Book Review: The Rise of Harm Reduction in the War on Drugs

Yves here. While harm reduction is a valuable policy, it also says a great deal about our society that “needle exchanges” and similar approaches need to be rebranded to make them more palatable.

By Troy Farah. Originally published at Undark

The War on Drugs may profess to be waged against narcotics, but it overwhelmingly targets people — a view increasingly shared by experts on drug use. Nora Volkow, director of the National Institute on Drug Abuse, touched on this recently when she wrote about addiction stigma in STAT, noting that “societal norms surrounding drug use and addiction continue to be informed by myths and misconceptions.”

Starting in the 1980s, a rowdy group of individuals began advocating for a different approach to drug policy called harm reduction. These activists, researchers, social workers, attorneys, and others, from a myriad of different backgrounds, have focused on the harms of drug use — not the drugs alone.

Maia Szalavitz’s new book “Undoing Drugs: The Untold Story of Harm Reduction and the Future of Addiction” is an in-depth history of a powerful idea, exploring many angles of drug policy, including prescription drug use, supervised consumption, and legalizing cannabis. Throughout, she also details the racial inequities and social justice tensions that have defined the drug war.

BOOK REVIEW“Undoing Drugs: The Untold Story of Harm Reduction and the Future of Addiction,” by Maia Szalavitz (Hachette Go, 384 pages).

Szalavitz, a science journalist, unwraps the many layers of harm reduction, a philosophy that has also been adopted in approaching sex work, restorative justice, Covid-19, and other areas. When it comes to illicit substances, harm reduction runs the gamut from sterile syringe access programs to supervised drug injection rooms to distributing the opioid-overdose antidote naloxone.

Depending on who you ask, harm reduction has many different definitions, including “radical empathy” which requires “meeting people where they’re at.” Szalavitz offers multiple interpretations, but writes that, simply: “Harm reduction applies the core of the Hippocratic oath — first, do no harm — to addiction treatment and drug policy. This takes the focus off of psychoactive drug use itself.”

Tracing the roots of the movement, Szalavitz introduces us to characters like the “Goddess of Harm Reduction” and the “Johnny Appleseed of Needles,” whose lives are dedicated to spreading evidence-based practicesof harm reduction. Some advocates were arrested, ostracized by friends and family, or lost their lives to overdose.

For years, the U.S. government rejected harm reduction services, even going so far as to ban federal funding for needle exchange programs. But now there are jobs, conferences, and nonprofit organizations committed to harm reduction. And in President Joe Biden’s budget for the 2022 fiscal year, $30 million has been earmarked for services like syringe access, the first time Congress has appropriated funds specifically for harm reduction, according to The New York Times.

Szalavitz follows the evolution of the movement, beginning with her own story in New York in the 1980s. Addicted to opioids during the height of the U.S. HIV/AIDS epidemic, the young writer had no clue that sharing syringes could spread the deadly new virus that was already killing so many. Yet between 55 and 60 percent of people who use intravenous drugs at the time were positive with the virus.

Ideally, of course, people who inject drugs should never share syringes. Doing so can spread bloodborne pathogens like HIV and hepatitis C. But ideal situations don’t always exist in the world of street narcotics. So some public health agencies, such as the Centers for Disease Control and Prevention, began recommending a middle ground: If you must reuse a syringe, properly disinfect it using bleach and clean water, which by some estimations can greatly reduce the chances of contracting HIV (though certain sources say otherwise).

Before that knowledge became more widely known, a friend’s girlfriend taught Szalavitz this trick to lower her risk of infection, setting her life on a completely different course. She credits this fortuitous acquaintance with saving her life.

Szalavitz became enraged that no one had given her this simple advice. Why had she not encountered a public health campaign blasting this information to all who needed to hear it? But back then, Szalavitz says, few in government seemed to care about people who use drugs. “It didn’t seem fair or right to see anyone as being that worthless,” Szalavitz writes. “I needed to know,” she adds, “how to keep others from suffering the fate I’d only narrowly avoided.”

Thus began a three-decade reporting career on harm reduction, drug policy, and crucially, science, that has spanned, as she likes to put it, “from High Times to The New York Times” (and includes Undark). In this book, she interviewed hundreds of people to catalog the first- and second-hand accounts of people who have helped bring harm reduction into the public consciousness.

The book takes us from Vancouver, Canada and San Francisco, California, to Liverpool, England. Throughout are gossipy details about regular people: their broken relationships and personal dramas, their allegiances and falling outs. This isn’t the book’s main focus, but is a reminder that every movement involves a decent share of infighting and argument, tiny tests that demonstrate the resiliency of an idea.

To make harm reduction work, its progenitors needed to rely on strong research. In 1987 several drug activists in Liverpool started The Mersey Drugs Journal, where they documented local efforts and helped put the term “harm reduction” on the map. Because their ideas reached beyond the borders of Merseyside County, the publication was renamed The International Journal of Drug Policy. Currently issued by Dutch publishing monolith Elsevier, the peer-reviewed journal has an impact factor of 5.0 (meaning it is often cited by other researchers) and is indexed in 11 international databases.

By “emphasizing conducting research on its efforts, harm reduction created an enormous intellectual obstacle for its opponents,” Szalavitz writes. “After all, if studies show that a policy doesn’t reduce harm, it can’t be part of harm reduction. And how can you oppose a policy that works?”

Szalavitz has often been witness to harm reduction history, including an important 1991 court case that paved the way for legalizing syringe access in New York. It began in March of that year with the arrest of eight demonstrators from the AIDS Coalition to Unleash Power, commonly known as ACT UP, a grassroots political group that fought to end the HIV/AIDS crisis through civil disobedience. They were about to hand out sterile syringes on a Lower East Side intersection when the police swarmed the crowd and handcuffed the activists, charging them with needle possession.

Reporting for local outlets, Szalavitz witnessed the arrests and much of the trial, with opposing sides offering evidence for and against syringe access. Testifying for the defense was the city’s former health commissioner, Stephen Joseph, who had notably clashed with ACT UP on numerous occasions. But this time he agreed with them, describing their actions as “courageous,” and drew a parallel to 19th-century British physician John Snow, who traced a cholera outbreak to a single London water pump, similar to how ACT UP activists traced HIV to unsterile injection needles and sought to eliminate the source of infection.

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  1. BrianC - PDX

    Any discussion of the “War on Drugs” has to start with understanding where the DEA came from.

    Search online for copies of:
    Agency of Fear: Opiates and Political Power in America by Edward Jay Epstein

  2. .human

    “The Politics of Heroin in Southeast Asia,” the seminal, 1972 book by Alfred W McCoy is a must read.

    Two generations and hundreds of thousands of souls incarcerated, millions of family affected, and no one held accountable for the known, abusive, misdirected, criminal US War On Drugs.

    I am ashamed.

    1. Ian Perkins

      McCoy’s The Politics of Heroin: CIA Complicity in the Global Drug Trade is a 2003 book, which I haven’t read yet. I think it’s an updated version of the book you mention (excellent, as you say), with added chapters on Afghanistan and South and Central America. There are also a few talks and interviews with McCoy on Youtube.

  3. Joe Well

    I am also horrified by the rejection of needle exchange. I would also favor safe injection sites. But would I want one near my family’s home? No.

    As things are, treatment centers and “sober houses” are already crowded into working class communities. That carries real costs in terms of crowds of addicts, some of which are almost zombi-like, walking into traffic, for instance, not to mention the devastation of businesses.

    I know one place where small business owners regularly find people asleep in their doorways and sometimes inside having broken in. The Dunkin Donuts had a sign on the restroom that it was not to be used as a shooting gallery until they finally closed it for good.

    The dumping of addicts into concentrated areas must stop. These services should be provided discreetly in every healthcare center and medical office building in the country. Syringes should be sold at cost in every drugstore, mandated by law. Of course, single-family residential zoning is also an inequity that makes this and every other problem worse as well.

  4. JEHR

    All the Wars on . . . bring mostly sadness and failure even the War to get rid of Wars. That expression should be put to rest. War on Drugs really means war on drug users rather than health treatment for usage of drugs. Just applying all the euphemisms that accompany War shows how horrible it is to believe there are any similarities between the two. We should lay to rest all Wars: on Terror; on Guns; on Poverty; on Christmas; on Waste, etc.

  5. Maritimer

    I searched the article for the word “alcohol” and did not find it. I wonder if the book itself mentions it.

    “Alcohol is a psychoactive drug….A 2010 study ranking various illegal and legal drugs based on statements by drug-harm experts. Alcohol was found to be the overall most dangerous drug, and the only drug that mostly damaged others.”

    “…mostly damaged others.” Very germane in these Take-one-for-the-herd days.

    Any drug study that ignores alcohol, well…. One reason the deleterious effects of alcohol are ignored is the huge alcohol industry and the fact that it is an acceptable societal lubricant and addiction.

    1. Ian Perkins

      Professor David Nutt made basically the same points when, as a UK government scientific adviser, he said the country’s drug laws were all back to front and not remotely evidence-based. He was promptly fired.

    2. Billy Chav

      This notion that alcohol and heroin are functional equivalents is one of those ideas that, pace Orwell, is so preposterous only an intellectual could believe it.

      I am currently on my second beer. I’d reckon I know about 100 or so people who are in the same state, who are raising families and paying their mortgages. I have known a dozen or so heroin users in my life and all of them were utter wrecks.

      There’s an argument to be made for legalization, but “…but alcohol!” is not it.

  6. ambrit

    This issue is intimately connected with the scandalous way in which America presently treats it’s “low income” mentally ill people. I distinctly remember Ronald [family blogging] Reagan closing the Federal Mental Institutions. Thousands and then tens of thousands of at best marginally competent men and women were put out on the streets. {More effectively, fewer and fewer “cases” were taken into the ‘system.’ Death by a thousand budget cuts.} Then the “Private Sector” took up the slack, probably by design, by providing “services” whose quality and quantity were governed through ‘fiscal restraints.’ The results of that race to the bottom now wander our streets, all of their possessions in the backpacks they wear, and fill our homeless encampments. The populations of the street bound mentally ill and the addicts overlap heavily.
    My point? This article shows just how low as a society we have sunk.
    We argue about ‘outreach’ programs when the best treatment regimes are in house. The Elites have made a decision to abandon the “dregs” of our society and look the other way as the mentally ill and or addicted ‘deplorables’ sink deeper into squalor and die.
    Wisdom Teachers over the years have mentioned the fact that the basic measure of a society is in the manner in which it treats “the least among us.” In this light, America is a failed state and spiraling down into darkness.
    I wish that I could be more sanguine about our prospects. Stay safe, stay sane.

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