Harm reduction historic shift in illegal drug policies, UB expert says

The Biden administration is tackling the opioid crisis through harm reduction, a new approach to the nation’s drug policies that UB drug policy historian David Herzberg says could save thousands of lives if political opposition doesn’t derail it.

In a Q&A with UBNow, Herzberg, associate professor of history, College of Arts and Sciences, delves into the history of harm reduction and how it challenges a long tradition of using drugs and addiction as political weapons.

He also discusses how the Biden administration is quietly leading what could become a historic shift in the nation’s drug policy — from nearly two centuries of “drug wars” to strategies that prioritize the well-being of people who use drugs.

Harm reduction is an umbrella term that refers to a range of different ways to address drugs that grew out of global HIV/AIDS activism in the 1980s and 1990s, all of which share two central elements: First, they are led, defined and driven by people who use drugs and their close allies; and second, they prioritize the well-being of people who use drugs rather than insisting on abstinence as the primary, most important and universal goal. 

Some versions of harm reduction focus first and foremost on health; for example, reducing the potential harms of drug use by providing clean equipment such as needles, drug testing to detect adulteration or toxins, safe spaces in which to use drugs, and health care, including medication assistance for people who use drugs. 

Other versions look beyond individual health to reduce socially determined harms. These include pushing back against drug stigma, political advocacy to end the racism baked into drug policy, seeking to replace criminalized prohibition with regulated safe supply, and social and political work to address the needs of people who use drugs, such as housing and health care, without first requiring them to abstain from drug use.

The 2022 strategy statement of the Office of National Drug Control Policy is the first to include (or even mention) harm reduction. The administration plans to build on the previous year’s $30 million in funding for harm reduction programs with additional actions intended to improve access to the overdose-reversing drug naloxone and treatment drug buprenorphine, invest in training and hiring of harm reduction workers, and build up needle exchange programs and drug-testing services.

Supervised injection sites are also under consideration, although there is no guarantee that the administration will ultimately endorse these. The administration is exploring the rescheduling of cannabis, which can also be seen through a harm reduction angle. The harms associated with cannabis use have mostly been the result of adulteration (a classic prohibition market problem fixable through robustly regulated legalization), or the negative consequences of criminal justice system involvement.

Drugs and addiction have been extraordinarily effective political issues in the U.S., and historically they have almost always fit into a recognizable template: Politicians and moral crusaders sensationalize the horrors of addiction and provoke white Americans’ fears by claiming that urban, racial minorities are seeking to entice young white people into addiction to profit from their need for drugs and to make white women sexually available to them. This same “drug scare” template has been used against alcohol and Southern and Eastern European immigrants (leading all the way to national Prohibition in the 1920s), as well as heroin, cocaine and cannabis, and a parade of different minority groups at different moments throughout the 20th century. 

No. The closest the U.S. came before this was in the 1970s, during Richard Nixon’s first term and during the first part of Jimmy Carter’s term. Nixon invested heavily in methadone maintenance, which can be seen as belonging to the harm reduction playbook. Methadone is a cheap, quality-controlled, long-acting (24 hours) opioid that frees a person with addiction from many of the damaging aspects of that condition — without requiring them to abstain from drugs (methadone is an opioid, just like heroin). 

However, at this time, methadone maintenance was implemented as part of a crime-control strategy and did not have clients’ whole well-being as the primary goal. Instead, success was measured almost exclusively by changes to the crime rate. As time went on, Nixon leaned ever more heavily into the “drug war” aspect of his policies, and methadone maintenance became one more site where people who use drugs were policed and controlled.

President Carter, meanwhile, came close to decriminalizing cannabis, stating that the penalties for a drug should not exceed the potential harms of using it. However, under fire from moral crusaders reviving the traditional drug panic template, Carter backed off from this policy and gave way to the renewed anti-drug campaigns of the 1980s.

People who believe that using drugs is in itself an immoral act may not be able to accept harm reduction. However, it might help to point out that almost everyone regularly uses drugs of one sort or another, from coffee, to alcohol, to tobacco, to antidepressants, etc. What makes one kind of drug use more immoral than another? If the answer is, “harmful drug use is immoral,” then harm reduction may hold new appeal. The whole idea is to reduce the harms associated with drug use so that, under this logic, it would no longer be immoral. Additionally, harm reductionists have noted, even if your goal is abstinence from drug use, “dead people don’t stop using drugs.” If harm reduction helps keep someone alive and in a trusting relationship with a health care provider, they will have the tools to quit using drugs when they are ready to do so.

For people whose primary concern is drug harms, rather than drug use — people worried about addiction, overdose, disease, derailed lives, etc. — then there is ample evidence, both present and historical, that harm reduction truly does reduce those risks more than prohibition policies. Here the issue is using dry facts to overcome what has become, over the centuries in America, a deep emotional commitment to fearing drugs. Typically, this doesn’t work. Instead, the long and patient work of cultural change will have to take place, perhaps similar to the work done to encourage awareness and acceptance of LGBTQ people and issues. This work involves a wide range of people: political advocates, health care workers, researchers, scholars, intellectuals and journalists.

That’s possible, but unlikely. Drugs and addiction have been central political issues since at least the 1840s and it is hard to imagine them disappearing. Instead, harm reduction, like other political reforms, will remain a process that requires constant commitment and energy to maintain against a drug panic template that continually tempts politicians and other authorities. It is so effective in mobilizing peoples’ fears that there will always be people who can’t resist taking advantage of it, even though, to those of us who study it, its catastrophic consequences are tragically clear.

History cuts both ways on this one. On the one hand, the historical record suggests it is unlikely. For every step toward pragmatic thinking about drugs, there has been a radical reaction back to the drug panic template. If the midterms show that drug panic rhetoric (about the border, etc.) is effective, the Biden administration could be just the latest to lose their nerve and step away from rethinking drug policy. On the other hand, this is the first time that the U.S. has seen people who use drugs organized politically so that their voices are included in the policy conversation. It is particularly intriguing that some harm reductionists have built bridges to antiracist activists pushing against the “new Jim Crow” of racially unequal policing and incarceration. When you have a genuinely new element like this, things may turn out differently than they did the last time around.