Harm Reduction Beats the Drug War as a Response to Addiction

Needles used for shooting heroin and other opioids and other drug paraphernalia in a park in the Kensington section of Philadelphia, Pa., in 2017. (Charles Mostoller/Reuters)It might make only a marginal dent in the problem, but that’s better than making the problem marginally worse.

The drug warriors in the Trump administration are doing everything they can think of to stop a nonprofit group in Philadelphia from opening a “safe consumption site” in the city’s horrifying Kensington neighborhood, a place for heroin users to shoot up under medical supervision, with clean needles and counter-overdose drugs close at hand. The matter is under litigation in federal court.

Philadelphia has a rough reputation, but, as with many similar American cities, you could visit there, see the sights, walk the streets, and never see anything that seemed especially amiss, only the usual panhandling and low-level urban disorder that you might see in any city. You can go hear Yannick Nézet-Séguin conducting one of the world’s great orchestras, try Jon Chicon’s menu at Lacroix and learn what fourme d’Ambert is, stroll around Rittenhouse Square, and think that you are in one of the country’s great urban oases — which you are. Philadelphia is a splendid city with an incompetent ruling class and a couple of very, very bad neighborhoods.

One of those is Kensington, which tourists may visit for one of two reasons: either to see where Rocky lived or to engage in illicit commerce. Kensington was in Rocky Balboa’s time a poor but safe working-class neighborhood. It has since devolved into an unlivable ghetto, with open drug sales, street-corner prostitution, and the other flashing neon signs of urban alarum. It is a near neighbor to Fishtown, a neighborhood made famous by Charles Murray’s use of it as the downward-bound counterpoint to Belmont in his famous treatment of America’s divergent classes. But Fishtown, thanks in part to the miracle of real-estate markets, experienced a dramatic turnaround in the early part of this century. Peter Lane Taylor of Forbes describes the scene:

Every Friday afternoon at 5:30 pm the doors of “the El­”—one of America’s oldest elevated subways—swoosh open at Girard and Berks Street stations, unleashing a stampede of Millennials, yuppies, hipsters, entrepreneurs, and empty nesters onto Front Street.

As fast as the doors close, they scatter east down a maze of narrow streets swirling with trash, bumping shoulders with the occasional heroin addict and scrappers pushing shopping carts piled high with salvaged sheet metal. Nobody blinks.

A half dozen blocks away from their newly-built, half-million dollar townhomes, the lines twist out the doors at Pizzeria Beddia and Frankford Hall, two of Philadelphia’s hottest foodie spots. Across the street, Johnny Brenda’s is already packed—hosting as they have for over a decade one of America’s hottest indie rock bands. Mothers pushing strollers window shop past Lululemon along Frankford Avenue’s buzzing retail corridor fronted with wine barscoffee shopscouture boutiquesyoga studios, a vintage motorcycle joint, and an Argentinian tango dance school.

Visually the dichotomies are jarring. Culturally the contradictions are even more confusing. Yet when the El disgorges its “New Fish” every afternoon it epitomizes the driving forces behind Fishtown’s warp-speed transformation, and the demographics fueling America’s new urban revolution.

Rising real-estate prices have driven some of that gentrification into Kensington. There is the usual tension between relatively rich new neighbors and relatively poor incumbents, between absentee real-estate investors and longtime homeowners, between new businesses and neighborhood fixtures, all of it heightened by the municipal insanity that is as much a part of Philadelphia’s local culture as Tastykake. The conflict is economic and social, racial, and cultural. There are disputes about noise and public spaces — and at the extreme end of the spectrum is the question of what to do about all the junkies.

On a per capita basis, Philadelphia experiences more opioid-overdose deaths than any other major city in the United States — about three deaths per day in recent years. More than 1,000 Philadelphians died of accidental overdoses in 2018 — three times the murder rate in a city with a hell of a lot of murders.

In cities from Houston to New Orleans to Birmingham, one of the few strategies for reducing the harm of heroin use is, not to put too fine a point on it, helping junkies pre-plan their overdoses. In New Orleans, the authorities began experimenting with giving addicts and their families prescriptions for Narcan (naloxone), an anti-intoxicant used to reverse the effects of opiate overdose, on the theory that they were likely to need it sooner or later, and that in the event of an actual overdose there would be little time to contact emergency medical personnel. They did this at a time when the city’s emergency rooms were seeing as many overdose deaths in a month as Philadelphia sees in a couple of days.

There is some evidence that safe-consumption sites reduce harm. The most significant metric is that none of them has been the site of an overdose death. (That figure comes from experience abroad; there are no safe-consumption sites currently operating in the United States with legal sanction.) Heroin addicts tend not to be very future-directed thinkers, but most of them are not actively suicidal, either. They will use clean needles when clean needles are available, and clean needles reduce the transmission of HIV and hepatitis C. A study of injection-drug users at a safe-consumption site in Vancouver found that 11.2 percent of those frequenting the facility eventually made use of on-site detox services, and that they were more likely to try medication-assisted treatment.

The Trump administration disputes that these sites significantly reduce harm and insists that they are illegal, conflicting with the “crack-house law” that prohibits the maintenance of a property for the purpose of selling or using illegal drugs. The evidence on harm-reduction is indeed modest, but modest as it is, it is not on the administration’s side. And the invocation of an anti-trafficking statute to block medical services and humanitarian treatment for drug users is legally questionable — and morally reprehensible.

Many conservatives, including William F. Buckley Jr. and the editors of National Review, concluded a generation ago that “the war on drugs is lost,” that the strategy most likely to actually improve the lives of America’s addicts — and, not to be forgotten, their neighbors — would be based on a public-health model rather than a law-enforcement model, that harm-reduction and treatment should be our priorities. Thirty years ago, WFB wrote:

A conservative should evaluate the practicality of a legal constriction, as for instance in those states whose statute books continue to outlaw sodomy, which interdiction is unenforceable, making the law nothing more than print-on-paper. I came to the conclusion that the so-called war against drugs was not working, that it would not work absent a change in the structure of the civil rights to which we are accustomed and to which we cling as a valuable part of our patrimony. And that therefore if that war against drugs is not working, we should look into what effects the war has, a canvass of the casualties consequent on its failure to work. . . .

. . . Pursuing utilitarian analysis, we ask: What are the relative costs, on the one hand, of medical and psychological treatment for addicts and, on the other, of incarceration for drug offenses? It transpires that treatment is seven times more cost-effective. By this is meant that one dollar spent on the treatment of an addict reduces the probability of continued addiction seven times more than one dollar spent on incarceration. Looked at another way: Treatment is not now available for almost half of those who would benefit from it. Yet we are willing to build more and more jails in which to isolate drug users even though at one-seventh the cost of building and maintaining jail space and pursuing, detaining, and prosecuting the drug user, we could subsidize commensurately effective medical care and psychological treatment.

I have spared you, even as I spared myself, an arithmetical consummation of my inquiry, but the data here cited instruct us that the cost of the drug war is many times more painful, in all its manifestations, than would be the licensing of drugs combined with intensive education of non-users and intensive education designed to warn those who experiment with drugs. We have seen a substantial reduction in the use of tobacco over the last 30 years, and this is not because tobacco became illegal but because a sentient community began, in substantial numbers, to apprehend the high cost of tobacco to human health, even as, we can assume, a growing number of Americans desist from practicing unsafe sex and using polluted needles in this age of AIDS.

But this line of thinking has not penetrated very far into Republican circles. During National Review’s recently concluded seminar at sea, I had the opportunity to speak briefly with former attorney general Jeff Sessions about this question; he is an intelligent and gracious man, and looked at me as though I were utterly insane to suggest that we’d be materially better off with heroin manufactured under the exacting conditions of an American pharmaceutical factory than with junk cooked up by criminals in a jungle shed. It is a sobering thought. But I cannot see how it would be otherwise.

Likewise, we would be better off with heroin users employing clean needles and having access to anti-overdose measures. We should not give in to “romancing opiates,” as Theodore Dalrymple puts it. And we libertarians should consider the limited success of marijuana legalization in places such as Colorado when we calculate how much harm-reduction our programs are likely to achieve. The answer is: not very much, probably, but making things marginally better is a much more intelligent choice than making things marginally worse.

To support the de-emphasis of prohibition in favor of treatment — or to endorse, as I do, the outright legalization of most recreational drugs — is not to make a declaration of moral indifference to the question. It is simply to acknowledge the reality that passing a law against x does not necessarily relieve the world of x, whether x is marijuana or heroin or irresponsible banking practices. Drug use is going to continue to do harm to our society and to our neighbors and families. We cannot magic that harm away — nor can we jackboot it away. What we can do is exert some influence on the nature and extent of that harm, and channel it into more predictable avenues.

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