Editorials of The Times

When Julie Eldred tested positive for fentanyl in 2016, 11 days into her probation for a larceny charge, she was sent to jail. Such outcomes are typical in the American criminal justice system, even though, as Eldred’s lawyer has argued, ordering a drug addict to abstain from drug use is tantamount to mandating a medical outcome — because addiction is a brain disease, and relapsing is a symptom of it.

Eldred’s case, now before the Massachusetts Supreme Judicial Court, has the potential to usher in a welcome change to drug control policies across the country. The case challenges the practice of requiring people with substance abuse disorders to remain drug-free as a condition of probation for drug-related offenses, and of sending offenders to jail when they relapse.

The prosecution’s counterargument — that the disease model of addiction is far from settled science — is weak. The National Institute on Drug Abuse, the American Medical Association and the Diagnostic and Statistical Manual of Mental Disorders, which is the final authority on psychiatric conditions that qualify for insurance reimbursement, all define addiction as a chronic, relapsing brain disorder that, like diabetes and heart disease, is caused by a combination of behavioral, environmental and biological forces.

The prosecution’s argument is also somewhat beside the point, because it is clear that relapses are common in people struggling to overcome addiction, whether one considers it a disease or not; specialists say that most opioid addicts relapse an average of five to six times before achieving full sobriety.

It’s also true that addicts can and do respond to incentives. But the balance of evidence suggests that carrots work far better than sticks, and that in any case, the particular stick of jail time thwarts the treatment process.

“Our patients are far less likely to talk honestly about their relapses and their struggles with recovery if they think it’s going to land them in jail,” says Sarah Coughlin, a social worker and addiction specialist in Charlestown, Massachusetts. “It puts us in a tough spot, because it breeds mistrust.” It also breeds fear: As The Boston Globe reported, one woman committed suicide in the bathroom of a Lowell, Massachusetts, drug court after she watched at least 23 of her 41 fellow probationers get sentenced to jail for relapses and other violations, and after she became convinced that she would soon be sentenced as well.

Of course, criminalizing relapse isn’t the only absurdity that exists at the intersection of drug addiction, criminal justice and public health. As a recent Times article explained, states across the country are enacting laws that allow for homicide charges against just about anyone connected to an overdose death, even if that person is also suffering from addiction.

The irony is both dark and profound: Only in death do drug users become victims. Until then, they are criminals.

In addition, a vast majority of American prisons deny opioid addicts access to medication-assisted therapy, or MAT, which uses Food and Drug Administration-approved medications that can relieve opioid cravings and withdrawal symptoms. Most addiction specialists say MAT is far and away the most effective treatment for opioid use disorder.

Anti-MAT policies have a number of unconscionable effects. They mean that incarceration necessarily disrupts a promising treatment before it has time to work. They also force addicts who are in treatment but faced with incarceration to rapidly and dangerously taper off serious medications. And they increase the risk of post-incarceration overdose deaths. “A lot of the overdoses that lead to homicide charges occur upon release from jail,” says Josiah Rich, a Rhode Island doctor who treats addiction in the prison system. A study by Rich and his colleagues found that providing MAT to inmates suffering from addiction could reduce such deaths by more than 60 percent.

Policies that punish relapse with jail time and keep sufferers from proven treatments are part and parcel of a nearly 50-year war on drugs, predicated almost entirely on criminalization, that no reasonable person would say is working. It costs about $33,000 a year to imprison someone for a nonviolent drug offense and $6,000 to treat someone with MAT.

A ruling in Eldred’s favor would mark a positive step toward rethinking this strategy.

It would not, as some critics contend, necessitate freeing everyone with a diagnosis of a substance abuse disorder from facing any consequences for drug use. “It doesn’t have to be, and it shouldn’t be, an all-or-nothing proposition,” Kleiman says. “You still want to have consequences, but they should be fair.”

The outcome of the Eldred case won’t have much effect on Eldred herself. With the help of her lawyer, she was diverted into a treatment program and is now in remission and rebuilding her life. But a decision for Eldred could help ensure that other people suffering from addiction get the chance she did.

It’s not easy to discern a political “crisis” in a country that has had at least 64 governments since World War II, but at the least, the Italian president’s unexpected decision to block the government proposed by two populist parties qualifies as a daring gamble. How it plays out could have major ramifications for Europe.

In normal times, the president of Italy plays a largely ceremonial role in his gilded Quirinal Palace. But when two disparate anti-establishment parties, the Five Star Movement and the League, came to him with plans to form a coalition that included proposals for enormous new spending and a finance minister openly hostile to the shared European currency, President Sergio Mattarella, a 76-year-old Sicilian expert on constitutional law and former government minister, stepped in on Sunday night and said no.

Technically, Mattarella blocked only the appointment of Paolo Savona, an 82-year-old economist tapped to be finance minister, on the ground that his covert plans to exit the euro posed a risk “for Italian families and their savings.” But the impasse over Savona prompted the coalition’s lowest-common-denominator choice for prime minister, an obscure law professor named Giuseppe Conte, to bow out, leading the president to ask Carlo Cottarelli, a solidly pro-Europe and pro-austerity economist and former official of the International Monetary Fund, to form a nonelected government. Cottarelli said new elections would be held in early 2019, though they could be held as early as September if he fails to survive a confidence vote.

Opponents of the coalition cheered Mattarella’s action as a courageous blow against the dangerous rise of populism and irresponsible programs that would have vastly increased public spending in a country already saddled with a 2.3-trillion-euro ($2.7 trillion) debt. The spurned parties, which had struggled since national elections on March 4 to overcome profound differences and form their coalition, complained of unwarranted presidential interference in a legitimate political choice. The leader of the Five Star Movement, Luigi Di Maio, called for the president to be impeached, while the League’s leader, Matteo Salvini, threatened to organize a march on Rome.

There is no real danger of Mattarella being removed or Rome sacked. A more ominous response came from financial markets, where yields on Italian bank bonds rose sharply on fears of another election, potentially with an even stronger showing by populist parties and a new threat of Italy giving up the euro. Markets in the United States shuddered as well at the prospect of more instability in Europe, with the Dow Jones industrial average down nearly 400 points, or 1.58 percent. Political analysts deemed it unlikely that the left-leaning Five Star, with its roots in the poor south, and the far-right League, based in the rich north, would maintain a partnership in the next election, and there is no way to predict what might emerge from another round of fierce campaigning.

However spooked the markets were, they had been equally wary of the coalition and its grandiose spending plans, and given the mutual hostility of the coalition partners, their government might not have survived for long. Mattarella’s stand, at least, gives Italian voters a second chance to weigh their options after glimpsing what their earlier choices might mean. That’s something some Brexit voters in Britain, or Trump voters in the United States, might have welcomed.