A safe injection site at OnPoint NYC (Kent Nishimura / Los Angeles Times via Getty Images)
Artillery Row

Against the neo-prohibitionists

Drug users have agency — let them choose for themselves

Whilst sitting in a community meeting for Melbourne’s first supervised injecting facility, one of the local traders stood up and said something that stuck with me: “these people need help,” she said, “and you’re telling them drugs are ok”.

Back in the 1980s when Nancy Regan launched her “Just Say No” campaign, people who used drugs were viewed as moral failures, utter dropouts to be avoided. Yet, whilst your local “junkie” was a bad person not worth saving, users were at least treated with the dignity of being autonomous actors, with a capacity to “say yes”.

Not so for a new wave of drug critics, who I’m calling the “neo-prohibitionists”. For the neo-prohibitionists, vulnerable drug users must be protected from liberal drug norms and, of course, themselves. Drug policies based around harm reduction, they say, have opened up the floodgates to lawlessness in our major cities, where deeply broken individuals are incentivised by progressive policies to self-destruct.

Ex-liberal Michael Shellenberger, author of San Fransicko: Why Progressives Ruin Cities, sees a direct connection between the shift towards harm reduction policies in American cities and entrenched poverty. Shellenberger argues for a form of “tough love” where homeless “addicts” are placed in involuntary treatment for their own good.

A similar tone is set by Jacob Siegal, who writes in UnHerd that harm reduction efforts — from clean needles to safer use education — “minimise the ravages attendant to drug addiction” and incentivise the “spiritual poverty of dependency”.

The majority of drug users don’t need saving

When neo-prohibitionists are feeling vaguely Marxist, they speak of drug use as a form of “self-medication” from the alienation and disenfranchisement of late capitalism.

In a piece for Compact Magazine entitled Drugging The Masses, Leila Mechoui argues that bureaucratic bodies “enable drug habits” writing conspiratorially how it’s “no coincidence that harm reduction spread in the wake of the defeat of the organized working class”.

Pop historian Johann Hari may unintentionally played a role in all this rhetoric with his widely popular book Chasing The Scream, simplifying complex research into drug use down to “the opposite of addiction is connection”.

Whilst the 1960s saw an unjustified glorification of drug use with the youthful hippy expanding her mind through the catchcry “turn on, tune in, drop out” — the romanticised image of the neo-prohibitionists is one of dour escapism, epitomised by the character Rue from the hit show Euphoria who is stuck in a cycle of addiction to medicate her “traumas”.

The neo-prohibitionist dogma stands contrary to decades of research into illicit drug use (and abuse) — which puts the blame for most drug related harms squarely on the unintended effects of drug prohibition.

Contrary to the sad sack narrative of the neo-prohibitionists, evidence consistently shows that the overwhelming majority of people who use illicit drugs don’t need saving.

Symptoms of dependence (whether psychological or physical) are prevalent in only a small proportion of regular drug users: around 15 per cent of users of methamphetamine and cannabis, 6 per cent of cocaine users and less than 1 per cent of users of MDMA and LSD.

Most people who use drugs do so because they feel good. The consistent pattern of drug use seen in most countries is a peak in recreational drug use amongst young adults followed by a sharp decrease into middle adulthood when priorities of work and family trump pleasure seeking.

When you ask people why they use illicit drugs, the most common response is that they enjoy them. Most illicit drugs provoke feelings of intense happiness, love, energy or connection — or trigger quasi-spiritual experiences beyond the limits of everyday consciousnesses.

Certainly, the most commonly used illicit drugs — from cocaine to speed to ecstasy — don’t support the dystopian musings of the neo-prohibitionists. As a result, people who use heroin and other opioids tend to do a lot of the heavily lifting in solidifying the connection between drug use and misery. However, even this relationship is far from straightforward.

Around 23–38 per cent of people who start using heroin will go on to become dependent. Opioid dependency has unique challenges; most people wishing to stop using will go through a period of withdrawal often resulting in relapse unless medical assistance is provided. Individuals who are initially attracted to opioids to manage chronic pain, could have symptoms return, making recovery downright unliveable.

However, the distinctive difficulties of opioid dependence shouldn’t give rise to a misunderstanding about the nature of drug use. Even amongst dependent heroin users, habitual use is best described as pleasure seeking rather than some dismal display of self-harm. Contrary to popular belief, there is not a direct path from opioid use to homelessness and poverty. In fact, most young people begin injecting drugs after becoming homeless.

We are all at risk of being trapped in poor decision-making

The phrase “diseases of despair” has gained currency in the United States to describe high rates of opioid dependence and overdose in vulnerable parts of the country. However, this term is best limited to specific demographics, not to be used as an all-encompassing perspective on drug use generally. The North American opioid crisis, the result of a perfect storm of predatory pharmaceutical companies and inadequate healthcare, has thankfully not been seen in other countries. Yet the United States tends to have undue influence in shaping popular perceptions of drug use and addiction, and it frequently does so in its own image.

Religiously inspired (and therapeutically questionable) US founded programs like Alcoholics Anonymous and Narcotics Anonymous have mainstreamed the notion of an “addict” — that is, some sort of uniquely predisposed individual who must pursue lifelong sobriety.

For the neo-prohibitionists, the “addict” should be protected from themselves and coercive therapeutic interventions initiated to protect them.

The notion of the “addict” is strongly connected to the brain disease model of addiction pushed by the US National Institute On Drug Abuse. The brain disease model of addiction sees habitual drug use as a pathology of neurophysiology causing chronic compulsive use.

This brain disease model has been heavily criticised outside (and inside) the US by alcohol and other drug researchers and clinicians. Whilst characterising addiction as a brain disease may help patients gain some compassion within the overly restrictive US healthcare system, it’s a pretty poor model for understanding the problem of addiction.

More evidence-based models of addiction see it as a result of difficult, but still very much volitional, choices. Individuals can often find themselves divided when faced with several, desirable options — to the point where they become at war with their decisions. Drug use is just one of many pleasurable experiences that provoke our conflicting desires.

“The kind of brain changes seen in addiction also show up when people become absorbed in a sport, join a political movement, or become obsessed with their sweetheart or their kids,” writes addiction neuroscientist Dr Marc Lewis in his ground-breaking work The Biology of Desire. Nobody is an “addict” — we are all at some risk of being trapped in the cycle of poor decision-making we call addiction, driven by a divided self.

For example, I may desire both another piece of a delicious cake and the narcissistic pleasure of an athletic physique. My self is divided by contradictory desires. The delicious cake has the distinct advantage of being right in front of me and instantly pleasurable, whilst getting six-pack abs requires a long, torturous amount of effort to acquire. So difficult is delaying gratification in the face of endless opportunities for cake slices, that my body goals are never achieved.

Illicit drugs are far more pleasurable than a typical slice of cake of course, but the dilemma of choice which fuels addiction is the same. Addiction is also not reducible to a form of “self medication” for the vast majority of users. Trauma, poor mood or unemployment may explain why continuing to use drugs is preferable to sobriety, but they don’t take away the choices made within the cycle of addiction.

As addiction psychologist Dr Grey Heyman notes, “[i]mplicit in the idea that addicts quit drugs voluntarily is that there is relatively easy access to non-drug activities that are more rewarding than the drugs… this may seem a highly unrealistic assumption given the poor economic prospects of many Americans.”

Many experts don’t see abstinence as a virtue, nor drug use a vice

Yet it’s only once we appreciate that drug use as a choice, and a largely unproblematic one for most, that the true horrors of prohibition can be appreciated.

Prior to the mid-20th century, most drugs that are currently illegal were widely available. One only has to look at the habits of some of the most influential thinkers and artists of the time. Freud loved his cocaine. Baudelaire treasured hashish, his “little green sweetmeat”. Nietzsche swore off alcohol whilst habitually partaking in opium and chloral hydrate, a potent hypnotic.

Whilst opium prohibition began earlier, the real global shift in the “war on drugs” started with the 1961 Single Convention On Narcotic Drugs, which encouraged signatories to isolate specific psychoactive drugs — heroin, cocaine, cannabis et cetera — for special regulatory (and eventually criminal) control. This prohibitionist regime was expanded to include amphetamines and psychedelics in 1971.

The unique illegality of these so-called “drugs of dependence” generated new harms for people who use them. With bans on legal manufacture, both the quality and potency of illegal drugs became highly variable. Users now had to take the gamble on whether they were snorting high purity cocaine or rat poison.

Crackdowns on distribution led to incentives towards smaller, high purity variations of illicit drugs (the so-called “iron law of prohibition”). Variable potency opium became pure heroin and now medical grade fentanyl. Powdered cocaine became crack. Speed became crystal meth.

The association of illicit drug use with deviancy generated problematic drug subcultures focused on transgression and excess. Being labelled a “criminal” also meant that people were far less likely to seek help when their habits got out of hand.

The anomie seen in open drug scenes in major cities, from violent arguments to public injecting to needle litter, is a direct consequence of a larger regime which excludes the figure of “the drug user” from polite society.

Harm reduction, the shift in public health policy since the 1980s and the target of criticism by the neo-prohibitionists, focuses on reducing harms caused by prohibition rather than worrying about use.

In my country, Australia, the relatively quick adoption of harm reduction interventions, such as needle and syringe programs, in the face of the 1980s HIV/AIDS epidemic is one of the reasons we have some of the lowest rates of blood borne virus transmission amongst injecting drug users in the world.

Most harm reduction interventions which cause front page controversies in the US and UK, are simply well functioning health interventions in many other countries.

Drug consumption rooms (or supervised injecting facilities) — where users can consume drugs whilst being supervised by trained medical staff — currently operate in Germany, the Netherlands, Spain, Norway, Luxembourg, Denmark, France, Canada and Australia. Such facilities have been shown to prevent overdose deaths, decrease public injecting and needle litter, reduce needle sharing, and increase the funnelling of problematic, dependent users into treatment.

Drug checking facilities that allow people to check their drugs for adulterants and purity now operate across 20 countries in Europe and the Americas. Allowing users to test their drugs has been shown to lead to smarter choices around drug use (with users binning drugs with adulterants and quartering pills of high purity), whilst also causing shifts in the illicit drug market towards higher quality substances.

Education campaigns around “safer use” are often the target of neo-prohibitionists who argue that health workers are giving a “green light” to self-destructive behaviour. However, the goal of safer use campaigns such as the Global Drug Survey’s High-way Code resource, is to reinvigorate the norms around responsible drug use — which have been lost as a result of prohibition.

Whilst Baudelaire is certainly no exemplar of restraint, there was a reason his contemporaries saw opium use as nothing more than an aristocratic “treat” with the occasional “annoyance” of physical dependency.

Far from endorsing hedonistic excess, treating people who use drugs as competent, autonomous individuals inevitably requires obligations in return for discretion, moderation and responsibility.

As Professor Carl Hart from Columbia University notes in his book Drug Use For Grown-Ups, “[r]esponsibility requires a considerable amount of self-inspection and a healthy sense of respect for fellow humans … grown-ups put in the work because it affords us liberty.” Hart, an advocate for harm reduction and (infamously) an out and proud recreational heroin user, sees the inevitable consequence of moving beyond the “brain disease” model of addiction as being greater expectations placed on responsible use.

Unlike the neo-prohibitionists, Hart and many other experts in illicit drug policy don’t see abstinence as a virtue, nor drug use a vice. In order to move beyond the harms caused by the global war on drugs, we need to respect those who use drugs responsibly and understand those who don’t.

Harm reduction interventions are specifically designed to remedy the ills of prohibition, and they are succeeding in that goal. To the neo-prohibitionists: drug users do not need your help, but they do need you to see them as human rather than props in a narrative about liberal alienation and despair.

Enjoying The Critic online? It's even better in print

Try five issues of Britain’s newest magazine for £10

Critic magazine cover