How to deal with substance abuse during pregnancy is a fraught issue, generating harsh sanctions against pregnant women who use drugs or who lose their fetuses before birth and are drug users. According to data compiled by Pregnancy Justice, the advocacy group formerly known as National Advocates for Pregnant Women, prosecutors filed more than 1,300 criminal cases against pregnant women between 2006 and 2020, a rate of more than a hundred a year. They are almost always poor women of color.

Hardnosed prosecutors and child protection agencies enabled by state and federal laws use a number of techniques and statutes to go after pregnant women who use drugs. As compiled by the Guttmacher Institute, a research and policy group committed to advancing sexual and reproductive health and rights, they include:

• Making drug use during pregnancy a crime. Such laws have been upheld by state Supreme Courts in Alabama and South Carolina.
• Several states have expanded their civil child-welfare requirements to include prenatal substance use, so that prenatal drug exposure can provide grounds for terminating parental rights because of child abuse or neglect.
• Some states, under the rubric of protecting the fetus, authorize civil commitment (such as forced admission to an inpatient treatment program) of pregnant people who use drugs; these policies sometimes also apply to alcohol use or other behaviors.
• A number of states require health care professionals to report or test for prenatal drug exposure, which can be used as evidence in child-welfare proceedings.
• To receive federal child abuse prevention funds, states must require health care providers to notify child protective services when the provider cares for an infant affected by illegal substance use.

But now, a growing number of experts, including maternal/fetal specialists, federal health officials and people who treat addiction, are saying that such responses are counterproductive. Women who feel subject to prosecution may avoid health care entirely or may shy away from interventions such as a medication-assisted treatment (MAT) with opioids such as methadone or buprenorphine, increasing their likelihood of fatal overdoses. Overdoses are a eading cause of preventable death among pregnant women.

A study published this week in the Maternal and Child Health Journal of 26 pregnant Massachusetts women found that the decision whether or not to use MAT "was entirely wrapped up in what happened with respect to mandated reporting to Child Protective Services at the time of delivery," according to Dr. Davida Schiff, the study author and an addiction medicine specialist at Massachusetts General Hospital in Boston. The women underwent "intense anxiety and stress" about the threat they would be reported to child protective services.

"This has led to many women either deciding to not start life-saving medication during pregnancy or to wean off of that life-saving medication during pregnancy and really risk poor outcomes for themselves and their babies," Schiff said.

That someone is using drugs while pregnant "does not diagnose anyone's ability to parent," said Dr. Hendrée Jones, executive director of the University of North Carolina's Horizons Program, a drug treatment program. "I have a woman getting ready to deliver, and she is terrified that somehow they're going to find drugs in her system and Child Protective Services is going to be called and her baby's going to be snatched away," Jones said.

"Across the entire country, we're seeing a general trend toward more punitive policies, and those are kind of the policies that consider substance use during pregnancy to be child abuse or neglect," said Laura Faherty, a policy researcher at the RAND Corporation.

The head of the National Institute on Drug Abuse (NIDA), Dr. Nora Volkow, also thinks things have gone too far.

"We should remove criminalization of women who are pregnant and taking drugs," she said. "That needs to stop. We know that mortality from overdoses is greater in women that are pregnant than counterparts of the same age that are not pregnant. This is extraordinarily important because it's telling us that there's something that is making these pregnant women more vulnerable."

The need for change from punitive prohibitionist policies is urgent. A 2019 study found that the rate of opioid-related diagnoses among pregnant women more than doubled between 2010 and 2017, with ongoing research suggesting another big increase after 2017. And a 2022 study found that the number of pregnant women and new mothers dying of drug overdoses reached a record high in 2020, nearly doubling to11.85 per 100,000 from 6.56 per 100,000 in 2017.

Punitive prohibitionist policies are not working. It is time for another approach.

The good, the bad, and the ugly in US domestic drug policy this year.

1. Overdose Deaths Appear to Have Peaked but Are Still at Horrid Levels

According to Provisional Drug Overdose Death Counts released by the Centers for Disease Control and Prevention (CDC) in December, the nation's fatal drug overdose epidemic has peaked. After reaching a record high of more than 110,000 fatal overdoses in the 12-month period ending in March, that number declined to 107,735 in the 12-month period ending in July, the last month for which data is available. That is a two percent decline from the March high.

While the decline is welcome, drug overdose numbers are still 25 percent higher than they were two years ago and double what they were five years ago. According to the CDC, synthetic opioids, mainly fentanyl, were implicated in more than two-thirds of overdose deaths and stimulants such as methamphetamine and cocaine were involved in nearly one-third. But some fraction of stimulant-implicated overdose deaths are not caused by the stimulants themselves but by stimulant users being exposed to drugs cut with fentanyl.

2. Neither Marijuana Legalization nor Banking Access Pass Congress

Senate Majority Leader Chuck Schumer (D-NY) vowed to make passage of a marijuana legalization bill a priority in this Congress, but it didn't happen. While the House passed a legalization bill, the Marijuana Opportunity Reinvestment and Expungement (MORE) Act (HR 3617) in April, Schumer and congressional allies didn't even roll out a draft version of their Cannabis Administration and Opportunity Act until this July -- 18 months after this Congress began -- and it never exhibited enough bipartisan support to go anywhere in the evenly divided Senate.

Schumer and his Senate allies also repeatedly blocked efforts to get a bill to allow state-legal marijuana businesses access to financial services through the Senate. The Secure and Fair Enforcement (SAFE) Banking Act (HR 1996) passed the House in April, and Senate allies tried repeatedly to attach it as an amendment to various spending bills, only to be stymied by Schumer and his holdouts for full-blown legalization. At year's end, though, while Schumer was finally ready to move forward with it, Senate Minority Leader Mitch McConnell (R-KY) came out in opposition, helping to scuttle one last effort to tie it to a defense appropriations bill.

3. With Biden's Signature, A Standalone Marijuana Reform Bill Becomes Law for The First Time Ever

For the first time ever, Congress passed and in December the president signed into law a stand-alone marijuana reform bill, the bipartisan Medical Marijuana and Cannabidiol Research Expansion Act (HR 8454). Some marijuana reform measures have been passed before, but only as part of much broader appropriations bills. The aim of the bill is to facilitate research on marijuana and its potential health benefits. The bill will accomplish this by streamlining the application process for scientific marijuana studies and removing existing barriers for research by allowing both private companies and research universities to seek DEA licenses to grow their own marijuana for research purposes.

4. Three More States Legalize Marijuana

In May, Rhode Island became the 19th state to legalize marijuana when the General Assembly passed and Gov. Dan McKee signed into law the Rhode Island Cannabis Act. Sales to any adult over 21 at medical marijuana dispensaries that acquired "hybrid retail licenses" began in December.

And in November, voters in Maryland and Missouri approved marijuana legalization initiatives. Maryland's Question 4 came not from the people but from the legislature and amends the state constitution and mandates that the General Assembly "shall provide for the use, distribution, possession, regulation and taxation of cannabis within the state." Missouri's Amendment 3 overcame multi-sided opposition not only from the usual suspects in law enforcement and the political establishment but also from civil rights groups and marijuana industry insiders to eke out a narrow victory. As of December 8, possession of up to three ounces by adults is no longer a crime, but sales to adults will not begin until next year.

But there were also losses at the ballot box this year. The Arkansas Adult Use Cannabis Amendment garnered only 43.8 percent of the vote, while North Dakota's Initiated Statutory Measure No. 1 managed only 45.1 percent, and South Dakota's Initiated Measure 27 came up short with only 46.6 percent of the vote. The South Dakota defeat was especially bitter, given that just two years ago, voters there approved a broader marijuana legalization initiative with 54 percent of the vote only to see it invalidated by the state Supreme Court.

5. The Year of Fentanyl Test Strip Decriminalization

Fentanyl test strips, which detect the presence of the powerful synthetic opioid in all different kinds of drugs (cocaine, heroin, methamphetamine, etc.) and formulations (pills, powders, and injectables) are recognized by the Centers for Disease Control and Prevention as a valuable harm reduction strategy and are increasingly seen by the states as a crucial tool in the fight to reduce drug overdose deaths. When the Biden White House first endorsed their use in 2021, they were considered illegal drug paraphernalia in a majority of states.

Not anymore. As of the end of 2022, 31 states have now legalized or decriminalized fentanyl test strips, with Alabama, Georgia, New Mexico, Tennessee, and Wisconsin doing so this year alone. But that leaves 19 states, mostly in the South and including Florida and Texas where they remain banned.

6. Colorado Becomes Second State to Approve Natural Psychedelic Reforms

Three years after voters in Denver opened the door to psychedelic reform by approving a municipal initiative that made possession of psilocybin mushrooms the lowest law enforcement priority, voters statewide have approved an initiative that decriminalizes plant- and fungi-derived psychedelics and creates a program for the therapeutic administration of such substances. On Election Day, voters approved Proposition 122, the Natural Medicine Health Act, with 53.55 percent of the vote. The victory makes Colorado the second state to enact reforms decriminalizing a natural psychedelic and setting up a program for therapeutic use. Oregon voters led the way on that by approving Measure 109 in 2020.

Proposition 122 has two main prongs: First, it decriminalizes the personal use, possession, and cultivation by people 21 and over of dimethyltryptamine (DMT), ibogaine, mescaline (not derived from peyote), psilocybin, and psilocyn, as well as providing for the sealing of conviction records of people who have completed sentences for the use or possession of those substances. The measure sets no personal possession limits. Second, it creates a "natural medicine services" program for the therapeutic administration of the specified psychedelics and creates a rubric for regulated growth, distribution, and sales of those substances to entities within the program. Only psilocybin and psilocin would be okayed for therapeutic use until 2026. Then regulators could decide on whether to allow the therapeutic use of DMT, ibogaine, and mescaline.

7. Marijuana Social Consumption Lounges Spread

Ever since the first states legalized marijuana a decade ago, one question for users was where to go to smoke their newly legal product. Most states ban smoking outdoors in public or indoors pretty much anywhere except one's home -- and even that can be an issue if your landlord isn't down with it. One solution is allowing places for marijuana users to toke up in a convivial setting, the marijuana social consumption lounge, whether as part of a retail shop or as a standalone business.

Social consumption lounges are now legal in 11 states -- Alaska, California, Colorado, Illinois, Massachusetts, Michigan, Missouri, New Jersey, New Mexico, New York, and Nevada -- although they are not actually up and running yet in some of them. Massachusetts has two lounges now operating; in New Jersey, regulators just approved rules for them; in Nevada, regulators just issued 20 provisional licenses; in New York, they're still waiting for regulators to act; and in California, the state's dozen or so lounges are set to double in number as more localities okay them. Meanwhile, the nation's capital could be next: In the District of Columbia, the city council just approved a bill allowing them.

8. Safe Injection Sites Are Operating in the United States

Safe injection sites, the harm reduction intervention proven to save lives after years of operation in more than a hundred cities in Australia, Canada, and Europe, are finally getting a toehold in the US. New York City's two safe injection sites have just celebrated their first birthdays after opening in late 2021, and in Rhode Island, a two-year pilot program is underway.

But there will be no safe injection sites in California after Gov. Gavin Newsom (D) vetoed a bill that would have allowed pilot programs in major cities across the state. And the fate of a proposed Philadelphia safe injection site -- and the Biden administration's attitude toward them -- remains in doubt. That facility was initially blocked by the Trump Justice Department, and two years later, the Biden Justice Department has yet to substantively respond to lawsuit from the site's would-be operators. Just this month, a federal judge gave DOJ just 30 more days to respond. A positive response would remove the obstacle to further expansion of such sites that fear of federal prosecution brings. Meanwhile, the Congressional Research Service has thoughtfully released a report about other options for getting them up and running, such as passing budget amendments similar to those blocking the Justice Department from interfering in marijuana laws.

9. In DC and New York City, Gray Market Weed Finds a Way

In both the nation's capital and the nation's largest city, unregulated marijuana vendors have popped up to supply pent up demand as both cities endure legalization without legal marijuana sales. In New York City, it's only a matter of time before taxed, licensed, and regulators marijuana retailers are able to open, but in the interregnum between legalization and legal access, the pot scene has gone hog wild with marijuana being sold everywhere -- head shops, bodegas, even from folding tables on street corners -- with one particularly hysterical estimate putting the number at "likely tens of thousands of illicit cannabis businesses." The market isn't waiting for the regulators, and its emergence could undercut the legal businesses waiting in the wings. The city has undertaken limited enforcement efforts, but to little effect so far.

In Washington, DC, a congressional rider barring taxed and regulated marijuana sales has seen something similar, but with a DC twist: a multitude of shops that will "gift" you marijuana when you purchase some other item. The stores call themselves I-71 shops, after the 2014 initiative that legalized marijuana in the city and they even have their own industry association, which estimates there are a hundred or so of them. The city vowed a crackdown in August, but put that on hold the following month.

10. For the First Time, SAMSHA Funds Harm Reduction

In December 2021, the Substance Abuse and Mental Health Services Administration (SAMHSA) announced that it would for the first time ever make grants available to harm reduction groups to "help increase access to a range of community harm reduction services and support harm reduction service providers as they work to help prevent overdose deaths and reduce health risks often associated with drug use." SAMSHA would make available $10 million a year in grants for the next three years.

And this year, the first tranche went out. Some 25 different programs from the Lost Dreams Awakening Center in New Kensington, Pennsylvania, to the Mile High Council on Alcoholism and Drug Abuse in Denver, to the Los Angeles County Health Department got grants this year, almost all of them for $398,960. It's a drop in the bucket compared to federal spending on prohibition -- and compared to harm reduction's full funding needs -- but it's a start.

There's progress on medical marijuana this week in the South, a key Rhode Island lawmaker slams the brakes on a marijuana legalization push, and more.

Marijuana Policy

Rhode Island Key Lawmakers Slams Brakes on Legalization Effort. On the day after the state Senate passed a marijuana legalization bill, an amended version of Senate Bill 568, House Speaker K. Joseph Shekarchi (D-Warwick) signaled he was in no hurry to finish the job. He said the state could afford to wait to legalize it while authorities consider diverging proposals, that a proper regulatory structure needed to be created, and that he wanted to ensure that the state gets adequate revenues from legalization. "If we're going to legalize recreational use of marijuana, we want to make sure that the state gets its fair share," he said. He said he had seen "six or seven legitimate proposals" for marijuana legalization that are "very divergent." But the Senate has only passed the one.

Medical Marijuana

Alabama Governor Signs Medical Marijuana Bill into Law. Governor Kay Ivey (R) has signed into law a medical marijuana bill, Senate Bill 46. The new law allows people suffering from a specified list of medical conditions to use medical marijuana with a physician's recommendations. The state had enacted a law allowing for the use of CBD in 2014 and broadened that law in 2016, but now has enacted a full-fledged medical marijuana law. But patients will not be allowed to use smokable marijuana nor grow their own. Instead, 12 commercial growers and 12 dispensaries will be authorized to cultivate and distribute medical marijuana. The system is expected to be up and running by the fall of 2022.

Louisiana Governor Signs Bill Allowing Smokable Medical Marijuana. Governor John Bel Edwards (D) has signed into law House Bill 391, which will allow patients to use smokable medical marijuana. The bill passed non-controversially, and its sponsor, Rep. Tanner Magee (D-Houma) said its purposes was to drive down costs and respond to popular demand. "Having the raw form of it, which the public has shown they really want, will allow them to drive down their costs so they can pass on to the consumer and have a real alternative to opioids," Magee said. Smokable medical marijuana will not be available for purchase until January because of time lags with the two state universities who are currently the only institutions authorized to produce medical marijuana.

International

UNODC Releases Annual Report, Warns That Fallout from Pandemic Could Last for Years. The UN Office on Drugs and Crime (UNODC) released the 2021 World Drug Report Thursday and warned that the coronavirus pandemic is propelling more people into drug use, has caused drug trafficking groups to adapt to changed conditions, and sowed economic hardship that could lead to increased cultivation of illicit drug crops. "[D]rug markets have swiftly resumed operations after the initial disruption at the onset of the pandemic; a burst that has triggered or accelerated certain pre-existing trafficking dynamics across the global drug market," UNODC said. "Among these are: increasingly larger shipments of illicit drugs, a rise in the frequency of overland and water-way routes used for trafficking, greater use of private planes for the purpose of drug trafficking, and an upsurge in the use of contactless methods to deliver drugs to end-consumers. The resilience of drug markets during the pandemic has demonstrated once again traffickers' ability to adapt quickly to changed environments and circumstances." On the potential increase in drug crops, UNODC said: "While the impact of COVID-19 on drug challenges is not yet fully known, the analysis suggests that the pandemic has brought increasing economic hardship that is likely to make illicit drug cultivation more appealing to fragile rural communities. The social impact of the pandemic -- driving a rise in inequality, poverty, and mental health conditions particularly among already vulnerable populations -- represent factors that could push more people into drug use."

UN For First Time Engages with Marijuana Regulations. In the 2021 World Drug Report released Thursday, the UN Office on Drugs and Crime called for a global ban on marijuana advertising, saying "a comprehensive ban on advertising, promoting and sponsoring cannabis would ensure that public health interests prevail over business interests." While the call is in line with the UN's long-standing opposition to marijuana legalization, it also marks the first time the anti-drug agency has engaged with the notion of regulating -- not merely prohibiting -- marijuana use and production.

On April 1, the Biden administration gave us the first big hint of what its drug policy will look like as it released the congressionally-mandated Statement of Drug Policy Priorities for Year One. The result is a definite mixed bag: a heavy dose of drug prevention, treatment, and recovery, along with an acknowledgement of harm reduction and a nod in the direction of racially-sensitive criminal justice reform, but also a reflexive reliance on prohibitionist drug war policies both at home and abroad.

And nothing about the most widely used illicit drug by far: marijuana. The word "marijuana" appears not once in the heavily annotated 11-page document, and the word "cannabis" only once, in the title of an academic research paper about the onset of teen drug use in the footnotes. That's perhaps not so surprising, given that, in response to a reporter's question, Vice President Harris said last week the administration was too busy dealing with other crises to worry about making good its campaign pledges about marijuana reform.

What is on the administration's mind is "the overdose and addiction crisis." Citing ever-increasing drug overdose deaths, the statement says "addressing the overdose and addiction epidemic is an urgent priority for [the] administration." But the solution is not to imprison drug users, with the statement noting that "President Biden has also said that people should not be incarcerated for drug use but should be offered treatment instead." (Underlying that seemingly humane approach is the errant presumption that all or most drug users are addicts in need of treatment when, depending on the drug, only between one in five and one in 10 drug users fit that dependent or problematic drug user description.)

Here are the Biden administration's drug policy priorities, all of which are gone into in detail in the statement:

• Expanding access to evidence-based treatment;
• Advancing racial equity issues in our approach to drug policy;
• Enhancing evidence-based harm reduction efforts;
• Supporting evidence-based prevention efforts to reduce youth substance use;
• Reducing the supply of illicit substances;
• Advancing recovery-ready workplaces and expanding the addiction workforce; and
• Expanding access to recovery support services.

Prioritizing treatment, prevention, and recovery is bound to be music to the ears of advocacy groups such as Faces and Voices in Recovery (FAVOR), whose own federal policy and advocacy priorities, while focusing on specific legislation, lean in the same direction. But the group also advocates for harm reduction practices the administration omits, particularly supervised consumption sites. FAVOR noted the administration's statement without comment.

As with the failure to even mention marijuana, the Biden administration's failure to include supervised consumption sites in its embrace of harm reduction -- it is wholeheartedly behind needle exchanges, for example -- is another indication that the administration is in no hurry no rush down a progressive drug reform path. And its prioritizing of supply reduction implies continued drug war in Latin America ("working with key partners like Mexico and Colombia") and at home, via support of High Intensity Drug Trafficking Areas (HIDTA) and "multi-jurisdictional task forces and other law enforcement efforts to disrupt and dismantle transnational drug trafficking and money laundering organizations." Prohibition is a hard drug to kick.

Still, naming advancing racial equity issues as a key priority is evidence that the Biden administration is serious about getting at some of the most perverse and corrosive outcomes of the war on drugs and is in line with its broader push for racial justice, as exemplified by Executive Order 13985, "Advancing Racial Equity and Support for Underserved Communities Through the Federal Government," issued on Biden's first day in office. And it is in this context that criminal justice system reform gets prioritized, although somewhat vaguely, with the promise of the creation of an "interagency working group to agree on specific policy priorities for criminal justice reform."

The Drug Policy Alliance (DPA) has some specific policy priorities for criminal justice reform, too, and they go far beyond where the administration is at. In its 2020 Roadmap for the incoming administration released in November, the group calls for federal marijuana legalization, drug decriminalization, and a slew of other criminal justice and policing reforms ranging from ending mandatory minimum sentencing and the deportation of non-citizens for drug possession to barring no-knock police raids, ending the transfer of military surplus equipment for counter-narcotics law enforcement, and dismantling the DEA. And the federal government should get out of the way of supervised consumption sites, or in DPA's politically attuned language "overdose prevention centers."

"We're glad the administration is taking important steps to address the overdose crisis -- by increasing access and funding to harm reduction services and reducing barriers to life-saving medications -- especially as people are dying at an alarming rate. We also appreciate their commitment to studying how to advance racial equity in our drug policies and best implement innovative practices on the ground. But it's clearly not enough. We need action," DPA Director of the Office of National Affairs Maritza Perez said in a statement responding to the administration's statement. "Black, Latinx and Indigenous people continue to lose their lives at the hands of law enforcement in the name of the drug war, and yet, the administration has chosen to prioritize increased funding for law enforcement. We need supervised consumption sites, not more money for police."

"And while we commend the Administration for taking steps to reduce employment discrimination, unless we address the biggest barrier for people trying to get a job -- past drug convictions and arrests -- we will still be left with significant inequities and racial disparities in the workplace," Perez continued. "It's time we get serious about saving lives and repairing the damage that has been caused by the drug war, particularly on Black, Latinx and Indigenous communities. We can start by passing federal marijuana reform and ending the criminalization of people for drugs in all forms."

Young drug reformers also had a few bones to pick with the administration's priorities. In their own statement in response to the administration, Students for Sensible Drug Policy applauded priorities such as more access to treatment and more research on racial equity, it complained that the administration priorities "fail to provide adequate support to Young People Who Use Drugs (YPWUD) in this country" -- especially those who use drugs non-problematically.

"There are no steps being taken to support YPWUD that do not want to and will not stop using drugs," SSDP said. "Young people have feared and faced the consequences of punitive drug policies and shouldered the burden of caring for their peers who use drugs for far too long. Young leaders calling for drug policy reform recognize that simply using drugs is not problematic and that we can support the safe and prosperous futures of People Who Use Drugs (PWUD) without forcing them to stop as a pre-condition for compassion, care, and opportunity."

Although only time will tell, for drug reformers, the Biden administration is looking like a step in the right direction, but only a step, and its policy prescriptions are limited by a vision of drug use rooted in the last century. Perhaps they can be pressured and prodded to plot a more progressive drug policy path.