Heroin-Asisted Treatment of Drug Addicts and the Political Pitfalls of Harm Reduction

By Jesse Singal, MPA 2013

In a piece published Monday in The Daily Beast, I covered a new study in the Canadian Medical Association Journal suggesting that the most cost-effective treatment for certain types of long-term heroin addicts might be... heroin. It's the latest in a rather long line of studies offering similar results.

It's a counterintuitive idea, and it highlights some of the political challenges of a favorite concept among public-health policy wonks: harm reduction. In short, harm reduction is the idea that rather than approach health issues with unrealistic, overly idealistic notions of the power of public policy, we need to understand that in many cases, the best we can hope to do is improve—not fix entirely—difficult, complicated situations. And as we seek to do so, evidence-based approaches should guide our efforts.*

Given how accustomed we are to big claims about quick fixes, it can be a hard concept to swallow. If one mayoral candidate promises to greatly drive down the "epidemic" of teen sex, and her opponent promises to improve sex education so as to reduce the number of teen pregnancies and the spread of STDs—well, it's easy to tell who will face more of an uphill battle come election day. A lot of people don't want to admit that teenagers always have had sex and always will.

Heroin-assisted treatment, or HAT, highlights this concept perfectly. No one wants to admit that a lot of addicts remain addicts for a long time, and the best we can hope to do (at a reasonable level of investment, at least) is to mitigate the damage they do to society. As I point out in the piece, even researchers sold on HAT's promise will admit that there’s something inherently crazy-sounding about the idea of giving heroin addicts heroin. “You sort of have to get over some pretty large hurdles of face implausibility,” Peter Reuter, a drug-policy expert at the University of Maryland, told me. “There’s something strange about the notion that on the one hand you prohibit this drug, but… if the user causes enough damage to society and to himself, well, we’ll give it to you free.”

But the idea starts to make sense the more one thinks about the neighborhoods that have been wrecked not because long-term heroin users use heroin (there is no more docile creature in the world than an addict who has just shot up), but because of the collateral damage done by their search for it—the petty crime, the violence, the black-market forces that shoot out of cracks in the social structure like thick tangled weeds. If heroin addicts didn't have to search for heroin, the damage wrought by the drug would be greatly ameliorated.

The notion of giving heroin to heroin addicts may make us uncomfortable; it just doesn't feel right in some deep, visceral way. But harm reduction is about being an adult, about realizing that sometimes you need to follow what the science tells you, even if it doesn't feel right.

* Thanks to fellow MPA1 and budding public-health expert Brett Keller for letting me run this language by him.