Caulkins: Here’s what policymakers need to know about drugs in 2025

There are seven ways policymakers could respond to the country’s surging supply of fentanyl, according to Jonathan Caulkins, a professor at Carnegie Mellon University's Heinz College of Information Systems and Public Policy.

Caulkins outlined the potential paths forward in a report published this month in the Brookings Institution, a public policy think tank. He wrote that policymakers could, among other responses, strengthen efforts to purge opioid markets of fentanyl or prioritize treatment over drug law enforcement. He did not choose a winning approach, instead detailing their pros and cons.

“This paper’s principal objective is to help readers clarify their own thinking as to how to conceptualize the role of [drug law enforcement] in this new, changed world of dramatically expanded opioid supply,” Caulkins wrote.

Fentanyl, a synthetic opioid, has become more prevalent in illegal drug markets because it can be up to 50 times stronger than the semi-synthetic opioid heroin and is cheaper and easier to make. 

Before his report was published, we sought Caulkins’s perspective on the country’s most pressing issues regarding drugs and drug policy. He highlighted not only the opioid crisis but also the “dysfunction” created by the inconsistencies between state-level legalization and ongoing de jure federal prohibition of cannabis. The takeaways from that conversation are below. 

The drug overdose crisis continues

Nearly 94,000 people in the U.S. reportedly died of a drug overdose between June 2023 and June 2024, according to the Centers for Disease Control and Prevention. The number reflects a notable decline from the previous year, one that NPR called a “huge reversal.” Even so, Caulkins said overdoses remain a top issue. 

“In absolute numbers, the number of deaths is still extraordinarily high compared to any other country besides Canada, compared to any time in history, other than the last handful of years,” he said.

There are several factors driving the crisis. Many people who struggle with substance use disorders developed the disease by taking prescribed opioids, which have a high addiction liability when used to treat chronic (as opposed to acute) pain. In 2023, nearly 8.6 million people in the U.S. said they misused prescription opioids in the past year. 

Overall, doctors are not prescribing as many opioids as they used to, but escalating addiction and tightening supply has led some people to seek cheaper illegal opioids, which now often means fentanyl. “When the illegal opioid markets switched from heroin to fentanyl, you got a huge bump up in deaths,” Caulkins said.

Illegal suppliers are now pressing fentanyl into pills, making the drug more accessible to people who are uncomfortable taking drugs by injection. On top of that, suppliers are adding fentanyl to cocaine and methamphetamine, a practice that could endanger people who have not built up a tolerance for opioids.

Caulkins believes that policies can mitigate, but not eradicate, the overdose crisis.

He noted that the Mental Health Parity and Addiction Equity Act of 2008, along with improved health insurance availability, have expanded treatment access. The U.S. Food and Drug Administration has approved several safer medications for treating opioid use disorder, and the growing availability of the overdose-reversing drug Naloxone has saved lives. The Federal Bureau of Investigation and Drug Enforcement Administration have also broken up some online drug markets, Caulkins said.

Going forward, he’d like the country to expand medication-assisted treatment options, improve access to Naloxone and offer more year-round locations for people to dispose of unused drugs. He’d also like cities to better protect communities impacted by the overdose crisis and for law enforcement to better control, without resorting to long prison terms, the disorder associated with street markets. 

“If you construe it only as an overdose death crisis, you forget there's a broader set of people who are harmed,” Caulkins said. “For example, the children – and parents – of the person who is struggling with addiction can be harmed. Neighbors living in places where folks congregate to sell and use drugs are also stakeholders, as are people living in countries where drug traffickers undermine democratic institutions.”

Among the approaches he outlined in his report with the Brookings Institution, Caulkins said he would prefer that drug law enforcement focus on constraining drug suppliers’ behavior instead of just trying to limit the drug supply. This could reduce “the violence, corruption, disorder, and other harmful externalities they impose on society,” and could be combined with other policy responses, he wrote.

Given the severity of the crisis, Caulkins said politicians may be tempted to propose policies that appear strict but are “worse than useless.” Some lawmakers have supported the idea that people who supply drugs that kill someone should be prosecuted under drug induced homicide laws, but Caulkins said it is often impossible to verify chains of custody back to a higher-level dealer, so those long sentences fall primarily on easily replaced retail sellers.  

Cannabis legalization has been ‘dysfunctional’

In the U.S., daily use of cannabis has surpassed daily alcohol consumption, according to recent research from Caulkins. But while cannabis is legal for recreational use in 24 states and the District of Columbia, the federal government has not yet legalized the drug. “That's a fundamental inconsistency, whether you want it to be legal, or whether you want it to be illegal,” Caulkins said. 

The federal prohibition has hamstrung cannabis companies in several ways, even if they’re legal at the state level, he said. They have to pay income taxes on their gross receipts, not their profits, substantially increasing their business costs. They can’t use credit card payment processing systems or receive services from traditional banks. States can constrain their marketing efforts, as First Amendment commercial free speech protections don’t extend to illegal activity. 

The quality control of cannabis products is also insufficient, as state regulators can’t ask their employees to break federal law to conduct independent tests. 

“There are a lot of efficiencies that would be realized with national legalization,” Caulkins said. “The greater efficiencies translate into more marketing, lower prices and so on, but also greater use, which could also produce greater dependence.”

Legalization could take many forms. Caulkins would prefer that the federal government allow only nonprofits to manufacture and distribute cannabis, and require their articles of incorporation to confine their mission to meeting existing demand – and thereby undercut illegal markets – without promoting greater use the way for-profit cannabis corporations do. 

“The mission of a for-profit company is to make money. The way they make money is promoting greater consumption of their product,” he said. “For blood products, we don't have Microsoft and Exxon harvesting blood and selling it. The American Red Cross is an organization we trust to put public interest and public health at the forefront for that unusual and sensitive product.”

“We should likewise recognize that cannabis is – in the jargon of the field – ‘no ordinary commodity’ and afford it ‘grudging toleration,’ not an enthusiastic embrace,” he continued.

Both Vice President Kamala Harris and President-elect Donald Trump signaled during the 2024 election season that they would be open to legalization.

Read more about Caulkins’s report at the Brookings Institution here.