As reported last month on JTO, the city of Baltimore will join New Mexico in giving heroin users access to Narcan, the opiate antagonist naloxone, that can reverse the sometimes fatal effects of overdose (Baltimore to give heroin users overdose drug, 3/4/2003).

Now, who in their right mind would oppose such a potentially life-saving intervention, one that might have prevented some of the 109 heroin overdose deaths in Baltimore county in 2002? Some ex-addicts, it turns out. JTO quoted Michael W. Gimbel, a former heroin user and past director of the city's department of substance abuse services, that "The Narcan program sanctions heroin addiction. It's like the city has given up."

Such a response comes as no surprise to those familiar with the debate over harm reduction, the philosophy that if we can't end drug use altogether, we can at least take steps to minimize harm to drug users. Giving addicts Narcan is quintessential harm reduction, in that it accepts the reality that some individuals will use heroin or other opiates, that some of these will overdose, and, crucially, that it's more important to save lives than to keep the threat of death as a disincentive to use drugs.
Like Gimbel, those who oppose harm reduction sometimes argue that measures such as providing Narcan or clean needles encourage drug use. By protecting addicts from the negative consequences of their behavior, harm reduction wrongly reduces the disincentives to use drugs. The implicit calculus here is that drug use is somehow worse than death, disease, or injury, such that keeping fatal overdose or brain damage or HIV infection as disincentives is a legitimate, even moral tactic. If a drug user refuses to get clean and incurs such harm, well, that's his comeuppance, and besides, it just might deter others.

Now why, one wonders, is drug use so morally bad that death and disease are justifiable deterrents, and that therefore we should forego measures which could easily (and cheaply) save lives, as well as the cost of treating AIDS, Hepatitis C, and other diseases? Why is preventing heroin use via the threat of death worth the lives lost when the threat fails to deter? As it must, of course, for fear of overdose rarely stops someone who's dope sick from using heroin.

The roots of moral objections to drug use lie in culturally transmitted attitudes about the proper pursuit and limits of pleasure, the virtues of honest toil over indolence, and the perceived dangers of altered consciousness. Without exploring the pros and cons of such beliefs, suffice it to say that those who see death as a justifiable deterrent to injecting heroin are at one end of the attitudinal spectrum. For them, succumbing to the evil of drugs is a failure of will, and harm reduction simply stays the harsh but nevertheless just hand of mean streets retribution. Harm reduction thwarts the moral, disciplinary purpose of the pain addicts would otherwise suffer, and so is itself immoral by their lights.

As a subset of those who oppose harm reduction, some ex-addicts harbor the most hard-line attitudes about addiction, perhaps because they got clean without the "crutch" of methadone or the safety net of needle exchanges or Narcan. They see immediate drug-free abstinence (methadone included) as the only acceptable route to sobriety, and anything that reduces the risks of drug use is construed as "enabling." And of course many who've never struggled with addiction feel much the same way, supposing that had they grown up in similar circumstances, they would have had the strength of will never to have tried drugs.

It is this assumption, I think, that underlies the punitive attitudes that characterize some (but certainly not all) harm reduction opponents. It says that addicts, if they had only chosen to abstain, wouldn't have got themselves into this mess in the first place. And since the choice to use was ultimately up to them, they don't deserve to be protected from the harmful consequences of addiction. They made their bed, now let them lie in it.

But as the science of addiction progresses, there is less and less reason to suppose the choice to use drugs and alcohol (and tobacco, for that matter) is explained by anything that's ultimately up to the individual. It's becoming clear that a person's character and choices are produced by the interaction of genetics, environment, and upbringing, and it's this causal story, not the exercise of uncaused personal willpower, that explains why some people end up addicted and others don't. As Alan Leshner, former head of the National Institute on Drug Abuse said, "We know that many factors that people cannot control can either increase or decrease their likelihood of making the initial voluntary decision to use drugs." ¹

If voluntary decisions are just as caused as anything else in nature, this should prompt us to question the notion that addicts essentially "make their own bed," and so deserve the harm that befalls them. If opponents of harm reduction accept scientific explanations of addiction, they must say precisely why those in its thrall should face a prevention regime that deliberately maintains the threat of disease and death. If, on the other hand, they don't accept scientific explanations, how do they account for the fact that some people have and use willpower, and others don't? Absent such an account, appeals to willpower lack credibility and utility.

They don't lack for a motive, however: to place blame solely on the addict, thus justifying punitive or laissez-faire policies on substance use and addiction. Once we understand the choice to use drugs as caused, not a failure of will, it will become considerably more difficult to justify such policies. And in light of the causal story, we'll devise more compassionate and effective approaches to reducing addiction and its harms.

Tom Clark is a research associate at Health and Addictions Research, Inc. in Boston. The views expressed here are strictly his own. Further reading: Clark, T. W., "To help addicts, look beyond the fiction of free will", The Scientist, 12[16]:9, Aug. 17, 1998.

¹"When the Question Is Drug Abuse and Addiction, the Answer Is 'All of the Above'" in NIDA Notes, Volume 16, Number 2 (May, 2001).