Drug Abuse

The goal of reducing drug abuse has shaped some of the U.S. government’s most uncompromising policies. From the strict surveillance of the U.S.- Mexican border to national antidrug advertising campaigns, federal efforts to reduce drug abuse have relentlessly targeted the supply and demand of illicit drugs. Many of these tactics, including the harsh punishment of drug dealers and habitual drug users, are punitive in nature.

However, the argument that drug abuse is a public health issue, rather than a criminal activity, has renewed the debate over existing drug policies. For instance, the theory that drug addiction is a neurological disorder, not a moral flaw, has caused some to view addicts less as criminals and more as sick individuals who need treatment and compassion. To this end, voters in Arizona and California recently approved measures that give minor drug offenders the choice between rehabilitation and prison. Also, “harm reduction,” an approach that focuses not on preventing drug abuse, but instead on reducing the risks associated with drug use, is gaining attention as an alternative to America’s hard line drug policies.

Advocates of harm reduction assert that a practical and nonjudgmental approach in confronting drug abuse is more effective than disciplinary action. According to drug expert Robert W. Westermeyer, harm reduction is based on three pragmatic central beliefs. The first belief is that “excessive behaviors occur along a continuum”; the moderate use of substances causes less harm than abuse. The second belief is that “changing addictive behavior is a stepwise process, complete abstinence being the final step.” He explains that the harm reduction model “embraces” any movement away from the harms of drug use, no matter how small. The third belief, Westermeyer states, is that “sobriety simply isn’t for everybody” and that drug abuse is a fact of life for some individuals. He contends that harm reductionists “hope that addicted individuals will ultimately come to eliminate their high risk behavior completely, though it is accepted that the only way to get people moving in the direction of abstinence is to connect with them ‘where they’re at.’”

The case of writer and former heroin addict Maia Szalavitz exemplifies the goal of the harm reduction approach: If abstinence is not a choice, the risks of using drugs should be minimized. “I was at risk of AIDS,” she says, reflecting upon her intravenous drug use during the mid-1980s. A friend advised her to always either use her own needles or clean a shared needle with bleach and water before using it. By following that advice, Szalavitz did not contract HIV or hepatitis B during her years as an addict. She feels that harm reduction saved her life. The practice of harm reduction began in the Netherlands in the late 1960s, when health experts proposed that decriminalizing the use of marijuana would reduce the use of cocaine and heroin. They believed that removing marijuana from the illicit drug market would lower marijuana users’ exposure to the culture of hard drug abuse. Today in the United States, the harm reduction movement consists mainly of two programs. Methadone maintenance, in which doctors prescribe the synthetic drug methadone to hardened heroin addicts as a less harmful substitute for heroin, generates little controversy. On the other hand, needle-exchange programs, which allow addicts to exchange their used needles for clean ones without fear of legal repercussions, are often the center of heated debates. These programs were first mobilized in the 1980s as a response to the epidemic of HIV and hepatitis B infections among intravenous drug users (IDUs), which was caused by the sharing of infected needles.

Many drug abuse professionals claim that encouraging IDUs to trade their used hypodermic needles for new ones lowers their risk of HIV and hepatitis B infection by preventing drug addicts from sharing needles. According to one study, the Scottish cities of Glasgow and Edinburgh, which experienced similar heroin epidemics in the 1980s, demonstrated the importance of the availability of clean needles for IDUs. Edinburgh, which banned the selling of hypodermic needles at the time, experienced an alarming rate of HIV infection among IDUs—approximately 50 percent tested HIV-positive by 1984. Although more addicts used drugs intravenously in Glasgow, needle distribution was not restricted, and less than 1 percent of its IDUs contracted HIV. In a similar claim, Ethan A. Nadelmann, director of the Lindesmith Center, a drug policy research institute, contends that the halting of federal funds for needle-exchange programs during George Bush’s presidential term (1988–1992) resulted in ten thousand more cases of HIV infection.

However, opponents argue that needle-exchange programs do not lower drug addicts’ risk of HIV or hepatitis B infection. Psychiatrist Sally L. Satel argues, “Most needle-exchange studies have been full of design errors, the most rigorous ones have actually shown an increase in HIV infection.” For instance, a 1997 study in Montreal, Canada, concluded that those who took part in needleexchange programs were two to three times more likely to contract HIV than addicts who did not participate. Others contend that although needle-exchange programs prevent some cases of HIV, they do not minimize the other threats to physical health and personal safety involved in heroin addiction. One University of Pennsylvania study followed 415 IDUs in Philadelphia for four years. Although 28 people died during the study, only 5 died from HIV-related causes. The majority died from other factors related to their high-risk behavior, including overdoses, kidney failure, and homicide. Besides failing to protect drug users’ health, challengers believe that supporting needle-exchange programs sends the message that society condones drug abuse. Barry A. McCaffrey, former head of the Office of National Drug Control Policy, insists that such programs should be abandoned because drug addicts should not be given “more effective means to continue their addiction. . . . The problem isn’t dirty needles, it’s injection of illegal drugs.”

Supporters of harm reduction programs contend that minimizing the harms of drug addiction is imperative in directing addicts away from high-risk conduct. They view drug abuse as spanning a spectrum of behaviors and phases, some of which are less dangerous than others. Because abstinence is the final step, harm reductionists support every movement away from addiction and the harm of using drugs. In contrast, critics of harm reduction argue that many of the programs are ineffective at lowering the risks of drug use. Moreover, they claim that the harm reduction philosophy abandons the hope that abstinence can be achieved for every addict and warn that removing the negative legal consequences from drug abuse will fuel addiction. Harm reduction is just one of the topics discussed in Drug Abuse: Current Controversies. Throughout this anthology, drug abuse experts, health care professionals, and others attempt to define the causes and effects of drug abuse and debate the effectiveness of drug laws and regulations. In doing so, the authors provide valuable insights into one of society’s pressing social problems.