Dilemmas in harm minimization

ABSTRACT

This paper discusses the dilemmas inherent in pursuing a philosophy of (drug) harm minimization. The dilemmas arise (i) because all drug control policies produce harms as well as benefits; (ii) because many of these harms and benefits cannot be measured; and (iii) because even when they can be measured, judgements about what harms matter the most are irreducibly political. The paper concludes by proposing that the interests of drug policy might be better served if we abandoned the idea of an overarching goal in favour of a set of goals dealing with specific identifiable problems.

INTRODUCTION

It has often been said that the goal of drug policy should be to reduce or minimize the harm associated with drug use rather than reduce or minimize drug use itself. At first blush, the injunction seems sensible enough. All societies use drugs of one sort or another and the eradication of drug use would seem well nigh impossible. Moreover, some of the measures we take to reduce drug use (e.g. imprisoning people for minor drug offences) seem to do more harm than good. There are many ways in which we can reduce drug-related harm without reducing drug use. If the main reason for seeking to reduce drug use is to reduce drug-related harm, why not make the latter the goal of policy and treat the former as one means among many directed toward that end?

If we probe a little deeper, however, the beguiling simplicity of harm minimization begins to disappear. Whose harm should we try to minimize and how do we compare qualitatively different types of harm? Is it possible to compare the harm done by injecting drug users when they discard their equipment in a public park, with the harm done to injecting drug users when they are unfairly harassed by police; when fear of arrest prompts them to inject too quickly; or when in a bid to avoid detection, they share injecting equipment? When reducing the harm suffered by users increases the harm suffered by everyone else, whose interests should prevail? What principle should we adopt to make such decisions? These questions are critical to the achievement of harm minimization but have attracted little scholarly attention.

The purpose of this paper is to examine these questions and their implications. The next section deals briefly with definitional issues. The three sections that follow discuss the dilemmas associated with supply, demand and harm reduction. The penultimate section discusses the problems with harm minimization as a policy goal. The final section puts forward an alternative to harm minimization.

DEFINING HARM REDUCTION/MINIMIZATION

There is little agreement on the meaning of the terms ‘harm reduction’ and ‘harm minimization’[1–3]. This is not the place for a general discussion of definitional issues, but clarity of terms is essential if the arguments presented below are to be understood clearly. Following the general approach adopted by Wodak & Saunders [4], I draw a distinction between ‘harm reducing’, ‘harm reduction’ and ‘harm minimization’. The first term I use to describe any intervention, programme or policy intended to reduce the harm associated with drug use, including measures designed to reduce drug use. The second term I reserve for measures that are designed to reduce the harms associated with drug use by means other than reducing drug use (e.g. needle and syringe exchange programmes). The third term (‘harm minimization’) I use to refer to the view that the overall goal of drug policy should be to minimize drug-related harm, in all its manifold forms.

DILEMMAS IN SUPPLY CONTROL

Harm minimization is pursued generally through three broad strategies: supply reduction, demand reduction and harm reduction [5]. There is little doubt about the harm-reducing potential of supply control. The risks and costs associated with drug trafficking make illegal drugs much more expensive than they would otherwise be [6]. There is now a substantial body of evidence [7] that demand for drugs such as heroin and cocaine is price-sensitive. Thus, even if supply-side drug law enforcement does nothing more than limit the extent to which illegal drug prices fall, it limits the scale of illicit drug use and some of its associated harm. The harm-reducing character of supply control policy is most vividly apparent in Australia, where a huge jump in Australian heroin prices produced dramatic falls in heroin-related crime, fatal heroin overdoses and notifications of hepatitis C [8]. Less spectacular but no less potent evidence of the harm reducing potential of supply control policy can be found in the inverse relationship between rates of entry into emergency departments in the United States and trends in the price of heroin and cocaine [9].

Supply control policy, however, also generates a great deal of harm. The harms associated with supply reduction or the law enforcement practices associated with it include loss of civil liberty [10], increased risk of overdose and disease [11] and greatly increased rates of imprisonment [12]. The risk of imprisonment may assist in keeping retail drug prices high, but imprisonment reduces substantially an individual's future legitimate employment and earnings prospects [13]. Evidence has emerged recently that it may also increase significantly the risk of further involvement in crime [14]. There are other problems as well. The risk we take when supply side drug law enforcement pushes up the price of one illegal drug is that drug users will switch to another. There is some evidence that efforts to restrict the supply of heroin have prompted some street-based heroin users to switch to methamphetamine and cocaine [11]. These are drugs that, if used frequently over a prolonged period, can produce aggression, hostility and paranoia [15].

DILEMMAS IN DEMAND REDUCTION

Recognition of the costs associated with supply control policy has prompted many to argue that we should put more emphasis upon demand reduction. One of the best ways to reduce the demand for illicit drugs is to provide drug users with treatment. Methadone maintenance treatment, for example, has been shown in a number of randomized controlled trials to reduce heroin consumption and heroin-related crime [16].

Despite its benign appearance, however, demand reduction strategies can also generate harm. Few injecting drug users are prompted to stop using illegal drugs because of their adverse pharmacological effects. The most common reasons given by injecting drug users for entering treatment are trouble with the police, the cost of illegal drugs and the life-style associated with illicit drug dependence—that is, the endless scamming, theft, violence, hassles with police and ever-present risk of imprisonment [17,18]. Policy makers may view these conditions as an inducement to seek treatment but drug users view them as significant harms, as indeed they are. If the effectiveness of treatment in reducing aggregate drug consumption depends upon the enforcement of sanctions associated with drug use, it is difficult to get the best out of treatment without inflicting a certain amount of harm.

Treatment is also capable of inflicting harm in a more direct way. Because it reduces demand relative to supply, the provision of treatment may drive down drug prices in the illegal market, enticing more people into drug use. People on methadone maintenance treatment sometimes sell their methadone to others. Some have given methadone to their infant children, with predictable and tragic results. In some circumstances treatment may even encourage illicit drug use. Best and colleagues [19], at the National Addiction Centre in London, found that polydrug users in methadone treatment were spending much more on crack cocaine than those who were not in treatment. This suggests that some heroin users may take refuge in methadone knowing that it will release funds to buy other illegal drugs.

DILEMMAS IN HARM REDUCTION

This brings us to harm reduction. There is no doubt about the benefits that flow from some harm reduction initiatives. The needle and syringe programme, for example, limited the spread of human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS). Do harm reduction initiatives ever cause any harm? This is a difficult question to answer, because the impact of harm reduction measures on illicit drug consumption is not examined very often.

The best-evaluated example of a harm reduction measure is the removal of penal sanctions from cannabis use (de-penalization). The effects of de-penalization remain the subject of considerable debate [12,20–22]; but even if we knew that although removing the penal sanctions associated with cannabis use reduced the harm associated with the drug, it would not follow that we can pursue a comprehensive harm reduction programme without any risk of stimulating drug use. Consider some of the things policy makers could do if they were really serious about reducing drug-related harm. They could provide all drug users with a service that allows them to test the purity and composition of the drugs they buy on the black market. To mitigate the risks associated with rapid injection they could adopt a policy of not arresting people caught in the act of injecting illicit drugs. To mitigate the risks associated with intranasal or oral storage of illegal drugs they establish a protocol limiting the power police have to search the mouth or nose of someone they suspect to be carrying drugs in those cavities. To avoid compromising the education of schoolchildren they could adopt a policy of not expelling or suspending students caught using illegal drugs. They could establish a medically supervised injection centre in every neighbourhood with substantial numbers of injecting drug users or remove criminal sanctions altogether from personal drug use or possession (decriminalization).

These sorts of initiatives are rarely, if ever, pursued because policy makers (and the general public) are fearful that they would ‘send the wrong message’; that is, increase the rate of initiation into drug use and/or consumption among existing users. It is customary in some circles to dismiss this fear but, as Hall [23] points out, we do not dismiss it when tobacco companies attempt to reduce the harm associated with smoking by creating a non-smoked form of tobacco. The point is that the harms associated with certain practices are sometimes the most important brake on their adoption. Musto [24] has argued that one reason for the cyclical nature of drug epidemics is that the rate of initiation into drug use begins to slow as the harms associated with heavy use become increasingly apparent. The model of the US cocaine market developed by Caulkins et al.[25], which is based on this idea, gives a good account of the time–course of the US cocaine epidemic. If his model is correct, there is an unavoidable trade-off between minimizing the harm associated with cocaine and minimizing the number of new recruits to the drug. If this is true of cocaine it may well be true of other illegal drugs.

PROBLEMS WITH HARM MINIMIZATION AS A GOAL

So far all we have done is show that supply reduction, demand reduction and harm reduction all result in harms as well as benefits. It could be argued that, while this complicates the process of minimizing harm, it does not render it impossible. All one has to do is measure the harms associated with various initiatives, weigh them in terms of their relative importance and then select whatever combination of initiatives best minimizes the harm associated with drug use. The UK Home Office is pursuing a project of this kind [26], and Ball [27] has also spoken recently of the possibility of ‘model (harm reduction) packages’.

The problem is that we have no practical means of measuring many drug-related harms. We know from ethnographic research, for example, that street-level drug law enforcement sometimes encourages drug users to inject rapidly or share needles to avoid being caught [28], but we have no practical means of quantifying the scale of this problem or the harm that it causes. The same applies to the loss of civil liberty that results from an expansion in police powers of search and seizure, the loss of privacy that results from an expansion of police powers of surveillance, the loss of public amenity associated with public drug use or the scale of the black market in methadone created by offering ‘take-away’ doses. Researchers might be able to make informed guesses about the dimensions of some of these problems but, as Hawks & Lenton [29] point out, in most instances drug policy decisions have to be made without any real capacity to measure the harms they may produce.

There is another even more profound problem. Even if we could measure the harms and benefits associated with alternative drug policies, there is no common scale against which they can be compared. To see this, consider two hypothetical policies. One policy cuts public drug dealing by 20%, but encourages needle sharing and results in many innocent teenagers being stopped, searched and questioned by police. The other policy reduces needle sharing and minimizes the number of innocent teenagers stopped, searched and questioned by police but, as a consequence, produces a higher level of drug trafficking and drug-related loitering in and around areas that have methadone clinics. Which policy should we adopt?

The principle of harm minimization is no help to us here. No amount of research or calculation can tell us whether the benefits associated with heroin supply reduction (in terms of reduced deaths, reduced disease and reduced crime) are worth the costs (in terms of increased uptake of psychostimulants and their sequelae). Nor can any research tell us whether the loss of civil liberty associated with an increase in police street-level drug law enforcement powers is worth the gain in public amenity. The harms associated with drug use (and our control strategies) are incommensurable. Even a complete understanding of the costs and consequences of various drug policy alternatives would not tell us what policy best minimizes drug-related harm. This is because decisions about what policy to adopt invariably come down to political (value) judgements about what risks, harms and benefits (i.e. outcomes) matter the most. This is not a job for researchers; it is a job for politicians and the public at large.

It might be objected that we are taking harm minimization far too literally; that a commitment to harm minimization is not a commitment to minimizing some measured quantity in the strict mathematical sense, but rather a commitment to putting the focus of drug policy on the harm caused by drug use rather than on drug use per se.

There are two problems with this. The first is that it is unhelpful to say that the goal of drug policy is ‘harm minimization’ if there is any room for ambiguity over precisely what this means. Some may be happy to use the terms in question in a way that is inclusive of use reduction. However, as Hall recently pointed out [23], the term ‘harm reduction’ is an anathema to North American drug warriors, who see it as a Trojan Horse for drug legalization. He has expressed doubts about the worth of a term that means so many different things to different people and that provokes such strongly opposed views. His doubts seem well founded.

The second and larger problem with the idea that the goal of drug policy should be to minimize the harm associated with drugs is that it obscures the central dilemma in drug policy—in an environment where reducing one set of harms usually increases others, which harms should we reduce? There is no meaningful sense in which we can minimize all the harms associated with a particular drug. All we can ever do is reduce some harms while trying, sometimes forlornly, not to generate or exacerbate others. Instead of forcing us to confront difficult questions about whether (for instance) enforcement practices designed to improve public amenity in drug-dealing hotspots are worth the cost in terms of unsafe injection practices, or whether strategies designed to raise the (monetary and non-monetary) cost of drug use are worth the cost in terms of lost civil liberty and higher rates of imprisonment, invocations to ‘minimize’ harm simply encourage us to ignore certain problems in favour of others.

BEYOND HARM MINIMIZATION

Hall [23] has recommended that we abandon the term ‘harm reduction’ and speak instead about ‘public health’ measures. This would be an improvement on the current situation, but it does not go far enough. Some of the harms associated with drug use are not, in any meaningful sense, ‘public health’ harms (e.g. loss of public amenity, poor school performance, theft). Rather than adopt any general guiding principle, it would make more sense to try to reach agreement on the specific drug problems we want to reduce and make their reduction the goal of illicit drug policy. Thus, instead of saying we want to minimize the harm associated with injecting drug use, we might (for example) simply say that we want only to minimize the number of new recruits to injecting drug use, encourage more injecting drug users into treatment, reduce the crime committed by injecting drug users and improve public amenity in areas where injecting drug use is prevalent. The advantages of proceeding in this way are twofold. First, the requirement to list the specific problems we want to address will stimulate a more open and frank debate about what problems matter the most. Secondly, if we engage in open debate about which problems matter the most, it should become much easier to identify the points where compromises must be made in the achievement of drug policy goals.

Declarations of interest

None.

Acknowledgements

My thanks to Professor Richard Mattick, Director of the National Drug and Alcohol Research Centre for his helpful comments on an early draft of this paper.