Notes on harm reduction and the opioid epidemic in the United States

Introduction

All societies that have had access to psychoactive drugs have used them. There are multiple positive aspects of psychoactive drug use, from creating positive mood states, to stress and pain relief, to increasing social bonding, to simple preservation of health (for much of human history it was safer to drink locally available wine or beer than locally available water). Psychoactive drug use also has many negative aspects, from impairing psychological and social functioning, to disinhibition and release of aggression, to inebriation and accidents, to causing infections and fatal diseases, and to fatal overdose. The potential positive and negative consequences of psychoactive drug use have led to many different social mechanisms for regulating access to and use of psychoactive drugs, from incorporating drug use into religious rituals, to informal social norms, and to civil and criminal laws.

The “Harm Reduction” framework is the most recently developed framework for regulating psychoactive drug use, and we would argue, the most appropriate framework for use in large, complex societies in which patterns of drug use, and the individual and societal adverse consequences of use can change very rapidly.

Much of harm reduction theory and practice was developed in Western Europe and Australia [ ], but as this book focuses on the current opioid epidemic in the United States, this chapter will also focus on harm reduction in the United States. There are three aspects of the US situation that have greatly influenced the course of harm reduction in this country. First is the sheer size of the psychoactive drug use in the United States. Recent estimates are that there are 6.2 million persons in the United States with illicit drug use disorders [ ]. The large size of the US drug using population creates the potential for enormous profits to be a made from importing or manufacturing illicit drugs, and from diverting drugs from medical sources. With this large demand, eliminating supply is simply not possible. Second is the great extent to which interracial and interethnic conflict has been incorporated into drug policies in the United States. A full examination of the relationships between drug use and racial/ethnic conflicts in the United States is beyond the scope of this chapter, but we would note several aspects of US culture that have been of great importance to drug use and drug policies in the country. Many of the original European colonists belonged to religious groups who held extremely negative views of drug use, considering drugs to be products of the devil and drug use to be inherently sinful [ ]. Slavery in the United States was developed in part to create very large-scale production of a psychoactive drug (nicotine in tobacco) [ ]. Prohibition of alcohol in the United States in 1918 was a product of cultural conflict between rural/small city dominated by Protestants and urban areas dominated by Catholic immigrants. The bars and saloons portrayed as dens of evil that ruined family life were in particular associated with German immigrants, and Prohibition was passed at the end of World War I. Third, the United States is a federal system, with state and local governments having great but not complete authority in the area of public health. Thus, state and local governments have often implemented harm reduction programs despite intense opposition at the federal level (for example, implementation of needle/syringe exchange programs). Many states, however, are dependent upon the federal government for the funding of their public health programs, so that opposition to harm reduction at the federal level can also be quite effective.

What harm reduction is not

There have been several attempts to define and characterize harm reduction with many common elements but without a definitive consensus [ , ]. This is not surprising given the rapid development of the framework over the last several decades. We believe that, as a starting point for understanding the current state of harm reduction in the United States, with respect to policy and direct services, it is helpful to begin with consideration of what harm reduction is not. In our assessment, there is probably more agreement on what harm reduction is not rather than on what harm reduction is (at any given historical moment).

First, harm reduction is clearly not an ethnocentric condemnation of people who use certain types of drugs. This is specifically relevant in the context of illicit versus licit drugs. Legality typically creates a framework for moral judgment about a person based on the psychoactive drugs they choose to consume (for example, the use of alcohol or cigarettes vs. heroin in the United States). Harm reduction does not make this global distinction, but rather considers individual drugs and individual routes of administration in terms of the potential harms to be addressed. As noted above, there are long traditions of drug use in many different cultures. Drug use that is new to a dominant cultural group and associated with minority groups within the society has often been moralistically condemned, with heavy criminal penalties imposed on active use and possession. Examples include the use of opium by Chinese immigrants [ , ], use of marijuana by Mexicans [ ], and, more recently, use of crack cocaine by African-Americans all in the United States [ ]. The imposition of extremely heavy penalties for possession of drugs as well as quality of life crimes often associated with dependence (panhandling, etc.) was often in the name of fear of more serious crimes associated with drug use and which incorporated overt racism. This has led to mass incarceration in the United States which has widely been condemned as racist and stands, in some ways, in opposition to how the United States has treated the recent opioid epidemic which has largely affected white, working class individuals.

A second point is the desired outcomes of substance use treatment. Harm reduction does not insist that abstinence is the only acceptable outcome for the treatment of substance use disorders. Harm reduction includes the use of psychoactive medications during treatment. Medication-assisted treatment (MAT), particularly methadone and buprenorphine, and the use of psychiatric medications are not only acceptable components of the harm reduction approach to treatment of substance use disorders but can lead to important improvements in physical and mental health and overall quality of life [ ].

Third, harm reduction is not confined to illicit drugs. Indeed, addressing licit drug use is an increasingly important aspect of harm reduction. In recent years, with the increase in the number of people who are becoming addicted to prescription opioids, harm reduction organizations have had to expand their services and outreach methods to work with communities where the primary drug problem has become the misuse of prescription opioids.

Fourth, harm reduction does not include unlimited commercial exploitation of psychoactive drugs. With their ability to generate dependence, both licit and illicit psychoactive drugs can be extremely profitable. Harm reduction recognizes the need for limitations on the distribution and marketing of drugs. In the United States, harm reduction organizations have been some of the biggest proponents for reform of prescribing practices for opioids and stricter regulation on how pharmaceutical companies market their drugs to healthcare providers and patients [ ].

Finally, harm reduction does not expect to create a perfect world. It is not a vision of a drug-free world, in which no one uses psychoactive drugs, nor it is a vision in which everyone who uses drugs does so in a harm-free manner. Harm reduction necessarily involves trade-offs between different forms and quantities of individual and societal harms associated with the many varieties of psychoactive drug use.