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Harm reduction has captured the US Bureaucracy is no better than the war on drugs

Do no harm. (Spencer Platt/Getty Images)

Do no harm. (Spencer Platt/Getty Images)


June 28, 2022   7 mins

It seems that every large city in America has marked off a neighbourhood where drug addicts are free to die in the streets. San Francisco’s Tenderloin district, downtown Portland, Skid Row in Los Angeles, Hunts Point in New York, Kensington in Philadelphia: These are places where, by unspoken agreement between society and its outcasts, the normal rules cease to apply and the bodies are collected.

Where it’s warm enough, people sleep in tents or on the streets. Drugs and sex are openly sold and laws are enforced erratically. The result, which I observed during a 2019 trip to Skid Row, was a “hellish concentration of deprivation and disorder”, interspersed with a concentrated complex of non-profit and social service organisations.

What was already hellish was made even worse in recent years by the rapid spread of fentanyl, a synthetic opioid some 50 times more potent than heroin. Driven largely by fentanyl, which is now used to cut virtually every other drug, overdoses set a new record in the US in 2021, killing nearly 108,000 people. Up roughly 15% over 2020’s record death toll, overdoses killed more people last year than guns and cars combined. In San Francisco, an average of 53 people died every month from overdoses last year, many of them “outdoors and on sidewalks in front of buildings”.

Before the fentanyl spike, overdoses had been rising in the US for the past two decades while raising little public alarm. But now, with the scale of deaths being declared an emergency and health epidemic, public officials are embracing supposedly radical new solutions to the problem, the most popular of which is harm reduction.

Harm reduction promises reasonableness. Rather than trying to eradicate drug use, the public-health framework, which has been embraced by the White House and cities across America, works to reduce risks by prioritising the safety of individuals over curing social ills. The point is to “meet people where they are”, according to advocates, not to change them. Its appeal is that it is humane and takes the opposite approach of the failed war on drugs. But that’s only part of the story.

Look through the harm-reduction telescope and you glimpse the grand project of the therapeutic society that animates modern progressivism. At one end the individual is seen in minimalist terms, powerless to control their own desires, a victim of systemic forces far beyond their ability to resist. Look through the other end, and you find a maximalist view of the state in which a vast apparatus of administrators surveil and treat citizen-patients based on vague definitions of “wellness” and “harm”.

Look back in time, and the rise of harm reduction from the work of devoted activists to the official policy of the federal government traces a larger transformation in American politics. It is a project, in short, of the same political forces who want to defund the police, while empowering a surveillance and enforcement regime that punishes people for making sexist Facebook comments.

While harm reduction has been an official policy for decades in a number of European countries, its expansion in the US, where it began as a grassroots movement during the AIDS crisis in the Eighties, is a more recent phenomenon. San Francisco was an early adopter. In 2000, the city’s Health Commission unanimously voted to adopt a harm reduction policy for drug offences. The city effectively decriminalised drug use while at the same time shifting public funding away from enforcement and toward providing clean needles, distributing the drug naloxone, which can reverse opioid overdoses, and offering methadone and other drug treatment plans. In 2020, San Francisco led the country in overdose deaths.

Last year, New York City allowed the opening of two “safe injection sites”, a term for facilities where drug users can consume their wares under the supervision of a mix of medical professionals and former addicts who can intervene and revive them if they overdose. The clinics have intervened in more than 300 potentially fatal overdoses since they opened, according to staffers. Despite the sites being illegal under federal law, city officials have allowed them to operate without interference, setting a precedent for other cities to follow.

New York’s experiment follows the three-decade harm reduction trial in Canada, which includes the establishment in 2003 of the Insite safe injection facility in Vancouver. While advocates point to the number of overdoses averted and reversed at these facilities, it’s possible that the policy led to more overall use, potentially contributing to more overdoses outside the clinics than lives saved within it. In British Columbia overdose deaths were up 151% between 2008 and 2020, with much of the increase coming from Vancouver. In Oregon, another place where hard drugs were decriminalised in 2020, overdose deaths were up 41%, in 2021 from 2020, compared to a 16% increase nationwide.

Some harm reduction programs such as needle exchanges, fentanyl testing strips, and free testing kits for HIV, appear to have been broadly beneficial. But in the absence of a commitment to the full recovery of individuals, harm reduction morphs into a permanent method of managing chronic drug addiction by expanding the nonprofit-bureaucratic sector. Administrators count lives saved and ODs reversed without registering the broader increase in addiction they help to accommodate. Success is measured not by freeing individuals from addiction so they can live full lives, but by the growth of the treatment bureaucracy.

General Jeff, a black community activist who has lived in Skid Row for a decade described a similar dynamic in the approach to homelessness when I spoke with him a few years ago. “There’s never been a shortage of funding in modern-day Skid Row,” Jeff told me, blasting the area’s nonprofits as “poverty pimps”. “This isn’t really about trying to end homelessness. That’s just a marketing campaign. Just to make people outside of Skid Row feel good.”

“Bureaucracy,” wrote Christopher Lasch in The Culture of Narcissism, “transforms collective grievances into personal problems amenable to therapeutic intervention.” Lasch does not pretend that individual moral accountability is sufficient to redress collective grievances or systemic injustices, but nor does he attempt to dismiss it as an anachronism. Morality grounds the sense of dignity and self-worth that provide us with our best internal defence against the unavoidable calamities of fortune. It is not a replacement but a precondition for a meaningful politics of collective action. The transformation observed by Lasch has repurposed the minimalist ”do no harm” ethos as a maximalist licence to redesign society.

“Harm reduction was never just about the drugs or the deaths or the diseases,” wrote Daniel Raymond, a policy and planning leader at the Harm Reduction Coalition, in a March 2020 essay on Harm Reduction in the Time of the Coronavirus. Rather, writes Raymond in the morally inflationary language used by activists staking out a claim to administrative power, harm reduction “is heir to the multiple legacies of the communities and struggles we come from… the hybrid wisdom that emerges from communal survival in the face of threats of being dispossessed, disenfranchised, displaced, disappeared”.

Because harm can be found anywhere, harm reduction now appears everywhere. The framework is applied to criminal justice, diet and exercise, prostitution, curbing adults’ sexual attraction to minors — otherwise known as paedophilia — and a range of other seemingly unrelated fields. “Harm reduction, as a framework, acknowledges that white supremacy, patriarchy, classism, fatmisia, transmisia, ableism, xenophobia, and myriad other systems of oppression infuse space and structures and are a part of our socialisation,” wrote the authors of an academic journal article on Observing Whiteness in Introductory Physics in March.

The essential alchemy of progressivism is performed by converting drug addiction from a vice afflicting individuals, which they have the power to change, into the basis of an identity group with a claim to government services. The collective grievances relating to the social and economic policies that might have pushed hundreds of thousands of people into drug dependency are first privatised through addiction and then bureaucratised so they can be managed by a class of appointed supervisors. In turn, the power of the bureaucracy is redirected from enforcing behavioural norms to overseeing the consequences of their dismantling.

This transformation is consummated with a novel language that marks the new political identity within the lexicon of professional progressivism. “Following the lead of those in harm-reduction and drug-users’ rights groups, I decide to scrub the word addict from my vocabulary,” wrote Sarah Resnick in a piece featured in ​​The Best American Essays 2017 anthology. As alternatives to “addict”, Resnick finds: “person with a substance-misuse disorder”; “person experiencing a drug problem”; “person who uses drugs habitually”; and “person committed to drug use”.

The stiltedness of the language would be a small price to pay if harm reduction policies reduced drug dependency but since it’s not clear that’s the case, the effort turns on trying to alter language and perception. “Don’t be ashamed you are using, be empowered that you are using safely,” declared a poster by the New York City Health Department that recently appeared in the subway system. “Shame is a useless emotion that often keeps ppl from investing in themselves or others. We should be celebrating ppl who are taking the steps in this poster,” tweeted Kassandra Frederique, the executive director of the Drug Policy Alliance, one of the leading drug policy reform organisations in the US. Frederique’s statement was retweeted by a spokesman for the New York City Department of Health.

Instead of fostering the behaviour necessary to give someone a genuine sense of self-worth — a project that may well be beyond the power of anyone but the individual and their maker — harm reduction converts the bare physicality of “safety” into the cheap currency of empowerment. The message presumes that addicts would not and should not feel shame for their dependency absent external judgements. It minimises the ravages attendant to drug addiction — such as criminality, homelessness, despair and decay — by framing them as the consequences of “unsafe” practices, without any connection to the spiritual poverty of dependency. In the religious and humanistic view, shame is the voice of the individual’s conscience. Others may seek to shame us, but true shame arises only when the individual has transgressed against their own innate sense of decency. But the conscience has no place in the maximalist world view of the harm reductionists, except as a relic of the retrograde morality that prevents addicts from experiencing empowerment.

At what end is the policy of harm reduction aimed? The war on drug’s promised end point was, obviously, unreachable, but the harm-reduction crusade has no ending at all except the construction of a new system of power, no less punitive than the one it seeks to replace.

Many people seem to have accepted that harm reduction efforts are a temporary life-saving measure — a way of buying time for people caught in a cycle of addiction while moving them gently toward recovery. But it’s by no means clear that people doing harm reduction work all see it this way. Some are explicit about the fact that they see nothing wrong with hard drug use and and view attempts to force people into recovery as puritanical efforts to stamp out pleasure.

Others genuinely want to help drug users and other people in high-risk lifestyles by keeping them alive and guiding them toward lives free from addiction. But even those efforts are bound up in the expansionist project to “treat” an endless and ever expanding litany of harms by means of a bureaucracy in which being exposed to racism and being addicted to drugs are understood as two expressions of the same oppressive system. “Harm reduction is friends; the law is cops,” wrote one devoted adherent to the practice in a 2019 essay about sex work.

In 2022, the White House National Drug Control Strategy devoted a full chapter to harm reduction. Which is to say that, whatever its beginnings, harm reduction is now the self-talk of the state bureaucracy, not only the law but its spirit.


Jacob Siegel is Senior Writer at Tablet Magazine

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Thomas Clark
Thomas Clark
1 year ago

Now you all know why Jordan Peterson is hated. What a threat someone poses when they work to help strengthen individuals rather than telling them they are weak and helpless … and that the “system” is to blame!

Matt Hindman
Matt Hindman
1 year ago

The thing about fentanyl that most people do not understand is that it is extremely addictive and even more dangerous. It kills its users frequently. This is nothing like smoking a little marijuana or doing a line of cocaine. It is bad enough that communities and law enforcement are more concerned about it right now than even Heroin or Meth. The body count has reached over six figures last year alone and it seems like few people in Washington or state capitols even care.

Last edited 1 year ago by Matt Hindman
Dick Illyes
Dick Illyes
1 year ago

It is time to take the profit out of addictive drugs. Users become pushers to help pay for their habits, and the Cartels are making huge amounts of money and taking over countries.
Let addicts go to any physician and get a prescription for their drug(s). The drugs cost very little to manufacture and the low cost would allow addicts to stop stealing and dealing, and defund the cartels.
This would also put them into contact with health care professionals who could help them if they decided to get clean.
Until we defund the cartels nothing will change.

Hardee Hodges
Hardee Hodges
1 year ago
Reply to  Dick Illyes

I have long advocated for such. The war on drugs was lost long ago and now the trade has created corruption wherever it goes. Of course, an understanding that addiction is a means of slow suicide underlies use. But more openness might open the doors to understanding why the individual is going down that path.

Louis Candell
Louis Candell
1 year ago

Mr. Siegel’s makes some valid points concerning the failure of harm reduction policies but his call to somehow make drug users appreciate that they are abusing themselves and transgressing “their own innate sense of decency” is no less a pipe dream. The overwhelming majority of addicts have already permanently lost any sense of personal dignity.

B Davis
B Davis
1 year ago

Remember that scene in Cimino’s 1978 film ‘The Deer Hunter’? You know the one.
De Niro’s Michael sits there at his captor’s table and spins the partially loaded cylinders in the gun they hand him. He puts the gun to his head and pulls the trigger. He survives…they add another bullet…and he does it again. Everyone screams (including the theater audience).
Now Michael does this in an insanely desperate attempt to escape. But he recognizes, absolutely, that the gamble he is taking is increasingly a suicidal one. Still he does it again, because he believes the terminal risk is worth the potential freedom.
Now imagine a world in which, for some bizarre reason, that same game became an addicting choice. Imagine millions of Americans, every day, taking their handguns, partially loading them, spinning the cylinder, and pulling the trigger. The death toll would be immense. Maybe more immense than what we see with opioid overdose.
What would Harm Reduction do?
Would we jigger the trigger mechanism to reduce the velocity at which the hammer impacts the shell? Would we mandate that special bullets be made with a lesser powder load such that a bullet fired wouldn’t necessarily ‘blow someone’s head clean-off’? Would we make the cylinders harder to spin? Would we build shooting parlors with big guns and massive cylinders holding few bullets so the ‘deer hunters’ can get their kicks with a lower kill rate? Would we pay doctors to stand-by for emergency surgery (blood transfusions at the ready?)
Or would we finally say, if you want to commit suicide who are we to object?
The thing is, it is the user’s choice (at least initially) to perform a suicidal act. It is a death choice made NOT to escape a Viet Cong prison camp, but because the Chooser sees it as a preference to a life un-drugged, un-high, un-stoned. Rather they choose oblivion.
Harm reduction normalizes the abnormal, enables the suicidal, tolerates the intolerable. This perversion we’ve pursued to reduce social harm and national body counts has instead increased both….as it would, now that the State has acted to enable and embrace the self-destructive. If the possibility of a sordid death in some back alley, needle hanging from my arm has not dissuaded me from fentanyl-flirting, the States creation of ‘safe spaces’ with clean needles, narcan, and EMT’s in white lab coats ‘standing by’ has handed me the engraved invitation.
Why the hell not? The State will catch me when I throw myself into the abyss from the cliff’s edge they made so attractive.
No! Instead we make choices; choices have consequences. Consequences, if we survive them, push us to be better. Either that or we die. And so we move on. If society does not recognize and incent the difference between good and bad behavior, moral and immoral choices, right and wrong decisions then life becomes shorter, nastier, and insanely more brutish.
Compare the San Francisco streets of 1962 to those of 2022…watch your step, download the human feces map before venturing out, keep your car unlocked to minimize the chance that you’ll return to find your windows broken as addicts scramble for the change in your console. Which street would you rather walk?
Tens of thousands couldn’t wait to get there 60 years ago; 60 years later tens of thousands can’t wait to get out. Freedom from these State-sponsored Sloughs of Despond… California Dreamin…

leculdesac suburbia
leculdesac suburbia
1 year ago

No one seems to care about reducing the harm caused by opioid (and now benzos, and next gabapentin!) hysteria to the millions of Americans with chronic pain, or controlling stimulant prescriptions to the few millions suffering from chronic fatigue disorder.
These are physical conditions, and yet one can no longer get these meds from the treating physician. Instead, you must be screened and managed by a psychiatrist, many of whom don’t understand pain and can’t wait to slap a psychiatric diagnosis on anyone who walks through their doors. Especially women. Especially people who are knowledgeable about their diseases because they had to spend years figuring it out after dismissal from ignorant physicians.
I don’t know of a single violent crime caused by benzos. In fact, I suspect a few thousand “loved ones” are alive who wouldn’t be otherwise because of the stress reduction they provide. And these busybodies, not satisfied w/ haranguing doctors from providing opioids (shades of COVID), and then going after benzos, now want to claim that GABAPENTIN!–used for nerve pain and dysautonomia–might somehow be “addictive,” and thus needs to be controlled too. At least they haven’t been able to make Kratom illegal, yet.

Laura Creighton
Laura Creighton
1 year ago

I had no idea that people were going after gabapentin. Thank you for letting me know.

Mikey Mike
Mikey Mike
1 year ago

Jacob Siegel wins again. Another brilliant piece by the best writer on the internet.

Julian Farrows
Julian Farrows
1 year ago

As an American I would vote for whichever political party decided to help the homeless and the addicted. Unfortunately, there is no animus from either Republican or Democrat parties to fix these problems. I rather suspect it is because there is no quick profit to be made from doing so.

Christopher
Christopher
3 months ago
Reply to  Julian Farrows

Help the addicted and homeless? Tossing even more money down a rabbit hole won’t get the horse to drink.

Curious Person
Curious Person
1 year ago

I appreciate Mr. Siegel’s concern about the rise of the therapeutic attitude and the general decline of personal moral responsibilty in our culture. However, I take exception to the notion that the harm reduction approach toward peccadillo offenses is a significant cause of our social decay. In particular, the rise drug use and drug abuse in America is a symptom of our social disintegration, just as alcoholism is a symptom of cultural disintegration on Native American reservations. I consider drug use a peccadillo because it does not directly harm other people.
In my view, harm reduction is an approach that, as the name implies, reduces the social harm resulting from whatever problem it addresses. In the specific case of opiod use, arrest and imprisonment used to be the preferred treatment for heroin addicts. While that got them off the streets and out of addiction (usually cold turkey), it also caused further social harm by breaking up families, reducing the ability of released convicts to obtain employment, and costing the state large sums of money to pay the necessary police and prison guards, and to feed and house the inmates. Methadone clinics, as a harm reduction tactic, have been highly successful, particularly when linked to personal counseling, group counseling such as Narcotics Anonymous, and job training/job placement. All of which work toward increasing personal responsibility.
I like most of Christopher Lasch’s writing and wish he were still around. If he were, I doubt that he would be complaining about harm reduction strategies. Incidentally, I walked through the Tenderloin in San Francisco late one night in 2019 and it was very disturbing and sad. And what disturbed me most is that any society would allow such hardship and yet consider itself civilized.

Jennifer O'Brien
Jennifer O'Brien
1 year ago
Reply to  Curious Person

I’m agnostic on the details of how to treat opioid addiction (I just don’t know enough about the subject to have a strong opinion either way), but I’m uncomfortable with the concept of “no indirect harm”. Firstly addicts do do direct harm to others in various ways. Secondly, the indirect harms of addiction to – for example – the dependent children of addicts are still ferocious. I may be particularly sensitive to this as my childhood was blighted by my mother’s alcoholism. I can’t begin to describe the toll of ‘indirect harm’ on all her family (she died in her 40s in an alcohol-related accident). Whatever the pros & cons of specific harm reduction policies in particular circumstances, the “be proud of using safely” rhetoric quoted in this article stuck a raw nerve, because it minimises the dehumanising degrading horror of addiction.

Hardee Hodges
Hardee Hodges
1 year ago

The truth is we have no idea how to treat addictions. Addicts are in the process of slow suicide and all associated with them will eventually grieve. We can understand how addiction starts and give warnings but once in full bloom, we fail to end it. It is obviously possible to escape addiction but generalizations of methods are elusive.
But is it really human kindness to allow the streets to claim their victims? We need to seek better ways to actually help them. Clearly moralizing along with tolerating isn’t the answer. Perhaps resident clinics with government furnished drugs/alcohol along with suitable services?

Richard Craven
Richard Craven
1 year ago
Reply to  Curious Person

“I consider drug use a peccadillo because it does not directly harm other people.”
Try living next door to junkies.

Warren Trees
Warren Trees
1 year ago
Reply to  Curious Person

Drug addiction doesn’t cause others harm? Not the other family members or children of the addicted? Or the neighborhoods in which they use?
Yet you lament the outcomes of the war on drugs, with its breaking up of families and reducing the prospect of employment. Sounds like the results of both strategies are identical. Both lead to destruction.
As far as society being blamed, I would agree. Life has always been challenging, but a society that focuses completely on the twin religions of consumerism and narcissism is bound to have these results.

Garrett R
Garrett R
1 year ago

I share the same sense of queasiness with open injection sites. On one hand, harm reduction strategies can achieve measurable public health goals. Programs such as clean needles can reduce the spread of illnesses such as HIV (Indiana failed to do so under Mike Pence in 2014) or Hep C. On the other hand, these strategies are very difficult dinner table conversations. It’s difficult to explain to children why the government funds (or taxpayers fund) such lifestyles without morphing into an extremely cynical understanding of addiction. It’s arguably cheaper to control the injection than to arm various agencies against it. But by doing so, you capitulate to an issue that signals utter defeat. However, as critics of the war on drugs say, previous strategies were an unmitigated disaster.

The Vancouver project was very interesting but its relative failure to successfully break the cycle of addiction needs more investigation by its advocates. Like the author, I yearn for a nobler strategy that sets people’s ambitions beyond the next high. However, like the author, I have no idea how to do that.

Last edited 1 year ago by Garrett R
Cristina Bodor
Cristina Bodor
1 year ago

Brilliantly sharp!

Cristina Bodor
Cristina Bodor
1 year ago

Brilliantly sharp!

Mark Shulgasser
Mark Shulgasser
1 year ago

The vile farce of harm-reduction programs is that the harm, i. e. fentanyl, is liberally imported into the country by the Democrat Party, which allows it into the country via the open southern border. How exactly the Mexican cartels fill the coffers of the Dems has not been uncovered, but clearly they do. The same party then with diabolical cynicism sponsors ‘harm-reduction’.

Last edited 1 year ago by Mark Shulgasser
M. Jamieson
M. Jamieson
1 year ago

This is one of the best things I’ve read on harm reduction. I’ve never seen anything else that really articulates this element of harm reduction strategies.
I think most people can see why some harm reduction approaches could be useful. IN some cases, like needle exchange, they might simply help prevent infection problems that will burn through drug users and even end up affecting others. And most people understand that it could be difficult for people to stop using drugs while underlying issues go unaddressed.
But like many social policy approaches, when you start moving from evidence based policy to ideology based policy, things easily go awry.

nigel roberts
nigel roberts
1 year ago

Singapore has the lowest rate of drug addiction in the world. Funny how the addiction-industrial complex doesn’t want to solve the problem by emulating others who have successfully solved it.
https://www.washingtonpost.com/opinions/singapore-is-winning-the-war-on-drugs-heres-how/2018/03/11/b8c25278-22e9-11e8-946c-9420060cb7bd_story.html

Michael Cavanaugh
Michael Cavanaugh
1 year ago

Point well taken about nudging & amelioration being different ends of the same telescope. However “harm reduction” is broader and older than recent events; it is at the core of utilitarianism (as one of the key modern moral alternatives). One might wonder however if harm reduction as a moral (and political) end means aggressively assuring that everywhere is some sort of “safe space.” (In other words, is the alchemy inevitable?)

Last edited 1 year ago by Michael Cavanaugh
nigel roberts
nigel roberts
1 year ago

BEING JUDGMENTAL is now the worst of all sins even though some good old fashioned judgmentalism and tough love may well be the best solution to this otherwise intractable issue.

John Sherbioni
John Sherbioni
1 year ago

We create our own reality and walk into the picture we hold of the future. Try being a senior citizen who has made the effort to ensure that generations following them would be able to enjoy a life that was interesting and gave some sense of self-worth. Now we have to be concerned that someone who is doing something that profoundly affects society as a whole is justified. You can’t have a working society and have its members tear it apart at the same time. We make choices and in the old days, the church helped those who needed it now we all pay the price for choices made by those who have not even considered the end result of their path. Remember this tune?
That suicide is painless
It brings on many changes
and I can take or leave it if I please.
We make choices and when we don’t consider the big picture we destroy that which we hold important for the sake of a “hit” for whatever reason.