July 7

The Controversy over Harm Reduction

This post originally appeared on healingrefuge.org

By all measures so far, 2020 set records for the number of people who died from drug overdoses. Last week, the New York Times reported that the Biden administration has begun to support “harm reduction” approaches in order to reduce the death toll from addiction. These include controversial programs like needle exchanges, Narcan availability, and support groups. The controversial methadone and Suboxone maintenance approaches, which replace illicit drugs with a long-acting, legal (but hard-to-kick) opioid, are also considered harm reduction, though the article does not specifically say the Biden administration supports these.

The article saddens my heart. It does so not because harm reduction is a bad thing– it is absolutely a good thing. Rather, much of what we call “harm reduction” most western nations call basic decency. Why shouldn’t addicts have access to Narcan in case of overdose, and clean needles so they don’t get hepatitis or HIV? Why shouldn’t there be testing to ensure that the drugs an addict uses aren’t contaminated with deadly chemicals?

The answer lies in our antiquated approach to addiction. Science tells us addiction is a disease. But our society, from politicians to law enforcement to the justice system, treats drug addiction as a moral problem. In essence, we say, “They chose to become an addict, they get to live with the consequences not only of their addiction but of choosing a life that gets them cast out of society.” We won’t help them. We won’t even treat them as human anymore. Nothing that could possibly enable that addiction will be provided, whether that’s a clean needle or a decent-paying job. (Many drug violations are felonies, and you can’t get a decent job with a felony on your record.) Instead, we lock them up until they’ve learned their lesson.

Imagine for a moment saying to someone who has cancer, “We’re going to lock you up until you decide to get better.” Let the absurdity of that sink in for a moment. Sure, addiction creates behaviors we don’t approve of. But if it is biological in nature, we don’t get to blame the sufferer for having it any more than we get to blame the diabetic for having diabetes. (If the diabetic robs a candy store, that’s another story. I would never say that an addict is not responsible for the behaviors they engage in to support their addiction, but they are surely not responsible for having the disease of addiction that compels them to use drugs.)

A couple of weeks ago, I went to court to testify on someone’s behalf at their sentencing. He was last on the docket, so I got to see eight other men and women sentenced. All but one were being sentenced for committing a drug- or alcohol-related offense while on probation. Every one of these struggling addicts received at least a year in jail. One man, who pleaded that he’d never been to rehab and had no idea how to stop using drugs, received six years in prison.

This is our answer to addiction: lock them up. It’s absurd, like locking up a heart attack patient. It’s cruel, dehumanizing, and alienating those who so desperately need help. And it doesn’t work. Which may be why judges are so frustrated that they’re locking repeat offenders up and throwing away the key. Some 68% of those incarcerated for drug offenses are rearrested within 2 years, so why let them out?

The most successful approaches to addiction, including the Twelve Step programs, all recognize one simple truth: someone struggling with addiction can’t quit without help. If we accept that as true, then our societal approach to addiction, which expects a person to just decide to quit and then do so, basically says, “An addict is not worth helping.” Our approach is a death sentence, because addiction is a fatal disease.

So long as harm reduction remains controversial, we are a nation that kills its sick rather than curing them. And that should be offensive to all of us. But harm reduction is just the beginning. Abstinence is the ultimate goal for anyone who has passed into the realm of addiction. My next post will explore what is needed for an effective abstinence-oriented approach, and why it is so difficult for addicts to get the help they need.

July 5

Of Guns and Butter: The Economics of Prohibition

Since the Harrison Act in 1914, the national policy for managing substance abuse in the United States has been prohibition. In 1970, the Controlled Substances Act began the War on Drugs, although under President Richard Nixon most of the funding went to treatment rather than enforcement. There have been many other legislative attempts to reduce drug and alcohol use in our nation. Yet despite these increasingly harsh laws, drug overdoses– an indicator of overall drug usage– have continued to skyrocket. In 1970, there were 7,101 drug overdoses. In 2020 there were over 90,000. The mortality rate from overdose has jumped from about 1 per 100,000 people in 1979 to 21.6 in 2019.

Clearly prohibition isn’t working.

Is there a better way? Consider the experience of Portugal, which has seen drug use (as measured by usage in the previous 12 months), overdose deaths, HIV, Hepatitis C, and drug-related social costs drop since decriminalizing drugs in 2001.

And yet these two very different national experiences were predictable– and should have been predicted by anyone who has studied economics.

If you’ve taken an economics class, you probably remember the “guns and butter” charts. These demonstrate that because production capacity is limited, producing more of one thing requires producing less of something else. But they also tell us something about price: If more guns are produced, the supply of butter drops and the price goes up. This makes it more profitable to produce butter– an economic opportunity. It’s also an opportunity to invent new substitutes for butter in order to fill the demand.

Now imagine we replace these two products with two others: milk and heroin. As the supply of heroin drops, the price goes up, making it more profitable to supply. And there’s incentive to find and supply substitutes, like oxycodone and fentanyl. Consider that an oxycodone bought by prescription costs about 33 cents, but on the street it sells for $20– a gross profit of 6,000%! That’s quite an incentive. As you can see, prohibition on heroin actually encourages increased supply because it becomes so much more profitable to sell.

But there are other economic behaviors that tell us prohibition should fail. For example, when something is scarce, people want it more. It becomes a status symbol. Which is more attractive to wear: a rare shirt you bought at the concert of your favorite band or a common t-shirt purchased at Walmart? Many people would choose the one that no one else has. Rarity adds value.

And prohibition removes any possibility of regulating content or safety. So long as the substance is outside governmental control, its quality relies solely on the ethics of the provider. And if the substance is illegal, the provider is by definition a criminal whose ethics are open to question. With so much money involved– and a desperate market for the product– customer satisfaction isn’t much of a concern. This is why so many overdoses are linked to adulteration. A poster in a New Hampshire hospital, above, warns that much of the heroin has been contaminated with carfentanil, an animal tranquillizer that is 10,000 times more potent than morphine. People are dying because the drug they are addicted to is illegal.

From the standpoint of economics, so long as there is a demand– for drugs or for any product– there will be a supply. The more we try to stamp out that supply, the more the price goes up and the more incentive there is to provide the product. We cannot reduce demand by reducing supply. That’s not how economics works.

On the other hand, when something is readily available, in the absence of other factors like billion-dollar marketing campaigns, it becomes less appealing.

There are, of course, many other factors driving the addiction crisis in this country. But so long as the substances are illegal, we have virtually no way to control the social cost of this epidemic, nor to limit the tragic loss of life.