There is an aphorism often used in politics: Don’t let the perfect be the enemy of the good. Its roots go back at least as far as a 17th-century Italian phrase, later popularised by Voltaire, which translates as “the better is the enemy of the good.” In the United States, it is currently being invoked in defence of the Republican Senate’s proposed income tax reform, bipartisan efforts at health care reform, and even debates on whether to allow self-driving cars on the roads.
It also should be applied to alcohol and drug abuse treatment programs. The “perfect” would be that no one ever uses or becomes addicted to illegal and/or harmful substances, or that everybody who is so addicted wants and can find effective substance abuse treatment. The good would be that we minimise the harm to individuals and society of such addictions.
The argument against minimising harm is that harm discourages people from illicit drug use. One American politician argued that stigmatising illicit drug users would help “push” them into treatment. Others argue that such stigmatisation can cause them to delay acknowledgement or treatment of the substance use disorder.
Such stigmatisation can include incarceration, although an International Journal of Drug Policy paper, The Cost-Effectiveness of Harm Reduction, concluded that “compulsory detention” does not reduce drug dependency. A combination of harm reduction interventions can.
Harm reduction policies are based on evidence, not faith, prejudices or hope. Harm reduction recognises that people, having free will, engage in dangerous, harmful and illegal activities – usually though not exclusively related to drugs, alcohol and similar substances – despite the best intentions of family, friends, the government and society to discourage them. This harm also may envelop other people and property, so it is in the interest of society to seek to reduce the potential for harm.
Harm reduction can save money as well as lives, but some people worry, fear or declare that if society makes such behaviour less harmful, it is tantamount to encouraging it. The more harmful it is, the less likely people are to engage in it. The evidence does not support this viewpoint, but rather shows that drug use does not increase with harm reduction programmes, nor are treatment programmes undermined.
Twelve Steps vs. Evidence-Based Recovery
In many ways, harm reduction is the opposite of the 12-step programs epitomised by Alcoholics Anonymous, which involve a rigid set of acts or acknowledgements, including putting your fate in the hands of a higher power, i.e. God. AA stresses abstinence and fellowship, not science.
Although there are chapters of AA that do not emphasise faith, and it is possible to attend meetings and work the steps without faith, there also are non-faith-based alternative groups, such as SMART Recovery (Self-Management and Recovery Training). Founded in 1994, in a way, it is a bridge between Twelve Steps and traditional detox recovery.
SMART is all about harm reduction, according to an article on The Humanist, and one of the first programs to embrace the concept. It stresses free will and balance, not extremism or absolutism. It does not even necessarily call for abstinence, only moderation. SMART is an international organisation, with in-person meetings on every continent but Antarctica – as well as online meetings – and partnerships with many UK alcohol and drug treatment providers, including some prisons.
Safe Injection Site
One controversial form of harm reduction that is being tested around the world is the safe injection site. A report by the Johns Hopkins Bloomberg School of Public Health and the Clinton Foundation has recommended the establishment of such “safe consumption sites” – also known as fix rooms, drug consumption room (DCR), supervised injecting facilities and shooting galleries – to combat the public health emergency caused by the opioid epidemic. Even the American Medical Association supports the idea.
One of the most dangerous aspects of illegal drug use is that they are dangerous to use. Heroin may be adulterated with poison or cheaper, more powerful opioids and easier-to-obtain drugs such as fentanyl or carfentanil. Needles may be reused and contaminated. And if you do overdose, you may not have a friend who knows what to do or is willing to get you to a doctor and risk arrest.
A safe injection site is just that: a safe place to use. Their drugs can be tested for potency or contaminants – at one site, 80% of the street drugs contained Fentanyl – clean needles are provided and, in the event of an overdose, trained medical personnel are on hand. According to this article, 66 cities have supervised injection sites, some more than one, including Europe, Canada and Australia. Amongst all the safe injection sites that have been established around the world, no deaths have been reported, but no sites in the United States or the United Kingdom have opened so far, in part because of opposition from law enforcement and neighbourhood groups.
It also is less expensive than the cost of overdose deaths, HIV and Hepatitis C transmission and the associated medical care expenses. One recent study estimated that placing a supervised injection site in a US city would net cost savings of $3.5m (US) per year. Another study found that the city of Baltimore alone could save almost $6m with a safe injection site.
One form of harm reduction is needle exchange programmes where intravenous drug users are given clean needles so that they do not share them with other users, potentially spreading HIV or Hepatitis C. The Global Commission on Drug Policies found that such programmes in Australia have not encouraged users to start at an earlier age, use more frequently or continue using for a longer period than they would have otherwise, but have prevented transmission and resultant deaths.
They also have saved money. Each Australian dollar spent on the program is estimated to have saved four Australian dollars in healthcare costs and 27 Australian dollars in overall costs to the community, saving billions in just a few years. Maybe those potential monetary savings can overcome the restraints of politics and human nature that continue to fight harm reduction initiatives.
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