Straight to the point

America is the greatest democracy in the world: a place where an incoherent system of contradictory beliefs has produced an equally incoherent politics. In the irrational ferment of what it may be best to call simply the thing that happened — the confluence of Trump and QAnon, the pandemic, Defund the Police, moral panics about gender and migrant caravans, and so on — Americans became inured, in a way rarely before seen, to the spectre of the counterintuitive miracle. One could choose any number of examples from across the ideological spectrum: the belief that a gaudy real estate mogul was a champion of the working man, or that reduction of law enforcement would bring down crime. My own favourite example, though, is the suite of measures broadly known as harm reduction that were adopted in many forms across the United States, and are now being rolled back, to the relief of some and the outrage of others.

In the best of cases, harm reduction is hard to define. It has, like most radicalisms, a front-facing and a covert side, and any given spokesperson upbraided for its defects can always resort to the no true Scotsman strategy, blaming its excesses on a fringe that is less fringey than one might be led to believe. The least objectionable of the harm reductionists cling to the addiction-as-disease model that has become commonplace despite the absence of any testable etiology, any efficacious cures, or even a good definition of what addiction is. They advocate for needle exchanges, Naloxone distribution, and the provision of basic services for the drug addicted. This is now the norm across America: all but a few states have these programmes in place, and even states with stringent drug laws are locking up far fewer people for possession than they used to.

The most extreme harm reductionists (I draw on here the unintentionally hilarious document “Harm Reduction Calls to Action from Young People who Use Drugs on the Streets of Vancouver and Lisbon”) claim that “drugs themselves can be forms of harm reduction and treatment”, and envision a novel social model in which drug abusing youth are provided with free housing, safe consumption sites, and “peer-led compassion clubs that sell pharmaceutical grade cannabis, heroin, cocaine”, free from “paternalistic and judgmental attitudes in encounters with caregivers and providers”. Attitudes of this kind are particularly prevalent among activists and academics, whose phobia of judgement has created a paradoxical, shifting model of the addict or, in their jargon, the PWUD (person who uses drugs): they must not be subject to censure, because theirs is a medical condition; at the same time, they ought not be pathologised, because they are free subjects engaged in self-care; if their behaviour is problematic, which not everyone can agree on, then the solution is to offer them more and better services and resources until they decide to quit on their own.

If harm reduction has a gospel, a foundational myth, it is surely Glenn Greenwald’s 2009 white paper for the Cato Foundation, “Drug Decriminalization in Portugal: Lessons for Creating Fair and Successful Drug Policies”. Greenwald’s work was intended to examine the effects of a 2000 law decriminalising acquisition, possession, and use of personal quantities of all psychoactive drugs. The author’s partiality was evident from the very first page — his claim that “there is no real debate about whether drugs should once again be criminalised” is rather disconfirmed by the fact that criminal penalties for possession had been reinstituted a year before his findings were published — and he systematically attributes causation to correlation to suggest a number of benefits, from reduced HIV transmission to a decrease in drug use and drug-related deaths.

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Greenwald’s conclusions were parroted more or less uncritically by The Economist, Time, and Scientific American, and became a model for a shift away from a punitive approach to addiction and toward a public health one in numerous states and municipalities. The most famous adopter was Oregon, where Measure 110 decriminalised possession of most psychoactive drugs until it was amended earlier this year following a rise in violent crime, the largest spike in overdose deaths in the nation, and a proliferation of open-air drug markets. Though its problems were more severe or more evident than elsewhere in the country, Oregon was less of an outlier than its critics may admit: over the past decade, imprisonment and drug enforcement have declined across America, at the same time, overdose deaths have risen steadily, from just over 20,000 in 2002 to 107,000 in 2022. Bad as they are, the numbers hardly exhaust the associated social ills. In Philadelphia, where I live, the drug-ravaged area of Kensington has 10 times as many shootings per square mile as the rest of the city; Kensington Avenue, its former main street, is a virtual dead zone.

There are lessons here. One, of course, is to look close at the data or the absence thereof. Greenwald’s report examined a narrow range of years: 2001 to 2007. Since Portugal didn’t track the prevalence of drug use prior to decriminalisation, Greenwald had little idea where usage stood in the period prior to 2001, and many of the positive tendencies he saw in that brief interval have reversed in the intervening years. Another is to seek context: HIV rates, for example, fell across the developed world irrespective of drug policy.

But most importantly, and most obviously, one should ask whether there is any reason to believe outcomes in one country can be extrapolated elsewhere. Portugal and the United States are a particularly odd comparison to anyone who knows the two countries at all. The first is tiny and peaceful, relatively poor and relatively old, well-behaved, orderly, cohesive. The second is the land of the vaping congressman, the Gathering of the Juggalos, Diddy’s Freak-Offs, Jeffrey Epstein, the Doritos Crunchy Crust Pizza, young earth creationists, and the emotional support peacock.

If I overdo myself a bit with these examples — though they don’t scratch the surface of America’s weirdness — it’s to say that restraint isn’t exactly my people’s jam. And yet it remains a virtual heresy to suggest that our gargantuan hunger for intoxicants might point to an ethical failing on our part, or even a problem with drugs themselves. As to the latter, with great certainty, and with no proof at all, Maia Szalavitz of The New York Times tells us that “most addiction results from attempts to self-medicate isolation, social disconnection, psychiatric disorders, trauma and severe economic distress”. The greatest predictor for addiction is, of course, the easy availability of drugs. I would broadly assume that some of the problems Szalavitz cites are more pressing in Chad or Iraq than in the United States; but in these countries, and many like them, drugs are scarce, few can afford them, and the penalties are severe. Studies of rats, which seem to display similar addiction dynamics to humans, show a significant minority of them are vulnerable to addiction (around 15-20% in the case of cocaine) — perhaps Szalavitz and the rest of the trauma inflation crowd think scientists are just really good at finding rats plagued with anomie?

If we shouldn’t generalise among countries, we should be wary of doing so among drugs, too. Users, police, counsellors, and drug dealers will all tell you fentanyl has been destructive on an unprecedented scale. Two milligrams — less than a pinch of salt — can be deadly, and because it’s cheap, hard to detect, and easy to transport, it’s now found in everything: fake prescription pills, cocaine, ecstasy. Fentanyl is shorter-acting than heroin, which it has nearly pushed out of the market, so users who might once have held a job or cared for their families now spend half their days chasing the next high. The xylazine and benzodiazepines people take with fentanyl, either unwittingly or to stretch out its effects, knock them out so fast that more and more are using methamphetamine and crack to stay awake, making the term “opioid crisis” a rank simplification.

A recent spate of articles has celebrated a drop in the rate of overdose deaths in America for the first time since 2018 (that year was an anomaly, and apart from it, rates have risen steadily since the Nineties). Many speculated on which political interventions have finally bent the curve. None that I’ve seen has stated the obvious: that the supply of hard drug users is not infinitely elastic, and that in the past decade, 700,000 of them have died. Moreover, this is an underestimate: the Center for Disease Control tracks overdose mortality, but not deaths from drug-related sepsis, cirrhosis, suicide, or violence. Drugs follow the pattern of epidemics: they strike at vulnerable populations, some of whom die and some of whom recover, and they confer a measure of immunity in their wake. In the Eighties, crack devastated many black communities, to the point that “crackhead” became one of the worst terms of abuse; now young whites are nine times as likely to try crack as young blacks (this is perhaps the place to say a word in praise of the efficacy of stigma, which despite its bad reputation among harm reductionists is the primary enforcer of behavioural norms). The same pattern has already begun to play out with fentanyl and meth, and cocaine will probably follow in short order.

When the numbers go down, the dead will be forgotten. Whoever happens to be in power will claim victory over problems they did nothing to solve, and we will attribute to the policy in vogue at the time the abatement of an affliction many have pontificated about, and few have bothered to try to understand. Then eventually, a new drug will appear, or an old one will come back into fashion, and we will start the cycle again.

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