How Key Early Ideas Helped Shape Today’s Harm Reduction Movement

    [This article is excerpted from UNDOING DRUGS: The Untold Story of Harm Reduction and the Future of Addiction, by Maia Szalavitz. Copyright © 2021. Available from Hachette Go, an imprint of Hachette Book Group, Inc.


    At the Oakland Convention Center in 1996, the first national conference of the Harm Reduction Coalition opened with an enthusiastic call to action by Allan Clear, the group’s new executive director. A British photographer who had immigrated to New York in the early ’80s, he’d helped found ACT UP’s illegal needle exchange on the Lower East Side—and had headed up that organization as it transitioned into a successful independent nonprofit. Initially a 12-stepper, he’d come to the movement via his own recovery from alcoholism. He was excited by the big turnout.

    “This is a historic meeting,” he said. He described HRC’s work, saying that its vision came from people who knew there was an alternative to the maltreatment that marked so much of American drug policy. The group’s goal, he said, was to make harm reduction into national policy for drugs and drug users.

    Clear described how isolating it could be to be one of a tiny number of people trying to fight against both AIDS and the drug war. Many attendees had not previously met more than one or two others who shared their views, except perhaps online. Simply being together in one place with hundreds of like-minded people was electric. One of the other organizers of the conference remarked that the team was simply amazed that they’d managed to bring off the event at all. They were astonished that so many people had shown up.

    Next to speak was Dave Purchase, the Tacoma needle exchange innovator and co-founder of the working group, which had made the conference and HRC itself possible. After riffing on how hard it could be to define harm reduction concisely, he went on to sum it up in a single sentence. “Harm reduction is against harm, neutral on the use of drugs per se, and in favor of any positive change as defined by the person making the change,” he said.

    Cautioning practitioners that they needed to be just as sure to be kind and nonjudgmental to themselves and each other as they aimed to be with their clients, he emphasized the importance of pleasure. “[H]arm reduction—being logical, practical, right and effective—is more enjoyable than following a path that leads nowhere and supporting ‘laws’ of behavior that do not work. Harm reduction is fun, and fun is what I suggest you [have] here.” From the fact that so few people can remember any specific details of the conference, I am certain that many people followed this advice.

    Edith Springer’s subsequent talk covered many of her key themes, exploring the difference between the all-or-nothing abstinence approach and the more gradual view of change embodied in harm reduction. She stressed that most current treatment fails to treat patients respectfully. And she emphasized how dangerous this can be, noting that in clinical training, therapists are taught never to try to break down people’s defenses before alternative coping skills are in place. When this is done— as it so frequently is in rehabs and therapeutic communities—she noted, “we run the risk of causing the person to decompensate and become worse off than … he or she was before.”

    Imani Woods—whom Springer had described as her most difficult student ever—followed her mentor and teacher up to the podium. She was all-in on harm reduction now, but that didn’t mean she completely disavowed her past.

    “I’m here to represent all of us who believe in abstinence,” she began defiantly. “That’s where I come from: abstinence. Years ago, when I would come into a room and hear someone say ‘harm reduction,’ I said, ‘You must be crazy.’”

    “I had to ask myself: ‘What about the other 90 percent? What about the 90 percent for whom abstinence didn’t work?’”

    Proudly stating that she’d grown up in Bedford-Stuyvesant and citing Malcolm X’s guidance about how it is okay to admit that you have been wrong, she described her previous self. “I was one of those dogmatic counselors, you know, ‘I came up the hard way and so can you.’” When HIV began devastating the Black community, however, she began to question this approach. “What is more important? That people stay alive or that people not use drugs?” she asked. “And then I heard Dave Purchase say, ‘Dead junkies can’t get clean.’”

    At the same time, Woods began to examine the outcomes of her own counseling work, recalling how she and her co-workers often told their clients that fewer than one in 10 of them would genuinely succeed at quitting drugs. “I had to ask myself the simple question: “What about the other 90 percent? What about the 90 percent for whom abstinence didn’t work?”

    She went on to explain how hard it was, specifically, for people of color to buy in to harm reduction. She noted the actual harmful effects of drugs like crack on families as well as issues of respectability and racist enforcement. She said, “Let’s be realistic. It’s a whole different ballgame when we’re talking about Black folks and Latin folks. Because the effects on the community are different … Our community, we see drugs as a barrier. It keeps us away from all that good stuff like family life, ambition, achievement and so on.” White drug policy reform advocates, in their efforts to distance themselves from drug-war scare tactics, had often minimized this.

    Addressing white people specifically, she said, “I must tell you: Y’all use most of the drugs. Y’all just don’t go to jail … we’re the ones who end up going to jail. When you go into the Black community and talk about harm reduction, you got a whole other ball of wax to deal with. All people can tell you is, ‘Reduce this! Reduce these police taking me to jail…’”

    Woods ended her talk with a call for unity, noting that there would undoubtedly be many arguments and clashes along the way. “Everybody thinks they’re right, including me,” she said. “With all that, you know it’s going to be a mess. But if we don’t do it, nobody’s gonna do it. Somebody’s got to make the change.”

    Other movement stars like Dan Bigg and Joyce Rivera also spoke, and there were sessions related to medical marijuana, which had just been legalized in California and was an issue that could get people who hadn’t really thought about drug policy to recognize how it did harm. Also, at least two high-ranking police officials, from Connecticut and California, spoke, advocating gentler policies like diversion to treatment rather than incarceration. Later, the question of whether law enforcement could ever practice genuine harm reduction would cause conflict. But at first, the movement welcomed all comers and deliberately brought disparate and sometimes clashing views together. To make change, harm reductionists would at the very least have to know how to engage with the mainstream.


    Alan Marlatt’s Trojan Horse

    [Psychologist] Alan Marlatt’s talk covered his own work with alcohol—highlighting the controversy over whether people with severe alcohol problems can ever learn to moderate or “control” their drinking. This acrimonious debate neatly paralleled the fight for needle exchange for drug injectors. Just as traditional treatment providers had argued that drug injectors couldn’t improve their health without kicking drugs first, they also claimed that no positive change could occur for those with alcoholism without total abstinence. And by showing that alcohol behaves just like other drugs, Marlatt helped dramatically expand the scope of the movement. That’s because, while less than 2 percent of Americans regularly inject drugs, at least 70 percent of the population has had at least one drink in the past year.

    Illustrating these parallels to expand the reach of harm reduction was a deliberate strategy. Marlatt knew that “undoing” drugs was essential to the mission: If alcohol isn’t seen as the drug that it is, its many users can easily dismiss “druggies” as some alien group whose experience is completely unlike their own. The spectrum of substance use must be seen in its entirety, so that we can recognize that it is indeed universal, across cultures and time.

    Years later, Marlatt would tell his students explicitly that he saw alcohol harm reduction as a Trojan horse: a way to get people to take in the key ideas of the movement without immediately raising their defenses about their implications. He told one postdoc, “When I started doing this work, I had a feeling that harm reduction was the right way forward, but I knew people weren’t ready to hear that message.” And so he worked first on more acceptable approaches. One behavioral therapy that he developed became known as “relapse prevention.” This would, surprisingly, be quite rapidly incorporated into most 12-step/Minnesota Model treatment programs, albeit in somewhat adulterated form. The idea was to understand what experiences might “trigger” relapse and learn ways to manage these risky situations while staying abstinent.

    Of course, relapse prevention, by its very name, does not threaten the supremacy of abstinence, since the whole point is to help people maintain it. However, it also includes information on how to minimize damage in the extremely common event of a slip—aka harm reduction.

    Marlatt’s support for what became known as “controlled drinking” stirred far more conflict.

    In fact, one of its key concepts is the “abstinence violation effect,” or more colloquially, the “fuck it” response. This refers to the idea that once you’ve had one drink or broken your diet or otherwise lapsed, you may as well continue since you’ve already blown it. Research shows that having this belief, especially if you also see yourself as “powerless” once you start engaging in the behavior you are trying to change, leads to more severe relapses. The phenomenon could be seen during the early days of AIDS, when without good information about risk, gay men would alternate between celibacy and sexual extremes. It recurred during COVID, when, again, people with little good information on moderating risk flip from going overboard with measures like double-masking and seeing no one to simply taking no precautions at all.

    In contrast to the relatively widespread acceptance of relapse prevention therapy, however, Marlatt’s support for what became known as “controlled drinking” stirred far more conflict. The idea that some addicted people can return to moderation is far more threatening to the core idea of the Minnesota Model, which is that 12-step abstinence is the only—or, at least, the best—way to recover. Both relapse prevention therapy and the controversy over controlled drinking, however, ultimately helped spread harm reduction into whole new areas of addiction research and practice.

    At the first harm reduction meeting, Marlatt described the colorful history of the cultural war over controlled drinking. The drama—in which he himself played a part—involved claims of research fraud, Congressional and university investigations, and the firing of a leading treatment doctor who was seen to be on the wrong side. There were arguments over who was to blame for a drunk driving crash that killed two people. At one point, Marlatt even received death threats.

    The first round, he explained, took place in the late ’70s and early ’80s. In 1973, two researchers, a husband and wife team, published controversial data on alcohol moderation. Mark and Linda Sobell had found that training people with severe alcoholism to control their drinking led to better life outcomes and functioning, compared with abstinence treatment. And in a three-year follow-up, the results remained consistent: The controlled drinking program was superior.

    This, of course, made abstinence supporters crazy and furious. It was simply not supposed to be possible for anyone with alcoholism, especially not severe cases, to cut back rather than abstain—just as people who inject drugs were seen as incapable of reliably using clean needles or moderating their use. Marlatt’s lab research had undermined the idea of “powerlessness after the first drink.” But the Sobells’ work put the terrifying notion into practice with real people who were undergoing addiction treatment. Minnesota Model supporters and many 12-step group members thought that the research simply couldn’t be true.

    And so the data and the researchers were attacked in a massive media blitz culminating in a 1983 60 Minutes investigation. A dramatic portion of the show included footage shot at the graves of several of the study’s participants. The expose was based on a 10-year follow-up of the controlled drinking study, conducted by a different set of authors. To top it off, this new research was published in one of the most prestigious journals in the world, Science.

    In their media appearances, the follow-up authors revealed that four out of 20 participants in the controlled drinking group had died, a full 20 percent. Before the Science paper was even publicly available, they claimed that the Sobells had faked their previous publications and lied about the positive outcome data for the earlier years of the study. And this deceit, they implied, had been fatal.

    “Beyond any reasonable doubt, it’s fraud,” one of them told the New York Times. The actual journal article was more cautious in its claims: Science’s lawyers had almost certainly toned down its shrill language about the Sobells for fear of being sued for libel. Ultimately, whoever made these changes would deserve every bit of their paycheck.

    When the truth finally came out, it was shocking, particularly given the zeal with which the Sobells had been attacked.

    At first, however, the coverage was positive. Other media proclaimed that Science and 60 Minutes had revealed a deadly scandal, in which the Sobells had essentially killed some of their research participants. AA was right: People with alcoholism could never achieve control over their drinking. Soon the Sobells were subject to a research integrity investigation by their employer. They were also investigated by Congress, because the National Institutes of Health had funded the study. Marlatt, who was a friend of the couple and had been given access to their data during the investigations, stood by them.

    And when the truth finally came out, it was shocking, particularly given the zeal with which the Sobells had been attacked. First—and astonishingly, given the journal’s reputation—Science had made a freshman-level research error when it published the attack paper. The article only included 10-year outcome data for the moderate drinking group, not for the control group, who had received typical abstinence treatment. Without 10-year data from the comparison group, the claim that the Sobells had done harm was unsupportable.

    In fact, as it turned out, the abstinence group had done even worse. Six of these participants had died, compared to the four who died after the Sobells’ treatment. And all of those who died had also tried abstinence programs after the moderation treatment had failed. Clearly, neither approach had been especially successful in these severe cases. However, the Sobells had not faked anything. All of the investigations exonerated them. They had not been the ones who’d made dishonest claims.

    When Marlatt wrote about the controversy in 1983, he noted that of the 22 then-published controlled drinking studies, 21 had found that it worked, producing successful outcomes in around 65 percent of participants who were followed for at least a year. Little of this background had been mentioned in the media. And research since then has only continued to support the idea. Indeed, by 1990, the highly respected Institute on Medicine—in a report that Marlatt coauthored—recommended that alcohol treatment programs across the US expand to include options like moderation. That’s because, even though people with the most severe alcohol problems are less likely to succeed at moderation, most cases of alcohol use disorder do not fall into that category. It’s also because when people choose their own treatment goals, they do better.

    Incredibly, however, when the issue came to public attention again in 1995, it replayed almost identically. I had a small role in the resulting skirmish, when I wrote an article for New York magazine that was wildly misinterpreted. Marlatt had tried to calm the media storm that resulted.

    My piece had been intended to highlight the progress made by a prominent Minnesota Model program in New York, which had added an evidence-based controlled drinking option for those who didn’t agree to its abstinence approach. Instead, what I actually wrote was ignored and my story was interpreted as having claimed that the program no longer supported abstinence at all. The resulting panicked attention from the New York Times and elsewhere led to the firing of the program’s director, basically for providing therapies supported by the most prominent and respected national experts on the research!

    To make the controversy even more intense, around the same time, the woman who had founded a self-help group aimed at teaching controlled drinking, known as Moderation Management, relapsed. She drove drunk and crashed, killing a father and his 12-year-old daughter. When she was arrested, her blood alcohol level was three times the legal limit. Most journalists assumed that the conclusion to be drawn from this catastrophe was self-evident: Surely, here was proof that it was unethical for alcohol treatment and self-help groups to do anything but demand full abstinence.

    But again, a big element of the story was simply ignored in most of coverage. The founder of Moderation Management had written explicitly in its literature that if moderation fails, people should go to AA or other abstinence programs instead. And indeed, two months before the crash, she’d started attending AA regularly. As a result, her story could just as easily have been used to illustrate the failure of AA—if that’s how journalists had wanted to play it.

    Throughout the ’80s and ’90s, this was the hostile climate harm reductionists faced, whether they were working with alcohol or other drugs. The media reflected the culture—and it was deeply committed to abstinence. When recovery was shown—whether in the news, on stage, in films, on TV—it was almost always via the 12 Steps. Indeed, 12-step programs were so popular in the early ’90s that a major film, The Player, had a storyline about Hollywood producers who didn’t have drinking problems going to AA—because that’s where the deals were being made. Around the same time, New York magazine suggested that AA was so hot that single non-alcoholic women should go there to meet men.

    The 1994 suicide of grunge god Kurt Cobain had been immediately preceded by a tough-love intervention.

    Celebrities touted the program; when they went to rehab it was Betty Ford or Hazelden or Eric Clapton’s program in the Caribbean, all Minnesota Model. When journalists tried to write or broadcast stories about other approaches, the response of editors was often dismissive or the piece would be played as a contrarian novelty, not exactly to be taken seriously.

    Just as journalists tended to see support for the War on Drugs as “objective” because both political parties favored it, the media also tended to reflexively favor 12-step abstinence—again, because alternatives were just not visible to the mainstream. Marlatt helped change that.

    Engaging with pop culture, he wrote about how the 1994 suicide of grunge god Kurt Cobain had been immediately preceded by a tough-love intervention, arranged by his then-wife, Courtney Love. Living with chronic pain, Cobain couldn’t face the idea of total abstinence, but quitting all opioids, including methadone, was presented as his only option for recovery. This made him feel even more hopeless. And as the connection between his death and the lack of harm reduction options became clear, Cobain’s record label planned to support a “Come as you are” harm reduction center in his memory, to be led by Marlatt. (Unfortunately, when the company was sold, these plans fell through.)

    Further, one of his colleagues noted that Marlatt’s work on college drinking alone “made harm reduction the paradigm in college health”—at least insofar as the counseling they receive. (Campus alcohol policy is another story.) Marlatt’s relapse prevention program was also one of the most important conduits of harm reduction ideas into traditional addiction treatment.


    Ram Dass and Questions of Identity

    The final speaker at the first harm reduction conference, fittingly, was the psychedelic guru Ram Dass. In his pre-drug life, he’d been known as Richard Alpert and was an assistant professor of psychology at Harvard. Working with Timothy Leary, he’d conducted some of the earliest research on LSD, psilocybin mushrooms and spirituality in the early ’60s.

    Critically, Dass helped develop the concept of “set and setting,” which is important in many types of harm reduction. Originally, this was the idea that psychedelic experience is determined not just by a drug’s pharmacological effects, but also by the user’s emotional state and expectations and the cultural and physical environment where the drug is taken. Understanding set and setting is important because it allows people to recognize dangerous situations for psychedelic use and avoid them.

    But the concept has also been highly influential beyond hallucinogens, because it turns out to apply to all substances: for example, the effect of alcohol expectations that Marlatt found studying drinking. And within harm reduction, a movement focused specifically on psychedelic drugs developed in conjunction with other organizing, starting in Liverpool and Manchester’s ecstasy rave scene, during the late 1980s and early ’90s.

    Dass’s own psychedelic experience, which led him to visit India and become a spiritual leader, had made him intimately familiar with the harms related to the War on Drugs. In his talk, he noted the importance of listening to people who take drugs when setting policy related to them. “I look at harm reduction as relieving the maximum amount of suffering,” he said.

    Answering the question “Who speaks for drug users?” would be at least as tricky as trying to redefine addiction and recovery.

    Then he went on to make a more subtle but just as important point. Explaining that lack of human and spiritual connection causes much of our pain, he noted that a great deal of this suffering is linked to our attachment to specific identities and the social status we believe we get from them. This attachment can cause serious problems, especially within political movements like harm reduction.

    “It’s perfectly fine if you are an administrator to administrate,” he said. “Just don’t get caught in thinking you are an administrator … If you are a junkie, God bless you, but don’t get caught in being a junkie! It’s not interesting enough, there is no role identity which is that interesting.” He added, “If you are recovering, recover, by God, recover! But don’t get caught up in the drama of being a recoverer.”

    This wisdom about identity would be greatly needed as harm reduction grew. In order to center people who use drugs, the movement had to come up with a way to determine who could legitimately speak for such people. Was it only people who injected drugs? What about abstinent former users—or those who took psychedelics? A group fighting for the human rights of drug users clearly shouldn’t be dominated by those without drug experience. However, if people’s social status within harm reduction relies on their continued use of dangerous substances, that could also obviously pose problems.

    Here was yet another situation in which the concept of drugs had to be deconstructed. Answering the question “Who speaks for drug users?” would be at least as tricky as trying to redefine addiction and recovery.



    Top photograph by Rohan Makhecha on Unsplash

    UNDOING DRUGS: The Untold Story of Harm Reduction and the Future of Addiction, by Maia Szalavitz. Copyright © 2021. Available from Hachette Go, an imprint of Hachette Book Group, Inc.

    • Maia is a neurosicience journalist and the author of Undoing Drugs: The Untold Story of Harm Reduction and the Future of Addiction, published by Hachette Go in 2021.

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