According to a recent forecast, as many as 650,000 people in the United States will die from opioid overdoses over the next 10 years.¹ Some 50,000 people died from opioid overdoses in 2016.² When that figure is compared to the 10,917 people in the United States who died from all types of drug overdoses at the peak of the crack epidemic in 1988, it’s clear that—as is now well understood—the United States is in the middle of a deadly drug crisis.³ Initially, the current crisis was centered among a white and rural or suburban population, but it’s now spreading into the black and urban populations. The relatively recent and broad introduction of fentanyl and other synthetics into the drug supply is greatly exacerbating the problem. Fentanyl is around 50 times more potent than heroin (as demonstrated by one Ohio police officer who overdosed after simply brushing some fentanyl off his uniform), and fentanyl analogues can be as much as 5,000 times more potent.⁴ Fentanyl deaths across the United States have increased over the past three years, and the death toll from synthetic opioids recently surpassed the death tolls from heroin and prescribed opioids.⁵ In New Hampshire, for instance, over 70 percent of opioid-related overdose deaths in 2015 involved fentanyl.⁶ In addition, the public health threat from this epidemic is—so far, at any rate—different from the previous crack epidemic. The death toll then was from market-related violence: it was guns, not crack, that mostly killed people. Now, although some law enforcement authorities are beginning to report market-related violence, especially through robberies of opioid dealers, the primary killers are addiction and overdose.⁷

Traditional, Ineffective Approaches

The most common way to think about addressing drug epidemics is in terms of supply and demand. Supply-side interventions involve going after sources both outside and inside the United States—keeping drugs out of the country, and addressing the grow houses and labs that produce them inside, as well as the street dealers and distribution networks. Demand-side interventions involve programs and initiatives like public health campaigns to prevent initial use and treatment to wean away users. If there’s anything the United States should have learned from previous epidemics, it’s that neither approach works very well, either alone or in concert. Decades of drug enforcement has moved in parallel with lower prices and wider availability, and incarcerated dealers are readily replaced with new ones. Public health campaigns against drug use are ineffective or even make things worse.⁸ Treatment may help particular users, but it has had no overall impact on the United States’ various drug epidemics. While border enforcement has resulted in increased cocaine and marijuana seizures, no such success has occurred for seizures of heroin, and one 2015 study found that border enforcement efforts to disrupt supply were associated with decreased heroin prices.⁹ Such efforts seem even less likely to be effective against what is essentially mail-order fentanyl. Harm reduction
efforts—particularly the drive to make the opioid antagonist naloxone widely available—have undoubtedly saved lives, but they are not keeping up with, much less reversing, the spread of the epidemic and its rising death toll.

Focused Deterrence Via Drug Market Intervention

During the U.S. crack epidemic, a similarly discouraging picture led to a different approach: attacking not crack itself or the supply of and demand for crack, but using a focused deterrence approach to shut down the drug markets where crack, crack dealers, and crack users all met. An unusual, but simple and mostly commonsense analysis emerged around the public, open-air and crack-house “overt” markets that were tearing apart communities, where dealers stood on corners or behind crack-house doors and sold to the users who drove in from outside the neighborhood. The logic was that geographically defined, overt drug markets operate because they become areas in which dealers know they can sell and users know they can buy illicit drugs. People who know each other don’t need to stand on street corners and flag down drive-through buyers; they can sell and buy from their high school lockers, their college dorm rooms, or their hedge fund offices. However, people who don’t know each other need a place to connect. Overt markets—usually no more than a couple of concentrated blocks—took root, almost entirely in minority communities, as places where dealers could be found, where buyers could go, and where business could be transacted. Once that dynamic was established, the market area had tremendous staying power. Dealers knew that users would be present; as such, they had a strong motivation to work in that area. Users knew that dealers would be present; as such, they had a strong reason to “shop” in that area. Heavy law enforcement attention to the market rarely broke the cycle, as low-level dealers were arrested and released and came back to the market or were replaced by new dealers, and buyers who knew the area as a market kept returning to it. The standard pattern was relentless enforcement and markets that persisted anyway, often literally for decades.

The market disruption logic was equally simple: if the cycle could be broken long enough, it would be broken permanently. If dealers came to the area and there were no buyers, they’d stop coming back. If buyers came to the area and there were no dealers, they’d stop coming back. If dealers and buyers stopped seeing the area as a market, it would no longer be a market; instead, it would be just another neighborhood. In practice, it seemed easier to disrupt the market by intervening on the dealing side, as law enforcement and scholarly insight suggested that, even in the most intense overt markets, there were usually a relatively small number of people who were willing, at any given time, to actually stand in public or behind a door and sell drugs to strangers.

High Point, North Carolina, Drug Market Strategy

As the market disruption strategy developed in High Point, North Carolina, into what became known as the High Point Drug Market Strategy or Drug Market Intervention (DMI), it took on these core elements:

• Identifying a geographic market

• Identifying all front-line dealers

• Creating prosecutable cases against all dealers

• Incapacitating all dealers through arrest or through a call-in, “influentials,” and banked cases

• Holding a call-in and mobilizing “influentials”

• Providing outreach and support to those previous dealers who would accept it

• Developing a maintenance strategy to prevent the reemergence of the market

In the traditional “street” or overt market DMI, law enforcement chooses and pays concentrated attention to a particular drug market and identifies all or nearly all the dealers driving it. While it involves real work, traditional investigative methods can nearly always, with sufficient focus, uncover the functioning of the market and the dealers involved. The original High Point intervention in the city’s West End neighborhood—the site of a thriving, intergenerational drug market—identified only 16 active, front-line dealers. This became the norm across DMI implementations, with law enforcement finding that there were no more than a few dozen such actors, which allows for enforcement and other interventions to be extremely strategic and precise.

Next, these key actors (high-level suppliers and dealers) are incapacitated through criminal justice mechanisms. In the High Point model, dealers with histories of serious violence were prosecuted, while nonviolent dealers were brought into a “call-in,” a technique drawn from other focused deterrence strategies. At the call-in, dealers heard a three-pronged message. Law enforcement explained that the market is closed and conveyed exactly what would happen if the dealing continued; community leaders and dealers’ family members delivered an unequivocal message against dealing; and social service providers offered a range of concrete social service and other supports. One innovative feature of DMI was the use of “banked” cases. All dealers invited to the call-in faced prosecutable cases produced by the up-front investigation of the market; therefore, dealers were told that any further overt dealing activity would result in the immediate activation of those cases, arrest, and prosecution. The intent was to produce a high level of deterrence while not damaging the dealers and their families and community by further high levels of arrest, and to shift community sentiment by demonstrating a changed understanding and commitment by law enforcement. Another mechanism was the mobilization of “influentials”: people close to the dealer who could establish personal standards and expectations and support compliance going forward.

Law enforcement and the community followed the market disruption with a long-term maintenance strategy in the overt market area, based on the simple idea that if no new dealers were allowed to establish themselves, the market would not return, and, eventually, new dealers and buyers would stop trying to do business there. The basic maintenance strategy looked out for new dealers and took immediate, obvious action to head them off: a knock-and-talk, a custom notification, police presence at the location in question, intervention with parents or landlords, and the like, followed, if necessary, by traditional investigation and enforcement.

The first High Point intervention in the West End succeeded—the market disappeared after the call-in and never returned—leading to broad interest in the approach, including replications under U.S. Department of Justice auspices and a number of other successful replications (and some failed ones, which highlighted the need for fidelity to the core strategy). Drug market disruption turned out to be a useful idea, workable in practice because such overt markets were driven by a meaningfully small number of dealers who could be identified, incapacitated through arrest and prosecution or deterred by banked cases, influenced by community norms and by “influentials,” and helped to change their lives. When those steps were completed, markets collapsed, violence and disorder were reduced, and the disruption could be maintained.

DMI in Opioid Markets: The Rutland Experience

Today’s opioid markets are different from the open-air drug markets that were subject to special attention in past DMI implementations; they are, in particular, covert rather than overt. People are not, for the most part, standing out on street corners selling opioids or operating flagrant drug houses. The role that was played by geographic location in overt markets is instead played by social networks of dealers and addicts. But, within those networks, potentially similar elements operate: supply, demand, and the need for the successful functioning of markets. In principle, as long as the structure of an opioid market can be analyzed and its key dynamics identified, the logic of market disruption might be applicable. In considering a “covert market” DMI, the two most pressing practical questions seem to be: (1) Is it possible to identify the shape of the market and, especially, the key dealers in it? and (2) Is the number of key dealers manageably small, and can we imagine a practical and potentially meaningful intervention?

In Rutland, Vermont, the answer to both of those questions was “yes.” Rutland, a town of only about 16,000 people, had emerged as a regional heroin hub in the new epidemic. Driven by escalating overdoses and opiate-related neighborhood crime and disorder, local, state, and federal investigators launched a classic drug investigation in 2013. They found a remarkably small group of actors at the heart of the problem. The heroin supply came largely from weight distributors traveling from Brooklyn, New York, to Rutland. Once they arrived in Vermont, a small number of “connectors” put the distributors in touch with addict-dealers who had their own connections to local heroin buyers. Out-of-town buyers could cruise the active neighborhoods and buy from obvious drug houses or leverage known contact information to arrange a meet-up at a local shopping plaza. For all the damage the Rutland heroin market was doing in the city and across the region, the core dealer network—the Brooklyn dealers, the connectors, and the initial addict-dealers—represented only a few dozen people. Once this was determined, it seemed that it might be possible to take that network out of action and break the connection between dealers and buyers.

Armed with the logic of DMI and building on the careful local, state, and federal investigations, the partners developed an enforcement and maintenance strategy to permanently shut down each layer of participation in the market, while also addressing the “hot places” where dealing had been facilitated. The initial steps included arresting and prosecuting the outside suppliers on federal charges and arresting (though not necessarily prosecuting) the connectors and addict-dealers on state charges. Once law enforcement had performed this initial sweep, the Rutland partnership pursued a tiered approach to engaging with dealers and permanently disrupting the covert market.

Between 20 and 25 out-of-state volume distributors and violent dealers faced federal charges. The Vermont Drug Task Force also arrested 27 drug dealers who faced significant state charges based on prior dealing behavior or their status as connectors. Of those 27 local dealers, 4 were connectors who faced state charges in criminal court, and 16 were addict-dealers who were sent to criminal court as well. The 7 remaining addict-dealers arrested by the Vermont Drug Task Force—who had not been involved in violence—were invited to a call-in associated with Rutland’s Drug Treatment Court (DTC). Under typical circumstances, the DTC accepts only those offenders who have been charged for possession or misdemeanor sale, but Rutland’s DTC made an exception for DMI call-in participants who had felony sales on their records. (It seems likely that in future covert market DMIs, larger proportions of those arrested might be identified for diversion.)

At the call-in, representatives from law enforcement presented the details of their case, community members demanded that the dealing stop, and social workers offered help and treatment. The Rutland partners understood the role played by banked cases in the covert market DMI, but also recognized that opiate addiction was a fundamentally different dynamic. In its place, the addict-dealers called in were offered the opportunity to plead to a charge with a reduced sentence and high levels of supervision, including enrollment in drug treatment, support programs, and regular drug testing and inspections of their primary residences. Law enforcement monitored this group to ensure they stopped dealing and to assess their program of recovery from addiction.

Rutland’s DTC lasts for a minimum of 180 days, and, if an individual relapses, he or she must restart the program. The DTC has three phases, each of which requires participants to attend one mandatory meeting each week and consistently test negative for drug use. The phases last 30, 60, and 90 days, respectively, and address an array of issues affecting the participants. The first phase is meant to stabilize the offenders with an individual needs assessment and orientation that address urgent problems ranging from homelessness to mental health issues. Phases two and three require participants to build on their successes and continue to progress toward self-sufficiency before graduating from the DTC. During each phase of the program, a Rutland police officer checks in with participants several times each week outside of the mandatory meetings. Officers ensure that everything is going well, review participants’ emotional states, inspect their premises, and offer support.

Simultaneously, the DMI partners implemented a maintenance program designed to sustain the disruption. Keeping the market closed in Rutland relied on two elements: preventing new dealers from setting up again after the call-in and offering community support to addict-dealers. The implementation sought not only to shut down the heroin market, but also to counter the idea that Rutland provides a haven for heroin trafficking.

Rutland’s law enforcement agencies monitor potential dealers trying to set up shop and use a variety of methods to disrupt them, including custom notifications of legal risk for criminal activity, building code enforcement, and strict enforcement of probation and parole conditions. A Community Response Team debriefs frontline officers and holds weekly meetings to review data, trends, and developments in heroin-related crime and offenders. The product of those meetings is a “hot sheet,” distributed to every officer in Rutland, which allows officers to identify people involved in the DMI who require extra enforcement or treatment attention.

Impact of Rutland’s DMI Effort

Rutland’s DMI effort has not been formally evaluated (and state data collection practices mean that heroin use and overdose data are not available for Rutland as such); however, there’s some reason to believe something significant (and positive) happened as a result. Between 2013 and 2015, larcenies and motor vehicle thefts in Rutland declined by 31 percent; disorderly conduct by 37 percent; vandalism by 49 percent; and burglaries by 53 percent. Those declines have contributed to a 17 percent decrease in overall crime in Rutland, and Rutland’s city and law enforcement officials attribute these drops to the city’s DMI work. Additionally, recent research from the Vermont Department of Health shows that, from 2015 to 2016, the state of Vermont overall, including the three counties adjacent to Rutland, had increases in drug-related deaths, while Rutland itself did not.¹⁰ Beyond that, front-line law enforcement and city personnel say that that there has been a marked change, for the better, in the atmosphere of the city.

Researchers and Rutland officials also cite the success of a local methadone clinic that was launched as part of the larger strategy and which now serves a caseload of 750 clients. Recognizing that a successful market disruption operation would mean that addicts would be cut off, the city created that capability to ensure that individuals would have access to treatment. Because the damaging effects of heroin markets are primarily pharmacological and not market-related—unlike during the crack epidemic, when open-air markets brought violence and prostitution, among other issues—ensuring mitigation of pharmacological harm to addicts should be considered critical to the long-term success of covert opioid DMI.

Lessons Learned and Next Steps

The historic and now predictable failure of traditional demand-side and supply-side approaches, the logic of disrupting markets, and the interesting Rutland strategy collectively suggest that the DMI approach may hold promise for other cities struggling with covert opioid markets. This strategy may provide a useful tool in addressing the United States’ current opioid epidemic. Federal, state, and local governments should consider the possibility that the strategy might be adapted to other cities and market areas; explore whether other local drug markets are being driven by a small core network of dealers; and conduct research to assess whether market disruption interventions have an impact on opioid use and addiction, overdose deaths, and related crime and disorder.

A decidedly nonscientific, but provocative, polling of frontline law enforcement embroiled in the new opioid markets consistently does, in fact, suggest similar dynamics elsewhere. In a number of small and medium-sized jurisdictions, those close to the problem can identify relatively small numbers of main suppliers, connectors, and a first tier of addict-dealers. By these agencies’ accounts, at that point in the supply chain, the market is very contained, which might present an opportunity for disruption.

Given the severity of the U.S. opioid crisis—and the current and probable future failure of traditional interventions, it seems reasonable to make a systematic investment in understanding and attempting to disrupt the new markets. What is the shape of such markets? How many of and what sort of actors are involved in the different market layers and roles? How, in the real world, does supply move around? Where does “dealing” move from high-level distribution and moneymaking to another aspect of desperate addiction? How can these issues be rapidly and efficiently determined in a real setting, and what range of steps will address each? Is any of this different for the especially deadly fentanyls, and can they and the harm they cause be given special attention? If law enforcement and communities hope to mitigate the damage from this crisis, more needs to be learned about the structure of the new covert opioid markets in order to develop and assess practical strategies to adapt the logic of market disruption to new contexts. ♦

Notes:

¹Max Blau, “STAT Forecast: Opioids Could Kill Nearly 500,000 Americans in the Next Decade,” STAT, June 27, 2017.

²Josh Katz, “The First Count of Fentanyl Deaths in 2016: Up 540% in Three Years,” New York Times, September 2, 2017.

³Kush Desai, “Fact Check: Is the Current Drug Epidemic the ‘Deadliest’ in US History?” CheckYourFact.

⁴Artemis Moshtaghian, “Police Officer Overdoses after Brushing Fentanyl Powder Off His Uniform,” CNN, May 16, 2017.

⁵Katz, “The First Count of Fentanyl Deaths in 2016.”

⁶Allison Bond, “Why Fentanyl Is Deadlier than Heroin, in a Single Photo,” STAT, September 29, 2016.

⁷Maia Szalavitz, “America’s Latest Drug Epidemic Is Weirdly Non-violent,” Vice, June 20, 2017.

⁸Robert Hornik et al., “Effects of the National Youth Anti-Drug Campaign on Youths,” American Journal of Public Health 98, no. 12 (December 2008): 2229–2236.

⁹Michelle Keck and Guadalupe Correa-Cabrera, “U.S. Drug Policy and Supply-Side Strategies: Assessing Effectiveness and Results,” Norteamérica 10, no. 2 (July–December 2015): 47–67.

¹⁰From 2015 to 2016, in Vermont overall, the rise in drug-related deaths was 108 to 148; in Bennington County, 3 to 13; in Windsor County, 5 to 8; and in Addison County, 1 to 7. However, during that same time period, in Rutland County, there was a decrease in drug-related deaths that occurred within the county—16 to 14. Vermont Department of Health, Drug-Related Fatalities in Vermont, January 2018, 5.