had been one of the concerns prior to this kind of natural experiment,” she said. The agency also put in guardrails to limit abuse and black-market sales. For instance, Kellyann Kaiser said she had to earn the right to take methadone at home. “I had to pass so many drug tests to get it,” she said. “And then you have to take a class, like a safety class, on what you do with your methadone, how you keep it safe in your home.” Kaiser lost custody of her son when she was using illegal opioids. She credits methadone with getting him back and the new rules with helping her stick to treatment. ### Adoption of the new rules slow and patchy, leaving many out Kaiser lives in Massachusetts, a state that embraced the new flexibility around methadone. Not all places have. The federal standards are voluntary. Olsen says states can choose to keep their rules more strict, including daily check-ins. “There are some states that are still really looking at and figuring out what's going to work best for their state and to what extent they will align \[with the federal rules.\]” Olsen said her staff is encouraging states to fully implement the federal guidelines by the official (albeit voluntary) compliance date in October, but many advocates say adoption has been frustratingly slow. “Substance use treatment programs love rules,” said Brian Hurley, who heads the American Society for Addiction Medicine. “It takes time both for state regs to change and, frankly, for business operations and clinical practices to evolve.” He says the general culture of methadone clinics — also called Opioid Treatment Programs or OTPs — is mired in the way things have always been done. So starting in Los Angeles where he’s based, he’s trying to help local clinics set up new protocols, “shifting the approach from a rules-based to a patient-centered approach.” But there are reasons some providers are going slowly. “When you look at a whole system of 2000-plus treatment programs, it's like watching an aircraft carrier change course in the middle of the ocean,” said Mark Parrino, head of the American Association for the Treatment of Opioid Dependence, a trade group for methadone clinics. “It does so, but it does so carefully.” Parrino said his group approves of the new flexibility but that members worry about liability when patients are not closely supervised. He pointed out that patients can overdose on methadone, which is itself an opioid. “Methadone is a very therapeutic medication when it's used wisely,” Parrino said. “But if it's used unwisely, it's unforgiving.” Parrino also brought up a financial concern. He said clinics —many of them for-profit and run by private equity firms — are waiting to see if Medicaid changes how it pays for methadone treatment when patients come in less frequently. Otherwise, he said, “the programs absolutely lose money. Some would not be able to continue.” But even if the federal rules are put into wide practice, many addiction doctors and advocates say they don’t go far enough. “They won't be enough until methadone is freed from methadone clinics generally,” said Massachusetts U.S. Senator Ed Markey, who is sponsoring legislation he says would break the clinics’ monopoly on methadone. Markey’s legislation, known as the Modernizing Opioid Treatment Access Act (MOTAA), would allow methadone to be prescribed by any board-certified addiction doctor and picked up at a regular pharmacy. The American Society of Addiction Medicine supports the proposed legislation. The clinic trade association opposes it.

Micheal Ray Richardson was a brilliant player: a four-time NBA All-Star guard. He was also the first player banned for life by the league for drug use, something which was far more common during his playing days. Back in the 1980s, substances like cocaine were not only part of professional sports but also [society and](https://www.yahoo.com/news/casual-cocaine-ads-show-lit-034207924.html?guce_referrer=aHR0cHM6Ly93d3cuZ29vZ2xlLmNvbS8&guce_referrer_sig=AQAAAHMFIIC0I8gRIjyL5Ph-tiwdxeSMiSc1V0Fv4xwrr9QNyjpRhZ4mLAej3B3Y4sfhnjBFzxcfzMnY9IEOPlR4V-CQpIEt3kViJFKF_2-_lXbrkS5m0nJZph6h3XPuM7wwtnmWFhCsFStqxjzNIeIDu3IfXdSJzRH7eabvm1XZuj65) [entertainment at large](https://faroutmagazine.co.uk/this-bill-murray-movie-was-a-permanent-cocaine-party/), and Richardson says talk about drugs was routine during what some still call the NBA’s cocaine era. “During warmups,” Richardson says, “guys on different teams would say, ‘Yo, man, I got what you’re looking for. Let’s get together when \[the game\] is over.’ And _boom_ that’s how it got going.” At the time, drugs were “everywhere – it was like a fad,” says Richardson, who also goes by the nickname Sugar. But in the NBA, it alienated many fans. So much so that to correct the problem, the NBA instituted a three-strike system, which led to Richardson’s 1986 banishment (all of which he discusses in his [forthcoming memoir](https://www.amazon.com/Banned-Squandered-All-Star-Finding-Redemption/dp/1683584902), [Banned](https://hoopshype.com/2024/09/19/banned-how-i-squandered-an-all-star-nba-career-before-finding-my-redemption/)). Today, aside from the 10ft basket and the five-on-five competition, the [NBA](https://www.theguardian.com/sport/nba) does not resemble the league in the late 1970s and early 1980s. But when it comes to drugs, that change took time. For Richardson, who grew up modestly in the midwest and only got into drugs after succumbing to peer pressure while living in New York City and playing for the Knicks, drugs were not a part of his early life. Then they overtook him and led to a debilitating years-long addiction. But his story is far from unique. When David Stern took over as commissioner of the NBA in 1984, one of his top priorities, along with promoting the Magic Johnson-Larry Bird rivalry, was cleaning up the game. That meant suspensions and lifetime bans (Richardson was also the first player reinstated to the NBA, in 1988, but he never returned to the league). Still, pro basketball in those days was littered with addiction and lost potential. Marvin “Bad News” Barnes is perhaps the poster child for drug issues. His biography, [Bad News](https://www.amazon.com/Bad-News-Turbulent-Basketballs-Original/dp/1683582675/ref=sr_1_1?crid=2X7JD0W75AM82&dib=eyJ2IjoiMSJ9.9xcKMDEHBV6wMLdwH0w53RPhkgZE3PSZcn4ALMVySrOdjBLSGLfRv9XbdZeZsg4oP4cQT3uthlPIYg0G0_RdwYMP1k9zYkmNVFGz60Hkau54EJCmip34_rmQL41K14EvOvNmpnWWsltbaiC-PEWqPg9H5taZs-kqmVChnBNtHJSM866lIYyD5FIfxjVeiYprlVdBAGTmf1IuCtHRn6QG-7IVyTBMY5ssdyrynXqaYlo.bfoB_qbjJ5JgbBpGfjJNqInB6rbwUtUR81QQ1CCNC3A&dib_tag=se&keywords=bad+news+barnes+book&qid=1728504234&sprefix=bad+news+barnes+boo%2Caps%2C153&sr=8-1), details a life of [drug abuse](https://www.chicagotribune.com/1990/03/04/bad-news-is-back-behind-bars/), which included hanging out with drug kingpins, derailing what could have been a Hall of Fame career. He went from averaging 24.1 points and 10.8 rebounds per game in 1975-76 in the ABA to 9.6 and 4.8 a season later in the NBA. Barnes was out of pro hoops by 1980 and, despite trying many times, never kicked his habit before passing away in 2014. But Barnes, too, is not an isolated case. In 1986, the same year Richardson was banned for life, Boston Celtics rookie Len Bias, died from a drug overdose at the age of 22 [mere hours after being drafted](https://www.bbc.com/sport/basketball/65953921). “He got ahold of some bad stuff,” Richardson says. “That was a sad moment. A wakeup call for everybody.” [](https://www.theguardian.com/sport/2024/oct/23/drugs-were-everywhere-the-rise-and-fall-of-the-nbas-cocaine-era#img-2) Len Bias died shortly after being drafted by the Boston Celtics. Photograph: AP Also in 1986, All-Star John Drew was banned for life for violating the league’s substance abuse policy. That same year, Rockets guard John Lucas was waived by the team because his drug issues [had become so bad](https://www.latimes.com/archives/la-xpm-1986-11-23-sp-12376-story.html). (Lucas later turned his life around, became an NBA coach, [founded a rehabilitation center](https://johnlucasenterprises.com/athlete-aftercare), which has helped save the lives of many athletes and even headed up a professional tennis team [featuring Steffi Graf](https://en.wikipedia.org/wiki/Houston_Wranglers).) In 1987, All-Star “Fast” Eddie Johnson was banned for drugs. Chris Washburn, a former No 3 pick, was banned in 1989. In 1991, former Sixth Man of the Year, Roy Tarpley, and promising rookie Richard Dumas were both sent packing. The list goes on. But it wasn’t just players. Coaches and executives were affected by substance abuse. Usually in the form of alcohol. “When I was in the \[Continental Basketball Association\],” says Richardson, “my coach [Bill Musselman](https://www.basketball-reference.com/coaches/mussebi99c.html) – he used to get at that bar when the game was over and he would be red as a beat. He would be so damn drunk. But there were a lot of coaches who drunk their alcohol. Back then it was more accepted.” In the NBA, drug abuse was so rampant in the 1980s ([even Michael Jordan has talked about it](https://www.nbcsports.com/nba/news/the-time-michael-jordan-walked-in-on-bulls-teammates-doing-cocaine)) that teams were said to have hired [private investigators](https://thehub.news/savoir-faire-norm-nixons-lakers/) to spy on their players, from Los Angeles Lakers All-Star Norm Nixon to Richardson when he was with the Golden State Warriors. Richardson believes his lifetime ban, along with Bias’s death and the other suspensions, finally forced players to confront their drug use. They knew real repercussions were around the corner, that the league was demanding better behavior. Still, the NBA, like all walks of life, has since had to deal with other examples, [from alcohol abuse](https://www.jsonline.com/story/news/health/2024/03/12/vin-baker-recovery-opens-tuesday-offering-mix-of-addiction-treatments/72894757007/) to [prescription drug dependence](https://www.cnn.com/2024/02/20/sport/rex-chapman-autobiography-drug-gambling-addiction-spt-intl/index.html). Other leagues [like the NFL](https://www.youtube.com/watch?v=bC6dRUz76B4) and MLB have also had to deal with serious drug issues, [from opioids](https://www.washingtonpost.com/sports/2022/02/22/mlb-opioid-epidemic-eric-kay-trial/) [to painkillers](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3095672/) [to steroids](https://www.nbclosangeles.com/news/sports/mlb/mlb-biggest-scandals-steroids-gambling-sign-stealing/3369188/) [to cannabis](https://www.cbssports.com/nfl/news/chiefs-travis-kelce-estimates-up-to-80-percent-of-nfl-players-use-cannabis/) use, which is legal in many US states now and which the NBA stopped [testing for in 2021](https://www.forbes.com/sites/ariannajohnson/2023/04/03/nba-will-no-longer-penalize-marijuana-use-report-says-heres-how-other-leagues-measure-up/) (a fact that irks Richardson, who has been drug-free now for decades). And all sports are facing [problems with gambling](https://www.theguardian.com/sport/2024/apr/15/its-an-addiction-nbas-ties-to-gambling-trouble-players-past-and-present) and [gambling addictions](https://www.cnn.com/2024/06/15/sport/sports-betting-gambling-professional-athletes-dg/index.html). When it comes to the NBA, Richardson says, there were issues with heroin (Kareem Abdul-Jabbar even [admitted to trying it once](https://www.upi.com/Archives/1983/11/05/Kareem-Abdul-Jabbar-expects-negative-reactions-to-revelations-he-used/6543436856400/)) and then crack. The only remedy was distance. “You’ve got to keep yourself out of those place,” Richardson says. “Where it won’t give you opportunities to do it. Keep yourself out of those environments.” [skip past newsletter promotion](https://www.theguardian.com/sport/2024/oct/23/drugs-were-everywhere-the-rise-and-fall-of-the-nbas-cocaine-era#EmailSignup-skip-link-11) Sign up to Soccer with Jonathan Wilson Jonathan Wilson brings expert analysis on the biggest stories from European soccer **Privacy Notice:** Newsletters may contain info about charities, online ads, and content funded by outside parties. For more information see our [Privacy Policy](https://www.theguardian.com/help/privacy-policy). We use Google reCaptcha to protect our website and the Google [Privacy Policy](https://policies.google.com/privacy) and [Terms of Service](https://policies.google.com/terms) apply. after newsletter promotion [ How Len Bias’s death helped launch the US’s unjust war on drugs ](https://www.theguardian.com/sport/2021/jun/29/len-bias-death-basketball-war-on-drugs) Today, the NBA looks at substance abuse and drug addiction as part of a bigger picture, offering its players a multi-pronged attack that focuses on mental health. At a time when the US is suffering from [fentanyl](https://www.economist.com/graphic-detail/2024/03/14/americas-fentanyl-epidemic-explained-in-six-charts) [and opioid epidemics](https://www.theguardian.com/us-news/2024/jan/28/us-opioids-crisis-fentanyl-appalachia) and [other debilitating social](https://health.ucdavis.edu/blog/cultivating-health/social-medias-impact-our-mental-health-and-tips-to-use-it-safely/2024/05) issues, the NBA is working to educate its workforce about the perils of drug use and addiction as well as focusing on others issues that can [affect one’s mental](https://www.theguardian.com/sport/2023/sep/05/money-social-media-and-trust-issues-why-loneliness-stalks-the-nba) state. With annual salaries rising to as much as $60m-plus, there is a lot to be protected. Indeed, the league has come a long way over the years. From players like DeMar DeRozan, who just wrote [a book on his mental health journey](https://www.amazon.com/Above-Noise-Story-Chasing-Calm/dp/0593581261), to Hall of Famer Spencer Haywood speaking openly about his [issues with substances](https://clutchpoints.com/lakers-news-spencer-haywood-gets-brutally-honest-on-deep-denial-of-drug-problems-affecting-game-with-la). “Even now,” says Richardson, “it’s not like it was back in the 80s when I was \[playing\]. Because now there’s the fentanyl. Now what they’re doing is mixing all the drugs with fentanyl and it only takes a little – because fentanyl will kill you.” And if fans wish to take a quick glance at a list of [recent NBA suspensions](https://pr.nba.com/tag/nba-suspensions/), they will not find many of the kind that the league suffered from decades ago. Rather, they will largely see the more garden variety on court fighting or run-ins with refs (though there are still some recent instances [of substance abuse](https://www.si.com/nba/2017/08/20/oj-mayo-drug-ban-comeback-milwaukee-bucks-travelle-gaines)). Two people charged with continuing the improvement of the NBA from a social perspective [include Jamila Wideman](https://sps.columbia.edu/person/jamila-wideman), a former WNBA player and current senior vice-president of player development in the NBA, and [Dr Kensa Gunter](https://www.linkedin.com/in/kensa-gunter-psyd-cmpc-4a722631/), a psychologist and director of NBA and WNBA mind health. Both, especially compared to Richardson’s era, [are doing an excellent job](https://eightypercentmental.com/category/the-podcast/series-3/), given the outside factors and demands on players’ lives today, from social media to gambling pressures. “One thing about alcohol and drugs,” says Richardson, “they do not discriminate.”

Singapore Prison Service A guard monitors CCTV in the Drug Rehabilitation Centre (DRC) control room Kim\* is a young professional who started using cannabis when family life became messy. Things improved, but her drug habit stuck - and by then, her social circle was primarily made up of people who also used. With a reliable local supplier of weed, Kim’s friends asked her if she would get some for them. “That’s what I did,” Kim says. “I never marked up the price in any way, because this was friendship... It’s like, I’m helping you to purchase something we both use anyway.” Singapore, where Kim lives, has some of the harshest drugs laws in the world. If you sell, give, deliver, administer, transport or distribute narcotics, that’s drug trafficking. And the law also presumes you’re a trafficker if you possess drugs in quantities that cross certain weight thresholds. Kim’s life unravelled very fast when one of the friends she sourced cannabis for was caught by the state’s Central Narcotics Bureau. Kim was named as the supplier of the marijuana, and picked up too. After the authorities trawled through her phone, another friend was arrested - and Kim was charged with drug trafficking. “I was wracked with horror,” she says. “To have charges of trafficking levelled at me? That was just overwhelming. I felt complete and utter fear of what was going to pan out for me.” Cannabis for recreational use has been decriminalised in many places around the world. In the US, 24 states have legalised it. While cannabis is illegal In the UK, punishments for its possession have plummeted in recent years. In Singapore, if you’re found with 15g you’re assumed to be trafficking - and with 500g or more, the death penalty is mandatory. It’s a controversial policy and there have been [several recent cases](https://www.bbc.co.uk/news/world-asia-65395390). The most recent execution - of a 64-year-old on a heroin charge - took place on 16 October. The Singaporean government won’t tell the BBC how many people are currently on death row. **Singapore’s death penalty becomes mandatory in drug cases involving** * 15g diamorphine (heroin) * 30g cocaine * 500g cannabis * 250g methamphetamine Kim’s not facing execution, but she could be looking at a lengthy prison term. “The minimum sentence would be five years,” she says. “The worst-case could be up to 20 years.” While Kim awaits judgement on trafficking charges, her friends have already been dealt with. But they weren’t prosecuted. Classed as drug consumers - not traffickers - they faced very different treatment. They were sent to the state-run Drug Rehabilitation Centre for six months each. When anyone’s caught using an illicit substance in Singapore, they’re assessed as low, medium or high risk. Only those deemed at low risk of reoffending are allowed to stay at home, where they are monitored in the community. Everyone else - even a first-time offender - is sent for compulsory rehabilitation. Singapore Prison Service The BBC was given rare access inside Singapore's austere Drug Rehabilitation Centre There’s no private, residential rehab in Singapore - no mooching around in fluffy bathrobes and then retreating to your own en-suite room. The Drug Rehabilitation Centre (DRC) is a vast complex run by Singapore’s Prison Service, which makes sense because this is incarceration by any other name. There’s barbed wire, a control room, and CCTV everywhere. Guards patrol the walkways. In December 2023, 3,981 Singaporeans were inmates - about 1 in 8 of them women. Institution S1 houses around 500 identically-dressed male inmates, most first or second-time drug offenders. A cell accommodates seven or eight men. There are two toilets, and a shower behind a waist-high wall. There are no beds. The men sleep on thin, rush mats on the concrete floor. And a detainee will spend at least six months here - even if they’re a casual, rather than addicted, drug user. “While it is rehabilitation, it’s still a very deterrent regime,” says Supt Ravin Singh. “We don’t want to make your stay too comfortable.” Singapore Prison Service Inmates are given items including a T-shirt and socks, and a rush mat on which to sleep The men spend up to six hours a day in a classroom on psychology-based courses. “The aim is to motivate inmates to want to stay away from drugs, to renew their lives without them, and to address negative thinking regarding drugs,” says Lau Kuan Mei, Deputy Director for the Correctional Rehabilitation Service. Singapore Prison Service Inmates take part in sessions including on mindfulness, during which they are taught how to control runaway thoughts “They teach us a lot about how to manage our triggers for using drugs,” says Jon\*, who’s in his late 20s and close to the end of a six-month stay. Jon has a history of using methamphetamine and is one of the inmates prison authorities have selected to talk to the BBC. Meth (also known as crystal or ice) is a powerful, highly addictive stimulant, and the most commonly abused drug in Singapore and the region. Earlier this year, on a weekday afternoon, Central Narcotics Bureau officers arrived at Jon's house where he lives with his parents. Before they took him away, he spoke to his shocked mother. “She said, ‘learn your lesson, pay your dues, and come back clean,” Jon remembers. And that’s what he’s aiming to do - but he knows it won’t be easy. “It’s exciting leaving,” he says. “But I’m also nervous... In here you’re locked up and not faced with drugs.” Jon’s worried he might be tempted to take meth again. His rehab programme has been obligatory, not voluntary as it might have been if he lived in North America or Europe. Even so, it might not impact his chances of staying drug-free. "If you look at evidence-based policies in drug addiction... it doesn’t really matter whether the treatment offered is voluntary or non-voluntary,” says Dr Muni Winslow, an addiction psychiatrist who worked in Singapore’s government institutions. He believes the treatment offered to drug users has improved. “It’s much better now because the whole criminal justice system has a lot of psychologists and counsellors who are trained in addictions.” Historically, drugs have been viewed as a criminal justice issue, rather than a health issue in Singapore. While the state execution of traffickers still sets the tone for how the government and most Singaporeans view narcotics, it hasn’t prevented changes to how drug users are treated. For example, no-one who spends time in the rehab centre gets a criminal record. “We talked to psychologists and addiction specialists and our thinking evolved,” explains Minister for Home Affairs and Law, K Shanmugam. “If they’re not a threat to society, we don’t need to treat them as criminals.”  Home Affairs and Law Minister K Shanmugam suggests thinking on how to treat drug users has shifted in Singapore Singapore commits huge resources to enabling people to stay clean once they leave the DRC. Most importantly, they’re helped to find work. But although authorities say the system has changed, critics believe it's still humane. The Transformative Justice Collective, a group which campaigns against the death penalty, describes the DRC as a form of mandatory detention where prisoners face "humiliation" and "loss of liberties". The group says programmes in the centre are superficial and focused on "shame" - failing to tackle the root causes of drug dependence. "We've seen a lot of lives disrupted and a lot of trauma inflicted from being arrested, from being thrown into prison, from having to share a cell," says Kirsten Han. "It causes a lot of stress and instability. And these are not harms caused by drugs. These are harms caused by the war on drugs." Singapore Prison Service Urine testing cubicles are the first of their kind in the world Surveillance remains a critical part of the country's mission to keep former inmates clean. At a supervision centre, a neat-looking man in his 50s arrives. He’s been in and out of the Drug Rehabilitation Centre six times, struggling with heroin. But for the last 26 months he’s been drug-free, living at home, monitored by an electronic tag. Now his sentence is over. When the tag’s snipped off, he’s delighted, and leaves quickly after exchanging a few words with Karen Lee, the director of the Community Corrections Command. “He looks healthy,” she says. “And that’s what we hope for all our supervisees… While three out of 10 do come back as repeat drug abusers, we shouldn’t forget there are seven supervisees out there, successfully living their lives as reintegrated citizens of Singapore.” While tagged, the ex-heroin user had another incentive to stay clean: regular urine analysis. Singapore’s state-of-the-art Urine Supervision Cubicles are the first of their kind in the world. Once a supervisee enters a cubicle, the door locks behind him. After he pees into the urinal the technology tests for drugs including cannabis, cocaine, ecstasy and heroin. It takes about seven minutes. “It’s not so boring - we’ve also prepared videos for him to watch, like Mr Bean!” says Karen Lee. If the test is negative, a green light goes on, and the man’s free to go. A red light indicates a positive test result - and the supervisee will be re-arrested. Singapore’s zero-tolerance policy doesn’t distinguish between casual drug users and those with an addiction. And although punishment is no longer front and centre of the system, Singapore retains draconian practices - including a legal requirement for doctors to report patients to the authorities if they disclose use of narcotics. This may well deter people from getting help with problematic drug dependency. But the harshest treatment is reserved for those convicted of trafficking. Kim - who sourced cannabis for her friends - is trying to keep busy while she waits for the court’s decision about the charges against her. “Once I heard there was very little possibility of me not serving a sentence, I took some time,” Kim says, “to mourn almost, for the period of my life I would lose. I think I've accepted prison on a deeper level. It just never gets easier as the day draws nearer.” If Kim’s incarcerated - as she expects - she won’t be unusual. In December 2023, around half of the country’s convicted prison population - 2,299 people - were serving time for drug offences. _\* All names have been changed._  [Singapore: Drugs, rehab, execution](https://www.bbc.co.uk/sounds/play/w3ct5mtb) The laws against illegal narcotics are notoriously severe in Singapore. Penalties for trafficking include the death penalty, but the government argues its zero-tolerance policy is effective. If you are caught using any illicit narcotic, including cannabis, you may find yourself in compulsory rehab. The BBC's Linda Pressly approached Singapore's authorities and was granted access to the state’s austere Drug Rehabilitation Centre. She speaks to drug users who have to spend months at the facility before being released back into the community under surveillance.

The father of the victim was first to testify. He wore a gray quilted vest, a blue-gray shirt and an expression trying but failing to show nothing. He refused for now even to look at the thickset man charged in the torture and murder of his son. “Thomas Rath,” he said, when asked to identify himself. The same name as his son. The same as an [upstate New York murder case](https://www.nytimes.com/2024/05/19/nyregion/ithaca-homeless-encampment-thomas-rath.html) that reflected the struggles of communities to meet the commingled challenges of addiction, mental illness and homelessness. Drug abuse transformed the younger Thomas Rath from an attentive father with a good job to struggling with addiction, living under a tarp in an Ithaca homeless encampment so firmly established that it had a name: the Jungle. There, in May 2023, he was handcuffed and beaten, then taken away to be brutalized, shot to death and left in a makeshift grave. Thirteen people, many of them Jungle denizens, were charged in the case, with the man on trial, Joseph Howell, 38, accused of orchestrating the nightmare. Prosecutors depicted him as a malevolent manipulator who used threats and drugs to get vulnerable people to do bad things. The Ithaca, N.Y., homeless encampment known as the Jungle. The trial took place two weeks ago in Owego, in the brick-and-limestone Tioga County courthouse built just after the Civil War. Its only courtroom features a balcony and two slowly spinning fans hanging from the high ceiling. Think “To Kill a Mockingbird.” Thank you for your patience while we verify access. If you are in Reader mode please exit and [log into](https://myaccount.nytimes.com/auth/login?response_type=cookie&client_id=vi&redirect_uri=https%3A%2F%2Fwww.nytimes.com%2F2024%2F11%2F01%2Fnyregion%2Fthomas-rath-father-murder-trial-ithaca.html&asset=opttrunc) your Times account, or [subscribe](https://www.nytimes.com/subscription?campaignId=89WYR&redirect_uri=https%3A%2F%2Fwww.nytimes.com%2F2024%2F11%2F01%2Fnyregion%2Fthomas-rath-father-murder-trial-ithaca.html) for all of The Times. Thank you for your patience while we verify access. Already a subscriber? [Log in](https://myaccount.nytimes.com/auth/login?response_type=cookie&client_id=vi&redirect_uri=https%3A%2F%2Fwww.nytimes.com%2F2024%2F11%2F01%2Fnyregion%2Fthomas-rath-father-murder-trial-ithaca.html&asset=opttrunc). Want all of The Times? [Subscribe](https://www.nytimes.com/subscription?campaignId=89WYR&redirect_uri=https%3A%2F%2Fwww.nytimes.com%2F2024%2F11%2F01%2Fnyregion%2Fthomas-rath-father-murder-trial-ithaca.html).

Getty Images There has been an 80% increase in women reporting problematic crack cocaine use Dublin is in the midst of a crack cocaine crisis, according to the city's drug counsellors. The number of people seeking treatment for the use of the drug in the Republic of Ireland increased by 594% from 173 cases in 2017 to 1,201 in 2023, [statistics from the Health Research Board (HRB) show](https://www.hrb.ie/press-releases/addiction-treatment-ndtrs-press-releases/hrb-reports-sustained-rise-in-demand-for-cocaine-treatment/). One user said he came to the city in his 20s where he became an addict. "I kind of slipped from maybe taking a few beers, to taking a couple of ecstasy, to taking some other stuff, and then I ended up on heroin and crack cocaine," said Ferghal Connolly. 'Communities on their knees' ----------------------------  Daithi Doolan said the current crack cocaine problem is a crisis Crack is the street name given to a solid form of cocaine that is usually smoked. Daithi Doolan, from the South Inner City Drug and Alcohol Partnership, said many homes in Dublin had some form of addiction. "It's actually a crisis," he added. "It's happening at the school gate in the playground." Doolan, who is also a Sinn Féin councillor, said communities cannot cope with the scale of drug use. "The drug-related intimidation is affecting individuals, families and whole communities are being held to ransom by the drug dealers." 'Drugs are all around' ----------------------  In previous decades, Dublin had been battling heroin in inner city communities. Those at the frontline of addiction say a heroin shortage, due to geopolitical changes in Afghanistan, has sparked an increase of crack cocaine use. * [Poppy crops slashed in the Taliban's war on drugs](https://www.bbc.co.uk/news/world-asia-65787391) In 2023, 4,923 people sought drug treatment with cocaine, in its powder or crack form, as the main problem.  Cheryl Kelly said women need separate services because of their complex needs Cheryl Kelly, an addiction counsellor in the Donore Community Drug and Alcohol Team, said women need separate services from men for their "complex" needs. "Women would find themselves in situations where they may be engaging in forced sex work, or they might be afraid of social services, and the women face an awful lot of shame and stigma in and around their drug use," she said. The HRB statistics showed an increase in females seeking treatment for cocaine use from 284 cases in 2017 to 1,387 in 2023. Where crack cocaine was the main problem, nearly half were female, just over one in 20 were employed and the median age was 39. 'A need for female-only spaces' ------------------------------- Ms Kelly said setting up a dedicated scheme for women was important. "They face an awful lot of shame and stigma because they're nurturing and minding their children, their family or whoever it may be. "It was very important for me to engage or to help in our community drugs and alcohol team to set up the pilot programme for women. "Women won't engage in services if they feel like the man that's been intimidating them down at a shop on Friday is also going to be in the same service seeking support, so there is definitely a need for female-only spaces where women can feel safe." 'No border that defines addiction' ----------------------------------  Alan Kinsella said his programme has had consistent full numbers Alan Kinsella, a case worker in the city centre's Coolmine Therapeutic community, said: "We have a specific programme which is aimed to work with people who are using cocaine, both powder cocaine and crack cocaine; it has consistently had full numbers," he said. "When a programme which is so specific to a drug which is busy and full, it kind of tells the story of the scope of what cocaine is like, particularly in Dublin city centre." Alan said there is no social border that defines cocaine addiction. "We see people presented with cocaine as an issue from all walks of life, and people who have jobs - there is no kind of differentiation between the people that we see and the drug that they're using."

[Claudia Sheinbaum](https://www.theguardian.com/world/claudia-sheinbaum) has said her “very kind” phone conversation with [Donald Trump](https://www.theguardian.com/us-news/donaldtrump), in which they discussed immigration and fentanyl, means “there will not be a potential tariff war” between the US and [Mexico](https://www.theguardian.com/world/mexico). The president of Mexico spoke to reporters on Thursday following Trump’s threat earlier in the week to apply a [25% tariff against Mexico and Canada](https://www.theguardian.com/us-news/2024/nov/25/trump-mexico-canada-tariffs-border), and an additional 10% tariff against China, when he takes office in January if the countries did not stop all illegal immigration and fentanyl smuggling into the US. Trump, in a [post](https://truthsocial.com/@realDonaldTrump/posts/113557687421746022) on Truth Social on Wednesday, claimed that during the phone call with Sheinbaum she had “agreed to stop Migration through Mexico, and into the United States, effectively closing our Southern Border”. During her [Thursday address](https://www.youtube.com/watch?v=InKlbqma_f4) Sheinbaum clarified she did not agree to shut down the border. “Each person has their own way of communicating,” Sheinbaum said. “But I can assure you, I guarantee you, that we never – additionally, we would be incapable of doing so – proposed that we would close the border in the north \[of Mexico\], or in the south of the United States. It has never been our idea and, of course, we are not in agreement with that.” She added that the two did not discuss tariffs, but that the conversation with Trump had reassured her that no tit-for-tat tariff battle would be needed in future. On Monday this week, Trump threatened to impose a 25% percent tariff on Mexico until drugs, including fentanyl, and undocumented immigrants “stop this Invasion of our Country”. He declared that Mexico and Canada should use their power to address drug trafficking and migration and, until they do, “it is time for them to pay a very big price!” The following day, Sheinbaum [suggested](https://www.theguardian.com/world/2024/nov/26/mexico-trump-tariffs) Mexico could retaliate with tariffs of its own. On Wednesday, however, the conversation between Sheinbaum and Trump was “very kind”, the Mexican president said. She said she told Trump of the various migration initiatives her government has undertaken, including providing resources and support to central American countries and to migrants arriving in Mexico. Potential immigrants “will not reach the northern border, because Mexico has a strategy”, Sheinbaum said. Trump “recognized this effort” by the Mexican government, Sheinbaum added. She also said Trump expressed interest in the government-driven programs to address fentanyl addiction and overdoses in Mexico. And she raised the problem of American-made weapons entering Mexico from the US to be used by drug cartels. Sheinbaum further added that she encouraged Trump to stop the blockades against Cuba and Venezuela, since “people suffer and it leads to the phenomenon of migration”. Asked by a reporter from Rolling Stone magazine that quoted anonymous Trump-aligned sources discussing a “soft invasion” of Mexico by deploying the US military inside the country against drug trafficking groups, Sheinbaum dismissed the idea, calling it “entirely a movie”. “What I base myself on is the conversation – the two conversations – that I had with President Trump, and then, at the moment, the communication we will have with his work team and when he takes office,” Sheinbaum said. “We will always defend our sovereignty. Mexico is a free, independent, sovereign country – and that is above everything else.”

In 2022, the US reached [a grim peak](https://nida.nih.gov/sites/default/files/images/fig1-2024.jpg) in drug overdose deaths: Nearly 108,000 people died that year, more than twice the number who died in 2015, and more than four times the number in 2002. Now, in what experts hope is more than a blip, the overdose epidemic that has affected every state in the nation might be showing some signs of abating. The Centers for Disease Control and Prevention’s preliminary data on the [12-month period ending in June](https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm) showed that [overdoses dropped about 15 percentage points](https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm) from the previous period. There were still roughly 94,000 overdose deaths, signaling that the public health crisis is far from over, though a positive change could be on the horizon. Understand the world with a daily explainer plus the most compelling stories of the day. Sign up [here](https://www.vox.com/pages/today-explained-newsletter-signup). America’s overdose crisis was exacerbated decades ago by the increasing use of and addiction to synthetic opioids, such as fentanyl, that have proliferated through the nation’s drug supply. Fentanyl was first produced in the 1960s and prescribed by doctors to people seeking relief from severe pain, such as cancer patients. A cheaper, more potent cousin of heroin, the drug soon became a favored commodity of traffickers, who began cutting other drugs with fentanyl and drawing people addicted to prescription painkillers such as oxycodone that have become increasingly more difficult to access. [As my colleague German Lopez wrote in 2017](https://www.vox.com/science-and-health/2017/5/8/15454832/fentanyl-carfentanil-opioid-epidemic-overdose), fentanyl made America’s opioid crisis — already the deadliest drug crisis in US history — even deadlier. So what might have turned the trend around? In the latest episode of Vox’s _Today, Explained_ podcast, we asked Lev Facher, a reporter covering addiction at STAT News. “There’s no one event that happened about a year and a half ago that would explain this sudden significant decrease in drug overdose deaths,” says Facher. “While there’s a lot of optimism in the harm reduction and addiction medicine and recovery world, it’s cautious optimism because people don’t really know what’s happening.” Despite that, Facher says, experts and advocates do have a few potential explanations: The simplest explanation for the drop in overdoses could be the nature of the drugs themselves; they simply may have become less toxic and less potent. Last month, DEA administrator Anne Milgram suggested [that the agency’s crackdowns](https://www.dea.gov/press-releases/2024/11/15/deas-third-annual-national-family-summit-fentanyl-highlights-progress) were having a direct impact on the drug supply. “The cartels have reduced the amount of fentanyl they put into pills because of the pressure we are putting on them,” she said at the National Family Summit on Fentanyl, which gathers people who’ve had loved ones die from drug use. Customs and Border Protection (CBP) data can’t give us the full picture of the effectiveness of cartel crackdowns, but it shows that the [rate of fentanyl confiscation at the border](https://www.cbp.gov/newsroom/stats/cbp-drugs-dosage-value-and-weight) is hardly consistent. In January, CBP confiscated 1.3 million doses of the drug. The number of confiscations dropped significantly in June before rising back to about 1.3 million doses again in August. And data on the potency of illicit drugs is limited, given that drug-tracking systems vary from one community to another, Facher told Vox. “The places that do have really good drug checking, there have been some changes detected in terms of the drugs people are using, but nothing that would explain this sudden drop,” he said. Another explanation could be that harm-reduction efforts are working. Access to [naloxone](https://www.vox.com/even-better/353129/you-can-help-reverse-the-overdose-epidemic), the lifesaving, overdose-reversing drug, expanded significantly in cities across the United States in the last few years. Local governments such as [Los Angeles County](https://laist.com/news/health/los-angeles-naloxone-overdose-deaths) made the drug available at schools, churches, libraries, and jails, and [everyday](https://health.ucdavis.edu/blog/cultivating-health/why-you-should-carry-naloxone-narcan-to-combat-opioid-overdoses/2023/08) Americans are increasingly encouraged to carry naloxone. Harm-reduction campaigns may have also had an impact on those who use recreational “party” drugs, who might favor stimulants but could find themselves unknowingly ingesting fentanyl if a dealer has mixed it into cocaine or MDMA. [Drug testing kits like Overdrive](https://www.amazon.com/Fentanyl-Overdrive-Substances-Detection-Sensitive/dp/B0D936KTKM) are available for less than $15 from retailers like Amazon and provide people with step-by-step directions on testing drugs for fentanyl. Data also suggests that the way people consume drugs might reduce the likelihood of death by overdose. Smoking fentanyl is becoming increasingly more popular than injecting it, and the former is linked to [fewer fatal overdoses and blood-borne infections](https://www.sciencedirect.com/science/article/abs/pii/S0376871623012917?via%3Dihub). The third explanation, floated by some epidemiologists, is the most bleak, and suggests that after hundreds of thousands of people were killed by drug overdoses in a relatively short time span, the [epidemic is essentially burning itself out](https://www.nejm.org/doi/full/10.1056/NEJMe2406359). “It’s a concept called the ‘depletion of susceptibles,’” Facher said. “And that’s just to say that so many people have already died of drug overdoses that there aren’t as many drug users left to die. That’s not necessarily a mainstream theory. And even if it were accepted, it probably wouldn’t explain the full significant sudden decrease in drug deaths.” The staggering number of deaths from the opioid epidemic, however, could be a contributing factor to declining youth drug misuse. [An analysis from KFF](https://www.kff.org/mental-health/issue-brief/teens-drugs-and-overdose-contrasting-pre-pandemic-and-current-trends/#:~:text=In%202023%2C%2010%25%20of%20high,alcohol%20use%20(30%25%20vs.) showed a small drop in opioid misuse among high school students from 2017 to 2023. As [Maia Szalavitz writes for the New York Times](https://www.nytimes.com/2024/12/02/opinion/drug-overdose-deaths-decline.html), “Drug epidemics are often cyclical. Younger generations witness the harm specific drugs have caused their older siblings or parents, leading them to avoid those substances.” The latest data on overdose deaths comes amid a pivotal presidential transition. While the addiction crisis is a marquee issue for both Republicans and Democrats, the incoming Trump administration includes high-level officials who’ve been intimately impacted by it. The vice president-elect, JD Vance, has spoken extensively about how opioid addiction affected his mother and his community of Middletown, Ohio. Trump’s nominee for secretary of the Department of Health and Human Services, Robert F. Kennedy Jr., is in addiction recovery himself and his policy proposals include a network of “[wellness farms](https://www.youtube.com/watch?v=liZq31HLnyA&t=1778s)” to serve [as treatment facilities.](https://www.statnews.com/2024/12/11/rfk-jr-opioid-epidemic-addiction-policy-tough-love/) It remains to be seen whether the administration will focus its efforts on addiction recovery or if it will devote more attention [to law enforcement](https://www.youtube.com/watch?v=NUClE1P8ApI) and [the US-Mexico border](https://www.npr.org/2024/11/18/nx-s1-5187973/fentanyl-trump-cartels-addiction). “There is trepidation about a potential shift toward law enforcement and away from treatment,” Facher said. “Most of my sources talk about harm reduction, treatment prevention, and really just keeping people alive \[by\] meeting them where they are and getting them the services they need to live healthier lives as the cornerstone of ending this drug crisis.” You’ve read 1 article in the last month Here at Vox, we're unwavering in our commitment to covering the issues that matter most to you — threats to democracy, immigration, reproductive rights, the environment, and the rising polarization across this country. Our mission is to provide clear, accessible journalism that empowers you to stay informed and engaged in shaping our world. By becoming a Vox Member, you directly strengthen our ability to deliver in-depth, independent reporting that drives meaningful change. We rely on readers like you — join us.  Swati Sharma Vox Editor-in-Chief See More: * [Criminal Justice](https://www.vox.com/criminal-justice) * [Health](https://www.vox.com/health) * [Policy](https://www.vox.com/policy) * [War on Drugs](https://www.vox.com/drug-war)

Vivian Qu is the Chinese film-maker who has directed three features and also produced the [noir drama Black Coal, Thin Ice](https://www.theguardian.com/film/2015/jun/04/black-coal-thin-ice-review-diverting-downbeat-noir) which in 2014 won Berlin’s Golden Bear. Now she brings this crime melodrama to Berlin, an engaging if tonally uncertain high-wire adventure that satirises China’s hopeless addiction to gangster capitalism. It is also acidly unsentimental about the bread-and-circuses escapism of the country’s booming film and TV industry with all its period-costume wuxia nostalgia. It’s an appealing film, though it contains some strangely broad comedy and is also, in a couple of violent moments, a bit naive about exactly how easy it is for a young woman physically to fight off a big strong guy. Above all, Qu gives us a rather amazing set-piece scene on the set of a wire-fu action movie, a scene that feels real in a way that the rest of the film really doesn’t, for all that it is watchable. Fang Di (Wen Qi) is a tough woman employed as a stunt double on a movie set, playing the black clad, sword-wielding ninja bouncing over terracotta rooftops and whizzing through the air in long shot. For the closeup, the preening star in the same outfit steps in while Fang Di staggers over to get a coffee at the craft table. The work is exhausting and dangerous and Fang Di is doing it to pay off her family debts to mob matriarch Madame Wang. Desperate for more cash, she takes on a gruelling night shoot in which, attached to a wire harness, she has to be submerged under murky water to fly up into the air. The callous director demands this shot to be repeated endlessly, despite Fang Di’s obvious distress – and seeing that there are too many ripples from the last take, he commands she stay under the water for 15 seconds before the camera rolls, instead of the almost-safe three. Just at this unimaginably low point in Fang Di’s life, her long estranged cousin Tian Tian (Liu Haocun) appears; she is being pursued by the mob, having fallen into debt and drug addiction at the hands of the same criminals who supplied drugs to Tian Tian’s notoriously parasitic and waster dad, the source of all the family’s despair. Now Fang Di and Tian Tian have to evade the same duo of hatchet-faced tough guys, as well as a local cafe owner from their home town who the mobsters have bullied into joining them. There are entertaining, incidental scenes mocking the craziness of show business; looking to graduate away from stunt work, Fang Di auditions for a drama, doing an absurdly written scene, and bursts out laughing in the middle of the dialogue, to the director’s outrage. And there is a moment of pure (and implausible) farce when the gangster tough guys, taking a wrong turn in the movie studio, are inveigled into taking part in a hospital drama and a war epic. It’s amusing, but the silliness doesn’t entirely work. All this is interspersed with flashbacks showing the two young women’s former intimacy and the painful anguish of their family dysfunction, establishing a mood of sadness that is underscored by the final, desolate scene of their early childhood. A flawed, but involving spectacle. Girls on Wire screened at the [Berlin film festival](https://www.theguardian.com/film/berlinfilmfestival).

At Guinea’s only private drug rehabilitation clinic, Dr Marie Koumbassa and her 15-person team are so convinced that drug use is a national emergency that they work for no pay. Every week, SAJED-Guinée (Service for Helping Young People in Difficult Situations due to Drugs) receives dozens of distress calls from relatives of addicts who are then taken to the facility in the working-class Conakry neighbourhood of Dabompa. In richer areas of the city, cocaine is the drug of choice. Elsewhere, the prevalent substances are tramadol, crack and – in a recent trend – kush, [a deadly mix](https://theconversation.com/kush-what-is-this-dangerous-new-west-african-drug-that-supposedly-contains-human-bones-220608) of cannabis, fentanyl, tramadol, formaldehyde and [reportedly human bones](https://www.theguardian.com/global-development/2023/sep/13/its-like-smoking-poison-sierra-leones-youth-battle-addiction-to-a-mystery-drug). People who smoke it have been known to collapse, cause themselves bodily harm or even die. “People come here from the madrasa \[Islamic schools\] and tell us that scholars told them: ‘Take this, you will read well and quickly learn’,” Koumbassa said, referring to kush. “It actually destroys them.” The team first encountered kush in Conakry last March. Its use has now spread so much that patrons of nightclubs and lounges are known to be mixing it into shisha pots. [](https://www.theguardian.com/world/2025/apr/20/kush-guinea-rehab-clinic-drug-epidemic#img-2) Dr Marie Koumbassa. Photograph: Eromo Egbejule/The Guardian Unlike its neighbours Guinea Bissau – seen as a “narco-state” – and Sierra Leone, which is the regional hub for kush, drug abuse and trafficking are not readily associated with the more culturally conservative Guinea. But experts say a crisis is under way, fuelled by a growing market operated by cross-border trafficking syndicates. “The gangs in Sierra Leone have always moved to Guinea \[when necessary\], said Kars de Bruijne, senior research fellow with Dutch thinktank Clingendael’s conflict research unit. “If a gang member committed a crime in Sierra Leone or was otherwise being looked for they would go to Guinea and hide out. “Similarly, we are aware of boats that sometimes move materials including drugs from Guinea to Sierra Leone. There’s really a lively cross-border informal trade.” Data about the drug abuse and trafficking situation is hard to come by, but according to [a UNODC report](https://www.unodc.org/westandcentralafrica/en/westandcentralafrica/press/world_drug_report_2024.html), at least 5.6 tonnes of cocaine were seized off the coast of Guinea between January 2019 and June 2024. Earlier this year, Guinean authorities said they [found seven suitcases](https://www.bbc.co.uk/news/articles/cn4zzq1vk87o) containing suspected cocaine in a car belonging to the Sierra Leonean embassy.  Inside the war on kush: The drug ‘mixed with human bones’ taking over Sierra Leone – video Staff at SAJED say there is a serious lack of awareness about remedies and therapy. Still, the nonprofit has handled more than 500 cases since 2019, when Koumbassa opened the centre after returning inspired from workshops for psychologists in Abuja and Accra. “We have patients who come from everywhere, from within the country, as well as students returning from places like America and France,” said Yamoussa Bangoura, the centre’s head of psychotherapy. “We want to extend our operations to Boké \[a city near Guinea-Bissau\], and all the regions. But we don’t have the means.” Many factors are to blame for the drug epidemic, including poverty and porous borders. Some social workers think demonstrators against the junta that seized power in a coup in 2020 began taking drugs to give themselves the confidence to take to the streets. Some say the junta’s all-encompassing focus on holding on to power has distracted it from daily affairs of the state. The scale of the problem has overwhelmed Guinea’s meagre capacity for treating addicts. The country only has two known state-run centres catering to substance abuse. During the Covid-19 pandemic, one was closed for a time, overcrowding the other. SAJED’s own resources are extremely limited. It can only take around a dozen patients at a time. The facility is mostly funded by the people who worked there, but it also receives small grants from private donors and the sale of fruits within the compound that patients help water daily to keep them engaged. Sales of medication for treatment provides another source of revenue, but most of the patients are poor, so the clinic gives the medication to them for nothing. [](https://www.theguardian.com/world/2025/apr/20/kush-guinea-rehab-clinic-drug-epidemic#img-3) Staff at SAJED say there is a serious lack of awareness about remedies and therapy. Photograph: Eromo Egbejule/The Guardian Rented from a member of the Guinean diaspora at a heavily discounted rate, the compound consists of a single-storey building with cubicles inside that serve as kitchen, laboratory and pharmacy. There is also a small emergency room and one bedroom each for men and women, as well as a common room with a TV. “People fear to come in sometimes because of the look of the building,” said Bangoura. People suffering from depression and alcohol addiction are also welcome at the clinic. One of those currently at the facility is Diallo Mahmoud, a 32-year-old whose alcohol addiction began as a teenager drinking with elders. Over the last three years, he moved to Abidjan and Brazzaville in search of work, drowning his failures in alcohol. After breaking a bottle on someone’s head in a fight at a Conakry nightclub, his siblings called SAJED. These days, he and other patients at the clinic discuss life together, anticipating a different direction when they are discharged. “After I leave here, I’ll not drink again and I’ll preach that to people,” Mahmoud said. Stories like his keep the clinic staff going, even when the road seems rough. “We have come to understand that drug consumption is recurrent in our homes, and the layer it consumes the most is the youth, the future of the nation,” said Koumbassa. “If we don’t help them get out of it, it will be a problem for the nation.”