Hitting Bottom on the Politics of Punishment: Needle Exchange and the Costs of Inaction

I think it’s time for harm reduction advocates to reclaim the word “enabling.” True confession: I got into harm reduction to enable people who use drugs. I enable them to protect themselves and their communities from HIV and hepatitis C and overdose. I enable them to feel like they have someone to talk to, someone who cares, someone who respects them and their humanity. I enable them to ask for help and to help others in turn. I enable them to find drug treatment and health care, to reconnect with their families, to rebuild their lives. And I enable people who use drugs to take personal responsibility for their health and their futures. If that makes me an enabler, I’m proud to claim that term.

But in a lot of addiction rhetoric, enabling is a dirty word akin to aiding and abetting addiction — conspiring with the enemy. It’s based on the creed that a person struggling with drugs has to “hit bottom” and suffer enormous loss and intolerable pain before they’re ready for help. Never mind that research actually contradicts the “hitting bottom” model; too many addiction counselors and self-styled experts still consider it an article of faith and warn us in dire terms against enabling. Does someone in your life have a drug problem, and you don’t want to cut them off, break up with them, fire them, kick them out? You’ll be accused of enabling them by interrupting their trajectory towards hitting bottom.

It’s a cruel philosophy that has caused immeasurable damage, both to people who use drugs and those who love them. Parents, partners and families seeking help and support have been taught the gospel of enabling, held responsible for their loved ones’ addictions, and blamed for their relapses. The taboo against enabling aims to strip away any and all forms of support, compassion, and aid for people who use drugs. Those who preach against the evils of enabling are deeply, almost sadistically, invested in seeing people who struggle with drugs isolated, and punished, as if they’d somehow be purified through suffering. No matter if that punishment takes the form of a fatal overdose — at least nobody enabled them.

The toxic mythology of enabling and hitting bottom seeps into public policy debates, most notably around needle exchange programs. Lawmakers fret that needle exchange is another form of enabling, sending the wrong message and encouraging drug use. 25 years of working in and with needle exchange programs has taught me a different lesson: needle exchange programs restore personal responsibility and enable people to seek help and recover from addiction.

An effective program gives people who inject drugs a chance to take responsibility for their risk of HIV, hepatitis C, overdose and addiction by seeking help and support. This responsibility extends beyond self-interest; in my experience, people who come to needle exchange programs care deeply about protecting the health of their friends and partners, families and communities. The best programs open the door to health care and drug treatment to those who had given up hope and succumbed to fatalism and shame. Needle exchange is our best early intervention for people who inject drugs, before they show up in jail — or the morgue.

This vision of needle exchange gradually seems to be persuading politicians and policymakers in places that have traditionally not embraced harm reduction. In Indiana, an HIV outbreak linked to painkiller injection is upending the traditional politics of needle exchange. Indiana’s Governor Mike Pence spoke of “a commitment to compassion” to justify an executive order making limited allowance for a temporary needle exchange program in Scott County. And last month, Kentucky passed a comprehensive heroin bill which included a provision allowing local health departments to establish needle exchange programs.

Needle exchange had been a major point of contention in 2014, when Kentucky lawmakers failed to pass a similar bill. This year was different: Kentucky’s growing heroin problem and the sustained advocacy of parents’ groups and people in recovery made clear that inaction was unacceptable. In the final hours of debate, one state senator invoked Thomas Aquinas to explain his opposition to the bill’s needle exchange provision. Aquinas praised the use of the death penalty “if a man be dangerous and infectious to the community, on account of some sin.” But the opioid epidemic is leading more lawmakers to reject the notion that death, whether quickly from overdose or slowly through infection, is a fitting penalty for heroin use. The senator’s argument to “let the punishment fit the crime” did not persuade his colleagues, who overwhelmingly voted in favor of the bill on a bipartisan basis.

In Indiana, outside of the county covered by the Governor’s declaration of public health emergency, needle exchange remains otherwise illegal, despite rising heroin use and hepatitis C infections across the state in recent years. Governor Pence has so far rejected calls for broader needle exchange legislation, but should consider the price of inaction. Each of the nearly 90 newly infected people identified so far by Indiana health officials will need to begin lifelong treatment with antiretroviral regimens. In most cases, their HIV care and prescription drug costs will be covered by the government through Medicaid and the Ryan White Program. A recent study found that preventing a single HIV infection saves roughly $230,000 in lifetime medical expenses. In other words, the cost to taxpayers of Indiana’s prevention failure runs to over $22 million. By comparison, in 2008 the combined annual budget of over 120 needle exchange programs across the country was only $21.3 million.

Costs also factored into Kentucky lawmakers’ support for needle exchange, with prescription opioid and heroin injection driving a dramatic rise in new hepatitis C infections. Hepatitis C, like HIV, is a virus transmitted through shared syringes and injection equipment. Northern Kentucky now has the highest rate of new hepatitis C cases in the country, mostly among young people in their 20s. With new hepatitis C treatments priced at over $80,000, the economic case for prevention through needle exchange takes on great salience for states struggling to absorb the costs of these medications in their Medicaid budgets.

Similar financial considerations have led a growing number of conservatives to rally around criminal justice reform. The Right on Crime Initiative has galvanized bipartisan reform efforts by insisting on rigorous accountability and cost-effectiveness standards in sentencing, corrections and public safety. Needle exchange programs fall squarely within these criteria, not only by preventing infections but also by reducing costs and overall drug use. Injection drug use is strongly associated with criminal justice involvement, and indeed several infections in Indiana’s HIV outbreak were identified among inmates of Scott County’s jail. Alternatives to incarceration for people who use drugs are now a cornerstone of criminal justice reform across the political spectrum.

Yet needle exchange still faces deep reservoirs of suspicion and outright opposition. To opponents, needle exchange represents the worst case scenario for so-called government handouts — taxpayer dollars subsidizing (read: enabling) addiction. We have abundant evidence that needle exchange does not increase nor encourage drug use, but the false specter of “enabling” looms over the policy debate. This logic underwrites the federal funding ban on needle exchange programs, championed for many years by former Indiana Congressman Mark Souder. The federal funding ban has starved needle exchange programs of both resources and legitimacy, relegating them to the margins of the health care and drug treatment.

Against these odds, needle exchange programs still managed to dramatically lower HIV rates among drug injectors, and were showing similar success in reducing hepatitis C infections until the opioid epidemic and a resurgence in heroin resulted in a 75% jump in new hepatitis C cases in only two years. This is a clear signal that we need more needle exchange in more places, particularly places like Indiana and Kentucky. And we need them now, before we see more HIV outbreaks.

Perhaps the convergence of compassion and cost-effectiveness will produce a reappraisal of needle exchange policy. In public health terms, the Indiana HIV outbreak is a sign that we may be hitting bottom on the bankrupt policies and ideological stalemates that have held us back. We need more needle exchange because we need to enable communities to take control of their drug problems using all available strategies.

When I spoke recently at a harm reduction summit in Ohio, I described working in a needle exchange program as a little like going to church: it requires humility, faith, and openness to moments of grace. Working on harm reduction policy is a lot like working in a needle exchange program. My deepest hope is that Kentucky’s legislation marks a turning point in our approach to drug use and harm reduction. We are already absorbing the staggering costs — human, financial, and moral — of our rejection of needle exchange. Our families and communities — and all those caught up in the prescription opioid and heroin epidemic — cannot afford to bear the punishment for the crime of our policy failures.



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