Beyond Harm Reduction: Encouraging Positive Drug Use

2 months

A traditional anecdote tells of a congressman answering a constituent’s inquiry about his position on alcohol. “If you mean the demon drink that poisons the mind, pollutes the body, desecrates family life and inflames sinners, then I’m against it,” he replied. “But if you mean the elixir of Christmas cheer, the shield against winter chill…then I’m for it. This is my position and I will not compromise!”

Going back a few centuries, Puritan minister Cotton Mather, remembered for his work in smallpox inoculation and the Salem Witch trials, considered alcohol as “a good creature of God,” but also believed that “the abuse of drink is from Satan.”

Any mature, societally useful consideration of substances must reflect that there are no demon drugs and no elixirs.

The full-out demonization of alcohol in our country came later, introduced by the 19th-century Temperance Movement, which still lives with us. Temperance invented the idea that a substance can control your behavior, fate, and identity in regards to alcohol; only at the turn of the last century was this belief applied to heroin and other drugs.

Any mature, societally useful consideration of substances must reflect that there are no demon drugs and (despite some advocates’ contentions) no elixirs. All drugs have benefits and harms depending on how they are used. Our project must be to amplify the former: to turn drug use, in which all of us engage and always will, into a personal and social asset.

America’s Jekyll-and-Hyde ambivalence about alcohol readily spread to drugs in the last century. From the 1914 Harrison Act to the present the United States has undergone repetitive cycles of drug scares. As Jacob Sullum describes this social process, “The history of drug control in America is a series of panic-propelled policies.” As one example of this transference, Carl Hart traces the meth scare of the last decade back to the crack panic of the 1980s and ‘90s.

Joe Biden is one of the politicians still apologizing for the special penalties for crack introduced in that period, with severe and racially disproportionate outcomes. Rest assured, he and others will have plenty more to apologize for in decades to come. Fentanyl, the demon drug du jour, is one focus of current pressures to increase penalties.

The Cost of Demonization

The argument against modern American fear and scapegoating of drugs is readily observed through examples of population-level drug harms.

In the mid-2010s we witnessed opioid deaths rise rapidly while public alarm around opioid use was reaching the flashing-red-light stage, leading to a radical decline in painkiller prescriptions.

At the same time, we can note that substance use disorders/addiction and drug-related deaths are extremely rare among patients who are prescribed opioids. These harms are instead overwhelmingly associated with chaotic drug use and mixing of drugs by people who obtain opioids illicitly.

Our increasingly stringent approach to opioids has thus paradoxically made the beneficial use of opioids less likely while increasing harmful use (often mixed with other drugs), primarily among disadvantaged people.

We are currently observing the same scenario unfold with amphetamines. People who are prescribed Adderall (chemically practically identical to methamphetamine) are experiencing medication shortages and discrimination. Correspondingly, illicit methamphetamine use and associated harms are increasing.

The story is the same in the realm of nicotine policy, where myriad recent government interventions to restrict access to vaping products have slowed, and threaten to reverse, long-term declines in smoking.

Must there always be at least one evil drug looming on the American horizon for law enforcement and politicians to rail against, with many public health advocates joining the chorus?

Somehow, these trends continue despite “PR-savvy law enforcement messaging about a public health response to mitigate the toll.”

Must there always be at least one evil drug looming on the American horizon for law enforcement and politicians to rail against, with many public health advocates joining the chorus? Of course, few in these groups would dare to be seen as insufficiently damning of drug use, what with people dying.

Deaths are occuring, including, as recently headlined around the media, with alcohol. But why is that?

A bifurcated response by different segments of society has led to seemingly paradoxical outcomes: Kids and Americans at large are drinking less; yet more people are dying from alcohol-related causes. As the New York Times noted in January:

The death rate tied to alcohol rose 51 percent overall [from 1999 through 2017], taking into account population growth …

Like much research of its kind, the findings do not alone offer the reasons behind the increase in alcohol deaths. In fact, the data is confounding in some respects, notably because teenage drinking overall has been dropping for years, a shift that researchers have heralded as a sign that alcohol has been successfully demonized as a serious health risk. [My emphases.]

The Stratification of Substance Users

How is this split between level of use and experienced harm possible?

First, consider that different groups—religious, social, ethnic and economic—display different drinking behaviors and attitudes. For example, Mediterranean (and Catholic) cultures are more likely both to drink and to drink moderately, with Protestants occupying the opposite positions.

High-income, highly educated Americans are also more likely to drink than their less privileged counterparts. However, research finds “the latter group seems to bear a disproportionate burden of negative alcohol-related consequences.”

Marginalized populations, it seems, are more likely to internalize negative, self-fulfilling images of drugs thrust upon us by government and media. This makes sense when we compare, for example, portrayals of drug use and harms in urban communities of color with those of whiter, richer suburbs. And rather than protecting these populations, the panic exacerbates the inequalities they suffer as expressed through disproportionate harms relating to alcohol, nicotine and other drugs.

Meanwhile, as Americans in general are drinking less, they are more likely to binge drink. This phenomenon is similarly noted across Europe. Northern European cultures create more negative images of drinking, drink less, but then drink in binges. This contrasts with Southern European cultures. In the words of Italian researcher Allaman Allamani;

“In the Northern countries, alcohol is described as a psychotropic agent … It has to do with the issue of control and with its opposite–‘discontrol’ or transgression. In the Southern countries, alcoholic beverages–mainly wine–are drunk for their taste and smell, and are perceived as intimately related to food, thus as an integral part of meals and family life. . .[so that drinking] is not connected to the topic of control.”

In Southern European cultures, which experience far fewer alcohol-related harms, alcohol is typically consumed with meals, in multi-generation, gender-mixed groups, and with explicit norms that emphasize, per Allamani, that alcohol is not to be used as an excuse for misbehavior.

Rather, positive drinking involves regular, moderate consumption that complements social interactions, enjoyable activities and life purpose. The Allamani/Mediterranean model (practiced as well by other groups of positive drinkers) confers benefits at psychological, social, and whole-population health levels.

This model of normalization would, and in certain instances does, apply to positive use of every substance that humans choose to use—albeit the safety picture for illegal drugs is clouded by the supply-side dangers inherent to prohibition.

What are the chances that American public health will encourage healthy drinking practices (let alone utilizing such practices for currently illegal drugs)?

For the foreseeable future, I would say nil, as US epidemiologists have joined with those from other Temperance cultures in classifying any drinking as putting people at risk—that’s right: WHO epidemiologists have declared zero to be the ideal level of alcohol consumption.

This recommendation flies in the face of research which consistently shows that—by far—the most common reason people give for consuming alcohol is that drinking is pleasurable. And pleasure is a priceless human benefit, despite its blacklisting by drug researchers.

Enjoying Drugs

The US has never learned that demonization of substances is a bad public health message. It encourages abstinence by the obedient and the vulnerable. But the latter, with higher psychosocial stressors, are especially prone to fall off the wagon (or never get on it), leading to the very worst outcomes, up to and including death.

The alternative would be a happy societal embrace of appropriate, medically desirable or personally enjoyable substance use, without oppression or stigma.

Impossible to guarantee such balance, you say?

Fine, but then don’t claim to trouble yourself about the death rates and harms that devastate our most vulnerable socioeconomic groups.

Replacing “harm reduction” for drugs with “pleasure enhancement” would be the most effective harm reduction measure of all.

Nicholas Kristof and Sheryl WuDunn, in their new bestseller Tightrope: Americans Reaching for Hope, graphically describe the decimation of “working-class men and women of every shade [who] increasingly are dying ‘deaths of despair’—from drugs, alcohol and suicide.”

These authors rightly decry the lack of economic investment in such populations. At the same time, they vilify the “explosion of drugs—oxycodone, meth, heroin, crack cocaine and fentanyl—aggravated by the reckless marketing of prescription painkillers by pharmaceutical companies.”

What Kristof and WuDunn fail to realize is that the focus on drugs is itself the cause of the drug war, which they also decry for its disproportionate impact on deprived populations. Moreover, money has over decades explicitly been diverted from social programs and used instead for drug control, prevention and treatment.

Instead, our resources could best be used in support of people’s lives through education, housing and healthcare. This is exactly what Kristof and WuDunn call for to reverse the downward life spirals of people that they so movingly document. But their demonization of drugs works in exactly the opposite direction of their stated goal.

One European college student attending an American university wrote me (as quoted in my book Addiction-Proof Your Child) about what moderate, pleasurable drug users have to teach us:

“I know quite a few parents who smoke marijuana or do an occasional line of coke, keeping such use secret from their children. But is it better that, given their own moderate use, they proffer their own drug-related behaviors as models, in case their children ever do drugs? This is of course a controversial suggestion. Still, having lived in a country where some drug use was decriminalization [this was in 2007], I believe that seeing adults use marijuana or ecstasy occasionally while maintaining their jobs, families and hobbies was a decisive factor in my own liberation from the idea that drugs are inevitably addictive and my own faith in moderation.”

This would mean replacing “harm reduction” for drugs with “pleasure enhancement”—which, let’s be clear, would be the most effective harm reduction measure of all.


Photo by Kelsey Knight on Unsplash.

Stanton Peele

Dr. Stanton Peele is a psychologist who has pioneered, among other things, the idea that addiction occurs with a range of experiences and recognition of natural recovery from addiction. He developed the Life Process Program for addiction and has authored many books since the 1975 publication of Love and Addiction (co-authored by Archie Brodsky). His latest book (with Zach Rhoads) is Outgrowing Addiction: With Common Sense Instead of “Disease” Therapy.

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