If we were to place the suite of drug policy options on a spectrum, we’d have Richard Nixon’s war on drugs on one side—let’s say the right—and full legalization on the other. Between these poles lie various strategies aimed at addressing some of the worst effects of drug use, including death from overdose. This is harm reduction: instead of trying to stop drug use altogether, we should find ways to stop the worst effects of drug use.
Researchers try to study the effects of these interventions, and the results are sometimes mixed. A paper published last month by the economist Analisa Packham in The Journal of Public Economics looks at the effects of syringe exchange programs (SEPs) in the United States from 2008 to 2016. The paper compiles data on HIV infection rates and opioid-related mortality, and compares counties that opened a syringe exchange program with those that didn’t. The main results are that exchanges reduce the number of HIV infections by 18.2 percent, but counties that opened an SEP saw a 21.6 percent increase in opioid-related deaths.
Packham’s explanation for the rise in deaths is that SEPs signal a lower legal risk of using illegal drugs while also making it easier to use drugs and connect with other people who use or sell drugs. She says her findings imply “that the introduction of such programs alone (without subsequent availability of treatment programs) generates large negative externalities that reduce total social welfare”, meaning that offering only SEPs causes a tradeoff between preventing blood-borne infections and drug-related overdoses and the tradeoff isn’t worth it.
This is big news, since SEPs are a popular harm-reduction tool. The World Health Organization supports them. The Centers for Disease Control and Prevention does too, and goes further by saying that they help stop substance use.
It’s worth noting that there’s a gigantic fight between public health experts and economists on the success of harm reduction strategies. In essence, the economists accuse the public health people of using bad research methods, while the public health experts accuse the economists of ignoring valuable data. Vice published an article about this fight back in 2018.
When I became a philosopher, I took a vow never to learn about social science research methods, so I’m not well placed to adjudicate this dispute. However, I am well placed to argue for other tools that we can use alongside needle exchanges.
It would be nice if SEPs reduced overdose deaths, and maybe they do, contrary to Packham’s findings. But the results of this study aren’t surprising to me, since the purpose of needle exchanges is primarily to reduce blood-borne infections, which they do. If the remaining problem is overdoses, we need tools to directly address them.
And we have them. One is heroin assisted treatment, which involves prescribing heroin to long-term users. The benefits of these programs are now well documented, including in a Cochrane Review article from 2011, a Rand Corporation report from 2018, and two studies from Canada.
While heroin assisted treatment is effective, it’s difficult to scale to address the magnitude of the current problem. It poses other challenges too, including that some people who use drugs don’t want to participate in long-term treatment, even if the treatment isn’t aimed at abstinence.
Most overdoses are caused by unregulated drugs of unknown strength and composition or by mixing drugs. According to the CDC, only five percent of overdose deaths in 2020 were caused by prescription opioids alone. It’s possible to overdose on prescription opioids, but most overdoses are caused by unregulated drugs, which are so much more harmful because their strength and composition is unknown.
The solution is to increase access to pharmaceutical grade drugs. Heroin assisted therapy is one form of this, but a broader approach would increase access to other drugs. In a paper in the Journal of Medical Ethics from earlier this year, my colleagues and I argue that prescribing safe supply is ethically justified.
But this is just one approach. A medicalized strategy has downsides. Another option is to offer free, anonymous drug testing so that people can verify the strength and composition of their drugs before they use them. Toronto has a testing program, and I recently came across this service in Vancouver.
Another strategy is to make drugs available without requiring a prescription. Each option has tradeoffs that need to be assessed, but the general upshot is that the main issue we need to address is the unregulated supply. People don’t know what they’re taking, which causes them to take too much. Providing needles is an important step to preventing blood-borne illnesses, but it doesn’t do anything to address other serious harms of unregulated drugs.