Pharmacists should not be gatekeepers but rather advocates for evidence‐based substance use policies

America's “war” on drugs is clearly a failure. Not only has it failed to reduce illicit drug use, but it has caused enormous harm. It has widened social inequities, imprisoned millions, and entrenched poverty. Given our expertise and privileged position in society, pharmacists should advocate for rational, evidence-based substance use policies that reduce, not amplify, these harms. If you are like me, you likely have at least one person in your life, someone you care about, someone you love, someone you work alongside, who has a substance use disorder (SUD). Indeed, according to the 2022 National Survey on Drug Use and Health, almost 50 million Americans aged 12 or older have a current SUD.1 Like any chronic disease, the severity of the symptoms and degree of impairment varies and fluctuates. Due to stigmatizing beliefs about SUD, most people actively hide their disease.2 Human beings have used psychoactive substances for millennia.3 Using substances to enhance focus, reduce inhibitions, boost performance, mitigate unpleasant feelings, and lubricate socialization is perhaps a universal human desire. Some substances are cultural norms (e.g., alcohol, caffeine) in most societies worldwide, and others (e.g., peyote, betel nuts) in only select populations. Tobacco (nicotine) was socially acceptable for centuries, but it is no longer favored. Cannabis use was socially unacceptable but has become increasingly normalized over the past 20 years. The acceptability of a substance is largely based on culture and politics, not pharmacology or potential for harm.4 Most people who use a psychoactive substance do not become addicted. A majority in our society consumes alcohol, some quite regularly, and millions have used opioids, cocaine, cannabis, tobacco, and psychedelics. But only a small faction uses them in excessive (binge) or obsessive (addictive) ways. It is true that the pharmacological and pharmacokinetic properties of a substance influence its addictive potential, but other factors are far more important drivers of SUD. Comorbid conditions, like mood disorders and attention deficit hyperactivity disorder, play a role. Genetics. Trauma. The social context in which the substance is used. The relative lack of reward from other stimuli (e.g., work, hobbies, relationships). However, the fear of punishment has a negligible effect—it merely drives consumption underground. Accessibility and cost also influence use, but these factors are modulated by the market. Governments can influence legal markets through regulation and taxation but have little control over illicit ones.5 As I put the pieces of the puzzle together in my mind, I see how, in the past, I've only had one label for all harm even remotely associated with drugs. Crime, addiction, broken families, overdose—I labeled it all “Harm From Drugs.” Now I see that a lot of those harms are created by using the criminal justice system to address drugs. We've been blaming drugs for harm largely caused by our drug policies. Pharmacists have become the gatekeepers in this “war,” policing who can have access to opioids, stimulants, and other controlled substances. Frankly, that is not a role I signed up for when I became a pharmacist, and it is antithetical to my core values as a member of a helping profession. Denying access to a substance, even when someone clearly has an addiction to it, does not address the underlying disease. It merely drives people underground to purchase the substance from an illicit source, from sellers who do not care about quality control or value the well-being of their clients. I am not suggesting that we legalize all substances and grant unfettered access to whatever people want. As a society, we should put constraints on things that are harmful. Smoking tobacco is dangerous. Consuming alcohol and flying an airplane is dangerous. Consuming 2 mg of fentanyl is dangerous. When people endanger the lives of others, there should be legal consequences. But outlawing and criminalizing substance use has not worked. Asking health professionals to police rather than help people will not save lives. We need to rethink our approach. The emphasis of our drug use policies should no longer be on prohibition but rather on educating people about the potential harms of substance use. Not in an exaggerated, fear-provoking, misleading way with law enforcement officials, but based on evidence and led by health professionals. We should talk about and screen for substance use in ways similar to heart disease and cancer. Access to harmful substances should be controlled using a variety of strategies short of outright prohibition. Tobacco is a good exemplar. Nicotine is a highly addictive substance. The reality is we will never eradicate tobacco or nicotine use from our society. Our efforts have, however, led to a dramatic reduction in tobacco use and the harms associated with cigarettes. And we continue to update and revise our strategies to address the harms of nicotine use as new threats emerge (e.g., vaping devices). Treatment for SUD should be readily available and encouraged. As health professionals, we should not glamorize or valorize harmful substance use. Conversely, we should not stigmatize or marginalize people with a SUD. We need to develop better tools to treat SUD, which requires us to invest in discovering new therapies and training health professionals who can skillfully help people achieve and maintain recovery. My thinking on these issues has evolved over the past few years, and I hope this editorial will prompt you to examine your own beliefs. All of us have been influenced by societal conceptions and views, particularly by the way substance use and SUD are portrayed by the media. Our personal experiences grappling with family, friends, and patients with a SUD have shaped us too. Three books have left an indelible impression on me, and I encourage others to read them: High Price: A Neuroscientist's Journey of Self-Discovery That Challenges Everything You Know About Drugs and Society by Carl Hart,4 Chasing the Scream by Johann Hari,5 and Curious by Christina Dent.7 I am not naïve about the harms that addiction and psychoactive substance use cause. We should not enable or condone destructive behavior. However, substance misuse and SUD are public health problems that should be addressed by health professionals, not the criminal justice system. Pharmacists should no longer be gatekeepers but rather advocates for rational, evidence-based substance use policies that reduce harm. Stuart T Haines is the Editor-in-Chief of JACCP.