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Reclaiming the Public Square of Opioid Addiction Treatment

Updated: Nov 2, 2021

Drug Use

The public square in American history can trace its roots to ancient Greece. Amidst the city-states that arose on rocky Mediterranean islands, Greeks developed the concept of the agora — a central “meeting place” that served as the “heart and soul” of the polis. According to one prominent archeologist, the agora was a “multivalent gathering place,” defined by both physical boundaries and the vigorous debate of competing viewpoints within those same margins.

This model spread throughout western Europe and colonists brought the concept to North America. On the eve of the American Revolution, passionate men and women of all classes and creeds debated politics, natural rights, and personal freedoms in central areas like Boston Commons and New York City’s Bowling Green. As one proponent put it, the “public square is the place where Americans — in all of our rich diversity — promote the general welfare, achieving as a community what we never could do as private individuals.”

In 2021, the American public square is as much metaphorical as physical. People do not need architectural commons areas or actual soapboxes to debate modern issues. Technology allows differing viewpoints to travel the world in milliseconds and the prevalence of social media blurs the line between expert and enthusiast.

In recent years, the theory of harm reduction has taken over the public square of the addiction treatment debate.

One vociferous proponent of harm reduction is Maia Szalavitz, a journalist focused on the intersection of science and public policy as it relates to the treatment of addiction. Szalavitz is a talented writer, who has published dozens of pieces in publications such as Elle, Salon, Redbook, Newsweek, the New York Times, and The Washington Post. In her most recent book Undoing Drugs: The Untold Story of Harm Reduction and the Future of Addiction (2021), Szalavitz posits that “harm reduction provides reason for hope…and it provides a way of understanding behavior and culture that has relevance far beyond drugs. Harm reduction is an important guide to all types of policy. It’s really a philosophy for living.”

On July 23, 2021, Szalavitz published “How Drug Users Developed a Key Approach to Fighting Covid” in the New York Times, which links the preventative measures taken by most Americans during the coronavirus pandemic to the hard-learned lessons of the AIDS crisis in the 1980s and 1990s. This article epitomizes how harm reduction proponents skew public debates on opioid addiction treatment.

She begins with an anecdote from her past. In 1986, Szalavitz was addicted to heroin, at a time when 50 percent of the New York intravenous drug-using population was infected with HIV. A friend taught her to bleach her hypodermic needles to stave off infection. According to Szalavitz, this friend “was guided by an innovative philosophy now called ‘harm reduction.’” This advice helped keep Szalavitz alive until she recovered from her opioid addiction, and she believes others can and should follow a similar path.

In support of her conclusion, she links the successes of harm reduction in two historic epidemics: HIV/AIDS and COVID-19. During the first decade of the HIV/AIDS epidemic, harm reductionists pushed recalcitrant politicians to approve needle exchange programs as a way of lowering instances of infection. The idea was simple enough, intravenous drug users could exchange used and potentially shared needles for new ones, in safe and sanitary locations. By eliminating the need for needle sharing you could lower the risk of infection significantly. Politically, this was a non-starter for many elected officials who supported hardline policies such as complete abstinence and criminal prosecution for drug use.

Militant advocates for HIV/AIDS treatments would not accept this political position. In 1990, for example, protestors from the AIDS Coalition to Unleash Power (ACT UP) instigated arrest by dispensing clean needles to addicts. At the time, it was illegal to possess hypodermic needles without a medical prescription. Eight defendants won at trial and forced New York to decriminalize the possession of hypodermic needles.

Thirty years later, Szalavitz argues, these efforts helped epidemiologists and elected officials create harm reduction policies during the outbreak of COVID-19. Mask wearing, social distancing, and frequent hand washing are simple, harm-reducing tactics designed to lessen the spread of this infectious disease.

In both cases, harm reduction helped save lives. Needle exchanges lessened the transmission of HIV in vulnerable communities and mask-wearing and distancing prevented millions from contracting COVID-19 worldwide. For Szalavitz, the lesson of this recent history is clear: harm reduction is a compassionate solution to today’s opioid epidemic.

“Rather than seeking an unattainable ‘drug-free world,’” Szalavitz writes, “harm reductionists focus on reducing drug-related damage. People always have and always will take drugs, they argue. A better approach is to target harm, not highs.” This is a noble goal that stems from a faulty premise. In this logic, addiction and drug use is an incurable disease and the best we can do (and what we should focus on) is mitigating harm to drug users.

This position ignores the very history that Szalavitz claims to appreciate. In both the HIV/AIDS and COVID-19 epidemics, health advocates used harm reduction as a tourniquet — an immediate response designed to prolong lives in the near term. Harm reduction was not the answer to HIV/AIDS nor COVID-19. It was a way to buy time until a medical solution could be researched and developed.

In 1990, the same year they courted arrest by giving out clean syringes to drug users, ACT UP activists stormed the offices of the National Institutes of Health (NIH) in Bethesda, Maryland. Their target was Dr. Anthony Fauci, the director of the National Institutes of Allergy and Infectious Disease (NIAID). On May 21, 1990, roughly 1,000 AIDS protestors occupied the NIH campus, some carrying signs that said “F*** You, Fauci.” In this case, their goal was not the publicization of needle exchange efficacy. Instead, they demanded access to experimental HIV drugs and a voice in recent medical research debates on the disease.

At the time, HIV was the number one cause of death of Americans aged 25–44 and ACT UP knew more could be done to treat this disease. “There was a feeling by ACT UP and others that [drug trials] needed to be more open to the communities that were dealing with AIDS at the time,” ACT UP’s Mark Harrington explained. “Some of us wanted to participate in the scientific discussions and decisions that got made.” ACT UP soon got their wish.

A month later, Fauci and ACT UP leaders spoke at the International Conference on AIDS in San Francisco, and they stressed the common goals of medical researchers and AIDS activists. Fauci invited ACT UP advocates to serve on research committees within NIH and as advisors at clinical trial locations throughout the United States. According to ACT UP activist David Barr, “that had never happened before in the history of the NIH and it was a model that was replicated in other disease areas.”

Since 1990, researchers have developed more than 30 HIV medications in about six distinct classes designed to treat the deadly disease and prevent its transmission. More importantly, there were virtually no barriers in accessing these medications and the treatment was firmly rooted within medicine. While there is still no cure for HIV/AIDS, most patients can now live full and active lives due to these medical breakthroughs. Why is that militancy lacking in the field of opioid addiction? We have exactly three medications approved for the treatment of opioid addiction and patients must navigate barriers to access two out of the three medications.

Likewise, the harm reduction mandates associated with the COVID-19 outbreak were a stopgap measure designed to bridge the period between the outbreak of the global disease and the development of effective vaccines. In 2020, as researchers raced to create a successful vaccine for the disease, Fauci (still the director of NIAID) called simple facemasks the “low-tech” yet “flagship” protection against COVID-19. Following the development of several vaccines, however, Fauci stressed that “if we want to crush this outbreak, we need to get the overwhelming majority of the United States population to get vaccinated.”

Harm reduction was not the endpoint for HIV/AIDS nor COVID-19 advocacy, and it cannot be the stopping point in the treatment of opioid addiction. Szalavitz believes that harm reduction should be the “cornerstone of drug treatment” and would lead to a “healthier, happier and more equitable world.” Yet, her own statistics bely her point. Szalavitz says that needle exchange participants are five times more likely to begin addiction treatment than other drug users, proving that harm reduction amongst users is a bridge toward medical treatment. This is what we need to focus on, what needs to be the cornerstone of American drug policy. Harm reduction does prolong lives among opioid users. Naloxone can reverse overdoses and needle exchanges can prevent the transmission of infectious diseases. Harm reduction, however, does not cure the disease of addiction.

Medical treatment of opioid addiction exists, but further advocacy and research are still needed. In the case of opioids, the “vaccine” is naltrexone, which acts like the “antibody” that blocks opioid receptor sites in the human nervous system and prevents the “antigen” opioids from causing any harm to the patient. The harm reduction folks act irresponsibly by not offering enhanced harm reduction with methadone and buprenorphine and harm elimination/avoidance with naltrexone.

In 2021, when opioids are seemingly everywhere and overdose deaths topped 90,000 annually for the first time in history, it is highly irresponsible to promote harm reduction as the cornerstone of drug policy. We have highly effective medications, like methadone, buprenorphine, and naltrexone available for medical treatment and we need to talk more about creative ways to break down the barriers preventing patients from accessing these medications.

We certainly need greater advocacy for drug addiction patients, hopefully leading to the research and development of newer, even more, effective medicines for drug addiction. ACT UP showed the efficacy of militant advocacy in the 1990s, which led to the development of dozens of HIV/AIDS medications and expanded the use of some of these medications for preventing infection. There is much we can learn and adopt from the amazing success in dealing with the AIDS epidemic. We need more than three drugs in this effort. Most importantly, we need to take back the public square and make medical treatment for addiction the focus of American drug policy.

Percy Menzies, M. Pharm. is the president and founder of the Assisted Recovery Centers of America (ARCA), an integrated medical clinic based in St Louis. He can be reached at:


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