Reducing Harm is the Right’s New Culture War Target

The final part of Safe Supply Saves Lives: a look beyond the deadly war on drugs, a 7-part series.

Harm reduction programs have become a target of right-wing “culture war” attacks that paint “big city liberals” as enabling drug use. In West Coast cities, residents and local politicians often see the overdose crisis as intertwined and exclusive to the housing crisis. Local media coverage paints that picture in pieces like “Seattle is Dying,” using poverty porn to call for mass incarceration of unsheltered people. In Seattle, Jonathan Choe¹ is one of the former local news personalities who now works for a right-wing think tank, The Discovery Institute, and uses his platform to portray leftist mutual aid activists and liberal politicians as “enabling” crime, chaos, and addiction. Choe and others like him point to policies such as legal syringe exchange, court diversion programs, and eliminating cash bail as allowing a “revolving door” of crime.²

Only if @MayorofSeattle would realize the reasonable people of #Seattle are behind him if he PUBLICLY prioritizes the war on drugs and confronts the insane no strings attached “harm reduction” lobby fueling the crisis. Maybe in year 2.🤷🏽‍♂️ https://t.co/2N13qUKC2t
— Jonathan Choe (@choeshow) December 5, 2022

Harm reduction programs are centered on working with the most vulnerable unsheltered people in historic “Skid Rows” like Seattle’s Pioneer Square, Vancouver’s Downtown Eastside, LA’s Skid Row, and San Francisco’s Tenderloin. Opportunistic political candidates fixate on this association and propose compulsory addiction treatment as a solution to the housing crisis.³ Substance use certainly exists among currently and formerly homeless populations, but is just one of many barriers to stabilization. The walls that most people take for granted hide the true scale and geography of drug use. Drug use is visible in unsheltered people because of the lack of privacy they’re afforded, but that does not mean that housed people don’t do drugs. West Virginia has four times the rate of deaths from overdose as Washington, Oregon, and California, despite West Virginia having the sixth lowest rate of homelessness compared to several of the highest.⁴ ⁵ Even within Washington State, Seattle’s King County has a lower than average rate of overdose hospitalization, with rural counties more affected.⁶ What is the failure of “liberal harm reduction” if the overdose crisis is dramatically deadlier in jurisdictions that have taken the opposite approach, and “prioritized the war on drugs” as Choe is calling for?

CDC National Center for Health Statistics. “Drug Overdose Mortality by State.”

Overdoses, death, and infectious disease transmission track more closely with harm reduction availability than homelessness. An infamous example is Indiana’s HIV outbreak during Mike Pence’s stint as governor. At the time, Indiana prohibited harm reduction programs that exchanged or distributed new syringes. Scott County, a rural area home to just 24,000 people, had 176 HIV infections in just one year. Pence eventually begrudgingly allowed the state’s first needle exchange program to open in Scott County in 2015. Transmission quickly fell to a single case per year.⁷ One study’s model estimated that 90% of cases would have been prevented if the program had already existed.⁸ Despite that success, the program was ordered to close at the end of 2021. County commissioner Mike Jones justified his pro-HIV transmission vote with the statement, “I know people that are alcoholics, and I don’t buy ’em a bottle of whiskey. So, I have a hard time handing a needle to somebody that I know they’re going to hurt theirself with.”⁹ It’s unclear whether Jones supports reintroducing alcohol prohibition.

When the U.S. Department of Health & Human Services was set to launch a $30 million fund for harm reduction programs early last year, right-wing media singled the policy out as “Biden’s free crack pipes.” The focus on pipes was a clear dog-whistle regarding 1990s-era tropes of Black people disproportionately smoking crack cocaine when white people were snorting powder cocaine or using injection heroin and methamphetamine. Tucker Carlson explicitly said, “Joe Biden’s latest idea is to pay Black people to smoke more crack.”¹⁰

Harm reduction programs have encouraged participants to switch use from injection to smoking with bubble pipes to reduce an opioid or methamphetamine user’s risk of disease transmission and infected abscesses, while allowing them to pace themselves better.¹¹ From July 2018 to July 2020, injection use fell by 50% in favor of smoking with a pipe among users in San Francisco.¹² Despite the clear public health benefit, the Biden administration reneged on the backlash by explicitly removing pipes from the list of supplies eligible for funding.¹³ HHS compromised with Tucker to an arbitrary line that we should support the legitimate medical purpose of syringes, but that pipes are a step too far in “enabling” (survival).

West Virginia Senator Joe Manchin responded to the sensationalism around the HHS funding by joining with Marco Rubio (R-FL) to introduce the Preventing Illicit Paraphernalia for Exchange Systems (PIPES) Act to ban federal funding of harm reduction supplies. Manchin represents the state with by far the highest rate of opioid deaths, the largest HIV outbreak in the nation, and a pattern of stymieing harm reduction efforts. Rubio and Manchin centered their press release on how the “disease of addiction” caused those 100,000 deaths last year, and “sending drug paraphernalia to addicts is not the answer.”¹⁴

Manchin’s state has adopted the same approach as anti-choice “TRAP” laws to over-regulate harm reduction. West Virginia’s Senate Bill 334, signed into law in 2021, applies high barriers to syringe exchange access, requiring photo ID from program participants, and each individual needle be barcoded, tracked, and replaced 1:1.¹⁵ Even the earliest syringe exchange programs acknowledged that asking participants to transport used supplies potentially contaminated with infectious diseases was not necessarily desirable, removing sharps from a safe disposal box to scan barcodes would be downright reckless. $10,000 fines are applied to nonprofit programs for violations. The law was inspired by a similar municipal law passed in Charleston, WV in 2018. In Charleston’s county, Kanawha, the nation’s “most concerning” HIV outbreak has been growing since.¹⁶ Between 2018 and 2022, half of West Virginia’s syringe exchange programs shuttered.¹⁷

Baffling anti-harm reduction rhetoric is not exclusive to right-wing jurisdictions. San Francisco Board Supervisor (city councilor) Matt Dorsey proposed a bill this past summer that would instruct police to consider the areas surrounding recovery and harm reduction centers as “high priority” drug enforcement zones.¹⁸ Police would be expected to “immediately confiscate” illicit substances and harm reduction supplies such as syringes and bubble pipes from participants and make arrests for possession after they’ve just received said supplies from the very clinic. Dorsey cynically touts the bill as “extending harm reduction to our neighborhoods,” seeing actual harm reduction as a blight on the broader community that can be shoed away with police. In Canada, the exact opposite best practice is precedent: cops are not supposed to surveil harm reduction clinics, for a very obvious reason; police surveillance outside a healthcare facility intimidates clients, discouraging engagement in harm reduction and treatment options. While Toronto Police stops short of establishing a non-enforcement boundary, their internal policy for Supervised Consumption Sites, “is that discretion should be considered so as to avoid a heightened police-presence, which could otherwise discourage potential service users of the sites from attending.”¹⁹

While Matt Dorsey’s legislation isn’t going anywhere, statewide harm reduction efforts were stifled this summer by Democrat governor Gavin Newsom. Newsom vetoed a bill passed by the legislature that would have allowed pilot program Supervised Consumption Sites to open in major cities. Newsom, eying the oval office and hence risk-avoidant, expressed concern that the pilot wasn’t limited enough in scale, tangentially waxing about how the theoretical clinic operators might grow too quickly and not be fiscally sustainable.²⁰ Local advocates, like San Fransisco State Senator Scott Weiner, acknowledged the deadly outcome of Newsom’s decision, saying, “Today’s veto is tragic. Each year this legislation is delayed, more people die of drug overdoses — two per day in San Francisco alone.” ²¹

The implementation of basic harm-reducing public health measures has become another vibes-only war for the American right (which includes Newsom). Harm reductionists must counter this propaganda to hold data and best medical practices within the Overton window:

Suboxone and methadone reduce the risk of overdose while abstinence-based treatment does not.²²
Heroin-Assisted Treatment is even more effective than Suboxone or methadone at stabilizing patients, who show an improved rate of treatment retention, reduced criminal activity, improved social relations and economic status, and psychiatric and medical recovery in the NAOMI study.²³
We know we’ve dramatically slowed the spread of HIV/AIDs and other transmissible diseases with syringe exchanges and pipe distribution – as was the case in Indiana. The visible “blight” of these services being concentrated in particular neighborhoods is a facile complaint against life-sustaining providers meeting their patients where they’re already at.
Fear-mongering about fentanyl has allowed conservatives and liberals to launder the war on drugs, but its disastrous effects remain clear. We know incarceration doesn’t induce recovery, drug enforcement will disproportionately target Black Americans, threatening homicide charges reduces Good Samaritan calls, and trying to stamp out one supply of drugs brings us an even denser replacement.

Whether independently pursuing treatment, being faced with an intervention from family, or anything involving the legal system, informed consent is essential in making lasting positive changes. For patients to truly have informed consent, they need to be presented with medically-accurate information about each option’s methods, efficacy and risks, and to have access to the treatment plan that’s right for them. This includes treatment options that are not currently legal in the United States, such as Fentanyl-Assisted Treatment. Law enforcement agencies and the court system should have no role in getting between a doctor and a patient in determining their medically-indicated treatment plan, whether that’s for a Substance Use Disorder or chronic pain condition.

Read a related article, Ending the Drug War is Essential to Reproductive Justice

References

1
Jonathan Choe. “WHY ARE WE ALLOWING THIS? Commuter Just Snapped Photo at Ballard Bus Stop near 15th Ave NW. No Doubt Drug Addiction Is Fueling Homeless Crisis. My Eyes Ain’t Lying. My Interviews Confirm It. How Does ‘HOUSING FIRST’ Work When Addicts Want to Stay on Streets to Do This? #Seattle Https://T.Co/GTrUZfRSL9.” Twitter. October 26, 2022. https://twitter.com/choeshow/status/1585351528919228416.
2
Jonathan Choe. “THIS IS HARM REDUCTION? It’s not a needle exchange when the needles end up scattered all over the street. @RohanJoseph12 waking up to another disaster outside his #Belltown biz, surrounded by addiction/homeless support services. @MayorofSeattle #Seattle. Twitter. December 8, 2022. https://twitter.com/choeshow/status/1601258927957872641.
3
Siegel, Zachary. “Michael Shellenberger’s Narrative of California Homelessness Is Seductive. It’s Also Dangerous.” San Francisco Chronicle, May 15, 2022. https://www.sfchronicle.com/opinion/openforum/article/Michael-Shellenberger-s-narrative-of-California-17172493.php.
4
CDC National Center for Health Statistics. “Drug Overdose Mortality by State,” March 1, 2022. https://www.cdc.gov/nchs/pressroom/sosmap/drug_poisoning_mortality/drug_poisoning.htm.
5
Statista. “Homelessness Rate in the U.S., by State 2020,” March 2021. https://www.statista.com/statistics/727847/homelessness-rate-in-the-us-by-state/.
6
“Drug Overdose Hospitalization County Map For 2015-2019 Combined.” Washington State Department of Health, June 27, 2022. https://doh.wa.gov/sites/default/files/2022-02/wa_lhj_quarterly_report_18_1_2_pub.html.
7
Facher, Lev. “Years Ago, a Syringe Exchange Helped End a Devastating HIV Outbreak. Now It Might Be Forced to Close.” STAT (blog), May 6, 2021. https://www.statnews.com/2021/05/06/years-ago-a-syringe-exchange-helped-end-a-devastating-hiv-outbreak-now-it-might-be-forced-to-close/.
8
Goedel, William C, Maximilian R F King, Mark N Lurie, Sandro Galea, Jeffrey P Townsend, Alison P Galvani, Samuel R Friedman, and Brandon D L Marshall. “Implementation of Syringe Services Programs to Prevent Rapid Human Immunodeficiency Virus Transmission in Rural Counties in the United States: A Modeling Study.” Clinical Infectious Diseases 70, no. 6 (March 3, 2020): 1096–1102. https://doi.org/10.1093/cid/ciz321.
9
Legan, Mitch. “Scott County Commissioners Vote To End Groundbreaking Needle Exchange.” News – Indiana Public Media, June 3, 2021. https://indianapublicmedia.org/news/scott-county-commissioners-vote-to-end-groundbreaking-needle-exchange.php.
10
Brown, Hayes. “How $30 Million to Prevent Overdoses Became a Racist Fox News Talking Point | Opinion.” MSNBC.com, February 11, 2022. https://www.msnbc.com/opinion/msnbc-opinion/fox-news-biden-crack-pipe-freakout-going-kill-people-n1288950.
11
Stöver, Heino Johann, and Dirk Schäffer. “SMOKE IT! Promoting a Change of Opiate Consumption Pattern – from Injecting to Inhaling.” Harm Reduction Journal 11 (June 27, 2014): 18. https://doi.org/10.1186/1477-7517-11-18.
12
Kral, Alex H., Barrot H. Lambdin, Erica N. Browne, Lynn D. Wenger, Ricky N. Bluthenthal, Jon E. Zibbell, and Peter J. Davidson. “Transition from Injecting Opioids to Smoking Fentanyl in San Francisco, California.” Drug and Alcohol Dependence 227 (October 1, 2021): 109003. https://doi.org/10.1016/j.drugalcdep.2021.109003.
13
Immediate Office of the Secretary (IOS). “Statement by HHS Secretary Xavier Becerra and ONDCP Director Rahul Gupta.” Text. HHS.gov, February 9, 2022. https://www.hhs.gov/about/news/2022/02/09/statement-hhs-secretary-xavier-becerra-and-ondcp-director-rahul-gupta.html.
14
U.S. Senator Joe Manchin of West Virginia. “Manchin, Rubio Introduce Bipartisan Bill To Prohibit Federal Purchasing Of Crack Pipes And Needles For Drug Use,” February 11, 2022. https://www.manchin.senate.gov/newsroom/press-releases/manchin-rubio-introduce-bipartisan-bill-to-prohibit-federal-purchasing-of-crack-pipes-and-needles-for-drug-use.
15
Peace, Lauren. “Judge Rules Law Restricting West Virginia Needle Exchange Programs Can Stand.” Mountain State Spotlight, July 15, 2021. https://mountainstatespotlight.org/2021/07/15/law-restricting-wv-needle-exchange-programs-can-stand/.
16
Peace, Lauren. “The CDC Says Kanawha County’s HIV Outbreak Is the Most Concerning in the United States – Mountain State Spotlight.” Mountain State Spotlight, February 11, 2021. https://mountainstatespotlight.org/2021/02/11/the-cdc-says-kanawha-countys-hiv-outbreak-is-the-most-concerning-in-the-united-states/.
17
Glenza, Jessica. “How Restrictions on Syringe Programs Led to a Severe HIV Outbreak in West Virginia.” The Guardian, May 9, 2022, sec. US news. https://www.theguardian.com/us-news/2022/may/09/restrictions-syringe-programs-severe-hiv-outbreak-west-virginia.
18
Matt Dorsey [@mattdorsey]. “‘Today I Am Announcing My Plan to Draft Legislation That Will Establish “Right to Recovery” Drug Enforcement Priority Zones[…].’” Tweet. Twitter, June 14, 2022. https://twitter.com/mattdorsey/status/1536856556775518208.
19
Bardwell, Geoff, Carol Strike, Jason Altenberg, Lorraine Barnaby, and Thomas Kerr. “Implementation Contexts and the Impact of Policing on Access to Supervised Consumption Services in Toronto, Canada: A Qualitative Comparative Analysis.” Harm Reduction Journal 16, no. 1 (May 2, 2019): 30. https://doi.org/10.1186/s12954-019-0302-x.
20
Newsom, Gavin. “I Am Returning Senate Bill 57 without My Signature.” California Office of the Governor, August 22, 2022. https://www.gov.ca.gov/wp-content/uploads/2022/08/SB-57-veto-msg-August-22-2022.pdf?emrc=435330.
21
Moench, Mallory. “Despite Newsom’s Veto, S.F. Might Push Ahead with Supervised Drug Consumption Sites.” San Francisco Chronicle, August 23, 2022. https://www.sfchronicle.com/bayarea/article/Gov-Newsom-vetoes-bill-allowing-supervised-drug-17390653.php.
22
Wakeman, Sarah E., Marc R. Larochelle, Omid Ameli, Christine E. Chaisson, Jeffrey Thomas McPheeters, William H. Crown, Francisca Azocar, and Darshak M. Sanghavi. “Comparative Effectiveness of Different Treatment Pathways for Opioid Use Disorder.” JAMA Network Open 3, no. 2 (February 5, 2020): e1920622. https://doi.org/10.1001/jamanetworkopen.2019.20622.
23
Oviedo-Joekes, Eugenia, Bohdan Nosyk, Suzanne Brissette, Jill Chettiar, Pascal Schneeberger, David C. Marsh, Michael Krausz, Aslam Anis, and Martin T. Schechter. “The North American Opiate Medication Initiative (NAOMI): Profile of Participants in North America’s First Trial of Heroin-Assisted Treatment.” Journal of Urban Health : Bulletin of the New York Academy of Medicine85, no. 6 (November 2008): 812–25. https://doi.org/10.1007/s11524-008-9312-9.