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Supervised Injection Facilities and the Morality of Harm Reduction

photograph of discarded syringe on asphalt

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People often support policies that lessen the harms others experience. For instance, proponents of abortion rights often argue that banning abortion does not eliminate abortions, it only makes them unsafe. Some high school sex education programs provide condoms to students to curb the spread of sexually transmitted diseases. Although traditionally alcohol is banned in homeless shelters, some have shifted to a “wet” model allowing residents to use alcohol and in some cases even prescribing alcohol. The rationale here being that it is easier to get one’s sobriety under control in a managed environment and when one has shelter at night.

More recently, some have considered the role harm reduction may play in addressing the U.S. opioid epidemic. According to the Centers for Disease Control, 93,655 Americans died of drug overdoses in 2020, a 30% increase from 2019, and a further 107,622 died of overdose in 2021. One of the leading contributors to this spike in deaths is the increased presence of fentanyl. Because of its potency, lower cost, and addictive potential, fentanyl is often mixed with other powdered drugs or sold in their place. As a result, people who unknowingly consume fentanyl may accidentally overdose, not realizing the strength of the drug they are consuming.

In response, policy makers have been taking measures to reduce the risk of harm fentanyl poses. For instance, although once labeled as “drug paraphernalia” lawmakers across the U.S. have worked to decriminalize fentanyl test strips, hoping to help drug users avoid fentanyl. Some have called for further steps including the creation of Supervised Injection Facilities (SIFs). At these facilities, individuals are permitted to bring in and consume drugs. They are then provided with the means to use these drugs as safely as possible; they receive clean needles, alcohol pads to sterilize injection sites, and medical staff remain on standby to monitor for potential signs of overdose. Additionally, staff can help secure access to resources such as addiction counseling and treatment. The idea is to reduce overall harm by ensuring that those who would otherwise use drugs in public are instead in a private, controlled space with access to resources which can help secure their long-term health. OnPointNYC, the organization running the SIFs, reports they have intervened in 848 overdoses on site and zero deaths have occurred in 68,264 uses.

SIFs, however, are not popular in the U.S. Although other locales have considered opening SIFs, New York City contains the only two officially operating in the U.S. – one in East Harlem and one in Washington Heights. However Representative Nicole Malliotakis of New York’s 11th District has called on the Justice Department to shut down “heroin shooting galleries that only encourage drug use and deteriorate our quality of life.” Pennsylvania’s state senate recently passed a bill banning SIFs by a 41-9 margin. Senator Christine Tartaglione, a Democrat from Philadelphia, stated that her “constituents do not want safe injections site in the neighborhood” and claimed that these sites “enable addiction… [and] we should be in the business of giving these folks treatments.”

These, and other potential objections, warrant further examination. For the purposes of this discussion, I want to consider arguments against harm reduction in the context of SIFs. However, in doing so, these reflections may lead to some insight about harm reduction arguments in other contexts.

One might object to SIFs because they appear to publicly endorse illegal behavior. Yet we may have reason to find this reason uncompelling – the law and morality often diverge. To oppose SIFs because the drugs consumed there are illicit is to merely pass the buck. Why should we regard the use of particular drugs morally objectionable? Why prefer a policy of abstention to moderation? Our focus is better placed on arguments that target SIFs themselves.

The claims by public figures quoted earlier suggest that SIFs fail to prevent harm and instead increase it. There seem to be two purported reasons for this. First, that SIFs enable or even promote drug addiction. Second, that SIFs lead to a deterioration of the surrounding area, encouraging drug users to occupy it, which leads to drug dealing, public drug use, and further threats to the local community.

The available data, however, does not support these arguments. Researchers have found that SIFs lead to lower rates of overdose and decreases in infectious disease rates among drug users. So, SIFs appear to lessen harm to addicts, at least in the short term. Further, SIFs do not seem to impact local crime rates, and, at worst, have no impact on public drug use and needle litter (though there is some evidence that they reduce both).

There is an intuitive argument that these facilities will deteriorate neighborhoods by drawing in drug dealers – the supply may seek out the demand. However, support for this claim is primarily anecdotal. Further, while narcotics arrests have increased in New York neighborhoods with SIFs, these areas now have additional police presence outside of SIFs. It’s at least plausible that an increased police presence is the cause of additional arrests.

Further, there seems to be little, if any, data on the long-term effects of SIFs for overcoming addiction. Perhaps more clarity on long-term consequences of SIFs will come as their impacts are further researched. But currently there seems to be little evidence suggesting they are harmful. They seem to benefit addicts, at least in the short term, and there does not appear to be conclusive evidence that they harm the surrounding community.

But perhaps considering only the consequences misses the point. As I have argued elsewhere, sometimes the consequences of a policy do not seem to matter in the face of other moral objections. Consider, for instance, someone arguing that making cannibalism illegal just produces additional harms – it pushes the market for human meat into the underground, making regulation and oversight impossible, harming both the producers and consumers of human meat. Thus, this person concludes that legalizing cannibalism and regulating human meat consumption would make things safer.

These points, however, fail to resonate as objections to prohibiting cannibalism. This is because harm is just one factor (if even a factor) behind cannibalism’s illegality. Part of the reason why we have laws is to express our attitudes towards a behavior. In this case, eating human flesh simply seems deeply morally wrong to us.

Following this logic, the opponent of SIFs could argue that there is something morally objectionable in drug use, even if SIFs do reduce harm in the long run. That explanation could come in various forms. For instance, in the Groundwork of the Metaphysics of Morals, Immanuel Kant argues that someone who refuses to develop their talents acts immorally by disrespecting her own humanity – she has a potential that she is ignoring in favor of seeking pleasure. Alternatively, one might ground an objection to drug use in virtues. Given the long-term risks associated with drug use, one who regularly uses may fail to demonstrate the virtue of prudence. Thus, one might argue that, if drug use is morally wrong, then facilitating it via SIFs would make one complicit in wrongdoing.

Even if one can give a compelling argument that drug use is in some way immoral (although this may be difficult given the disease model of addiction) there are hurdles this explanation must overcome. Namely, it is unclear whether these concerns are the proper basis of legislation. The government has, at best, a limited prerogative to promote virtue, at least in a society with robust individual rights to self-determination. Further, given the sheer scale of deaths from drug overdoses in the United States, it seems more plausible that reducing harms by participating in or facilitating wrongdoing is a lesser evil than continuing with a status quo that results in tens of thousands of deaths a year. And even still, it is not clear that facilitating a wrong behavior for the sake of minimizing harm is itself wrong.

Opponents of SIFs seem to have two rhetorical options available to them. They may argue that SIFs do not, in fact, reduce harm. But this claim has a tenuous relationship to current data. Alternatively, they may argue that even if they do reduce harms, SIFs are ultimately unjustifiable for moral reasons. There is more flexibility in developing arguments of this nature, but there are still serious theoretical difficulties one must resolve even if they can give a plausible argument for drug use’s immorality. Perhaps this is why opponents of SIFs couch their arguments in terms of the consequences of SIFs, even when they lack the data to support these claims.

Ultimately, if OnPoint’s figures are accurate, SIFs show great promise at limiting deaths from overdose. Even if this is their only benefit, this alone should make us pause before rejecting them. While they may only address the symptoms of the opioid crisis in the U.S., we have compelling moral reason to minimize harms while solving the underlying problems behind addiction.

From Conscience to Constitution: Should the Government Mandate Virtue?

photograph of cards, dice, chips, cigarettes, and booze

You have probably heard it said that you can’t legislate morality, that making laws that require people to do the right thing is both ineffective and authoritarian. Nevertheless, in his recent Atlantic article entitled “American Has Gone Too Far in Legalizing Vice,” Matthew Loftus encourages politicians to do just that. By legalizing sports betting and recreational marijuana, Loftus argues that states are neglecting to consider the countless addicts that will result, and that lawmakers should do more to outlaw these harmful vices.

On Loftus’s view, public policy plays a role in the habits that we form, and creating an environment where more people succumb to their vices is neither good for addicts nor the political communities that will be left picking up the pieces. A substantial portion of gambling revenue comes from those who struggle with addiction, and legalizing marijuana is linked to higher rates of drug abuse. If these activities remained illegal, then fewer people would get hooked.

On this score, it seems that Loftus is obviously correct. Our environments play a significant role in the habits we adopt. If I am surrounded by responsible peers, I will be more likely to study for my next exam, while if many of my friends are cutting class, I will be more likely to skip out as well. These choices then form my habits. In the good case, my habits will be virtues like temperance, honesty, and diligence. In the bad case, my habits will lead me into all sorts of vice, including destructive addictions like gambling and drug use.

But even if it is true that our environments form our habits, the question still remains whether it’s the government’s place to guide us towards virtue instead of vice.

As a democracy founded on the rights to “life, liberty, and the pursuit of happiness,” it may be too heavy-handed for political leaders to require us, or even nudge us, to live a certain way.

This concern is amplified by the fact that many of the philosophers who have been the staunchest advocates of state-sanctioned virtue have not been very enthusiastic about democracy. According to Plato, a well-functioning political community should mirror the way that virtuous individuals conduct their lives, while for Aristotle, the purpose of government is to help citizens to live flourishing lives of virtue. But Plato also held that we should all be ruled by philosopher kings, a class of highly educated rulers, and that the freedoms granted within democracies would inevitably lead to anarchy. Likewise, Aristotle thought that monarchy and aristocracy are superior to democracy. An emphasis on character formation through the law might also lead to rejecting democracy as a promising form of government rather than embracing important constitutional freedoms.

These considerations reveal that there is some tension between allowing citizens the freedom to conduct their own lives and passing laws that promote virtue. Part of this tension arises because we often disagree about what is morally best, a fact that the political philosopher John Rawls called reasonable pluralism. Intelligent, well-intentioned citizens can find themselves at odds over many key moral questions.

Is gambling a harmless pastime or a serious moral vice? Is access to abortion a central human right, or the murder of an innocent human being? By enforcing policies that promote particular virtues, lawmakers may have to come down on one side or the other of these ongoing debates.

Furthermore, even in cases where we can agree on what is morally best, it is not clear that the law should prevent us from doing things that we know are to our detriment. Certainly the law should prevent us from interfering with how others choose to pursue happiness, but if we are only hurting ourselves, then why is that anyone’s business besides our own? Part of making room for the pursuit of happiness is allowing citizens to decide for themselves what they pursue, not limiting them to only a menu of government-approved options.

All of this, however, overlooks the fact that promoting certain virtues might be an unavoidable aim even for democratic governments. If it is true that political institutions should enable their citizens to freely pursue their vision of the good life, this goal cannot be accomplished by being completely hands off.

To form and pursue their understanding of the good, citizens need wisdom, discernment, courage, and perseverance, amongst other virtues. These virtues are necessary, not because the government wants to control our lives, but because without them we would be incapable of controlling our own lives.

We would instead be left to the dictates of momentary desires or, in the worst case scenario, crippling addictions from which we cannot recover.

This insight opens up a potential middle road between fully laissez-faire public squares and domineering, authoritarian governments. According to the philosopher Martha Nussbaum, political institutions should cultivate the capabilities necessary for their citizens to pursue self-directed lives. By promoting these capabilities, or virtues, governments ensure that their citizens are able to pursue their own unique visions of the good.

This approach allows that the law can encourage citizens in virtue in a way that creates and supports their ability to choose the life that they want to lead. On this model, the rule of law would not be completely value neutral, but it would make space for people to be able to choose many of their own values.

Forbidding certain kinds of vice, like preventing adults from gambling or using addictive substances, would for the most part be off the table. Unless the government wants to endorse a more robust picture of what a good life is like, the default position would be to let those who can choose their own informed goals pursue those ends. Recreational activities, like football or freediving, come with substantial dangers, but it is typically left up to individuals whether they want to take on those risks. In contrast, protecting those who are still forming the ability to choose their own life paths, like forbidding Juul from marketing to children, would be well within the purview of government officials.

Of course, just having laws that promote virtue does not ensure that anyone will become particularly moral. While they may succeed in outlawing vice, laws simply compel behavior, and those who begrudgingly comply out of fear of punishment would not for that reason become deeply good. The law, rather, would act as a guide for what kinds of values might be worth adopting, and citizens can then decide whether or not they want to choose these ideals for themselves. Policies like sin taxes, for instance, allow states to discourage vice without outright banning it.

Thus, even a view like Nussbaum’s leaves plenty of room for people to develop their own distinctive moral characters. Democracies can lay the groundwork for citizens to live meaningful and fulfilling lives, but at the end of the day, it is up to them to decide what values their lives will ultimately serve.

Reduction of Harm: Fentanyl Testing Strips for Drug Users

Photograph of a kit for needle exchange, including three needles, cotton pads, and alcohol wipes

In 2017, more than 49,000 Americans died from opioid overdoses, the highest rate that America has ever seen. Of these opioids on the rise is the illicitly manufactured fentanyl drug which can be mixed into heroin and other powdered drugs. Fentanyl is also a prescribed pain killer, but it is the illegally synthesized opioids made with this drug that have caused 29,406 deaths the past year in the US and a 22-fold increase from 2002 in overdose-related deaths. Fentanyl is a drug that is 50 times as potent as heroin and this deadly synthetic could be responsible for the worst drug epidemic in U.S. history.

There is now a way for users to take caution from using drugs that contain this synthetic opioid. On the market for $1 a piece, there are two-inch fentanyl testing strips. When drug users dip the strip into a drug it will reveal if the drug contains fentanyl by the presence of a red line. Along with detecting fentanyl, it can detect nine different chemically analogous drugs, such as carfentanil, which is 10,000 times as potent as morphine. The test strips were originally created for doctors who use them to test the urine of patients  who use fentanyl as a prescribed pain medication. BTNX Inc, a main commercial provider of these strips, is now selling more strips to harm-reduction groups and city/state governments then they are to doctors.

A study conducted by Research Triangle Institute (RTI) International,  looked to see if drug users would change how they used drugs if they had access to these fentanyl strips. They surveyed 125 heroin users from Greensboro, North Carolina at a needle-exchange program site. Eighty-one percent of users reported using the strips and 63 percent got a positive result for fentanyl in their drugs. Those who had a positive result for fentanyl were five times likely to change how they use in order to avoid overdosing. Responders reported using less drug then usual, administering a tester shot, pushing the syringe in slower than normal, and snorting instead of injecting. These practices can decrease the rate and amount of the drug that goes into the bloodstream making them a safer way to use.  Jon Zibbell, an author of the study, says, “An important insight from the study is that people who inject drugs can and will change their behavior when they have information about the risks involved. The bottom line is that fentanyl test strips may represent a new technique to prevent opioid overdose by allowing people to check street drugs for fentanyl and modify consumption behavior accordingly.”     

These testing strips have similar intentions to needle-exchange programs and naloxone antidotes for overdoses. Needle-exchange programs have been found to reduce the amount of blood-borne infections, keep the streets safer for kids with less loose syringes, and provide safe spaces for drug users who have been rejected from their families. These spaces create opportunities for users to turn their lives around and make productive, clean lives. Similarly, naloxone is a medication that will rapidly reverse overdose. It comes as an injection, auto injection, or nasal spray for trained personnel or family members of opioid users to access in case of emergency.

The intentions behind the fentanyl strips for drug users are morally sound in that they align with the needle-exchange programs and naloxone antidotes. They work to decrease overdose, spread of disease, and overall harm to users. However, we must consider if these fentanyl strips are actually effective at decreasing drug overdose. Are they actually being used as something productive, to decrease the amount of harm to users? Or are they promoting the drug industry as “safer” ways to use? If they do little to eliminate harm to users then they could just be weakening drug laws and promoting usage as an unintended consequence.

A few cities such as Baltimore, Philadelphia, Columbus, Ohio, and Burlington, Vermont, have started providing test strips at their needle-exchange sites. However, something that is restricting the wide distribution is that there are paraphernalia laws in place that prohibit the use of devices to aid drug users in using drugs. The needle-exchange sites are not nationally used today: fifteen states still outlaw them. Though this restriction has been loosened for when it comes to clean needles, it could still apply to test strips.

The cons of the testing strips, according to the RTI study, is that though users are more likely to change the way that they use the drugs, they do not stop using. The respondents said that they were more likely to reduce how much they use. They were also more likely to snort the drug instead of inject it, which leads to less being absorbed in the blood stream. However, none of the respondents said that they would throw out the drugs even though they had a 63 percent positive finding for the potent fentanyl drug. Not to mention, the cost of the strips may be too much of a burden for the users to take on as a way of protection.

On average, a clean syringe costs $0.97, similar to the $1 cost of a testing strip. The fact that the strips cost one dollar may seem like a cheap price but on average, heroin users inject four times a day. When injecting this frequently, the process could potentially become too costly to be worth clean syringes and testing strips to users. To counter this barrier, some people suggest that users should just assume that all heroin contains fentanyl and adjust accordingly. Jon Zibbell says, “We have a poisoning epidemic. When there’s E. coli in the lettuce, you test the lettuce. You have to test the product to see what’s in it.”

In order for these testing strips to be implemented in a positive way, there needs to be more solid evidence that they will function as harm prevention. From the Harm Reduction Journal, Don C Des Jarlais writes about how the way that needle-exchange programs were so successful was through vast amounts of research and activism to put the harm reduction measures into place. He says, “The researchers then provided the data needed to justify large-scale public expenditures on harm reduction programs (primarily by state and local governments). Without these public expenditures, the harm reduction programs would not have achieved the scope they needed to be successful to stop the HIV epidemic among people who inject drugs (PWID)”. Fentanyl testing strips seem to be in the horizon towards lowering drug overdose, but more research needs to be done. This research must prove that because of access to the fentanyl strips, drug users will change the way or amount that they use, ultimately proving that the fentanyl strips can decrease the rate of opioid overdose deaths.