March 26, 2019 9:52AM

Libertarians and Harm Reduction

Last week we held a day-long conference at the Cato Institute devoted to exploring the strategy known as “harm reduction” to address the rising rate of drug overdose deaths and the spread of infectious diseases, such as hepatitis and HIV.  

In my remarks at the beginning and at the conclusion of the conference, I pointed out that the harms afflicting the drug-using community and their intimate contacts are the direct result of drug prohibition. Cato’s Jeffrey Miron emphasized that point in a key presentation and discussed the success Portugal has had in reducing overdose deaths, HIV, hepatitis, and the heroin addiction rate after it decriminalized all drugs in 2001.

While I stated that the ultimate act of harm reduction would be to end the War on Drugs, I argued that, as a start, the goal of drug policy must shift from one that is focused on prohibiting and punishing the consumption of certain unapproved substances to one that is focused on reducing the disease transmission and deaths that come from drug prohibition. Rather than continue to pour huge amounts of resources into putting people in cages for buying, selling, or placing certain unapproved substances into their bodies, those resources would be put to better use reducing the harms our current policies inflict on people. Harm reduction is realistic. It recognizes there will never be a drug-free society and therefore seeks to make nonmedical use of licit and illicit drugs in the black market less dangerous.

Harm reduction strategies include:

  • Needle-exchange programs and safe (aka supervised) injection facilities 
  • Medication Assisted Treatment with drugs like methadone, buprenorphine, and sometimes hydromorphone (dilaudid) and heroin—so those with addiction or dependency can avoid the horrors of withdrawal (and the use of dirty needles) while stabilizing their lives, then gradually taper off the drug on which they are dependent.
  • Making the overdose antidote naloxone as well as fentanyl test strips more readily available. 
  • Decriminalizing cannabis, which has demonstrated potential in the treatment of pain as well as in the management of withdrawal and possibly even as Medication Assisted Treatment.

Some may reasonably question why libertarians might take an interest in harm reduction, especially in light of the fact that many harm reduction programs are likely to be run by the government.

First, many of these efforts are privately funded and receive no taxpayer subsidies. For example, Pennsylvania Governor Ed Rendell spoke at our conference about an effort he is leading to establish a safe injection facility in Philadelphia called “Safehouse.” The Philadelphia City Council gave his organization the green light. The Justice Department has warned that safe injection sites violate federal law and threatens prosecution. Such sites operate legally in other countries since the 1980s and are now in roughly 120 major cities in Europe, Canada, and Australia. They have a proven track record of reducing overdose deaths. HIV, and hepatitis—as well as drawing users into rehab programs. Safehouse relies completely on private funds from reliable donor sources. Governor Rendell announced at our conference that a real estate developer donated a building to house their program. The only thing standing in the way is the government. Rendell stated he will move forward with Safehouse and he’s prepared to go to prison if the federal government tries to stop him.

Similarly, in my state of Arizona, seven needle-exchange groups have operated for several years on completely private funding, giving out fentanyl test strips (illegal in Arizona), handing out naloxone, offering free HIV and hepatitis blood tests, and exchanging dirty needles for clean ones. They operate under the radar because Arizona is one of several states with anti-paraphernalia laws that make them illegal. Fortunately, most police support the idea and tend to look the other way when they see the harm reduction groups in action. But the fact that they are illegal in Arizona prevents them from holding public fundraising events, receiving grants from foundations, or advertising their presence to drug users on the street.

Harm reduction doesn’t necessarily require government funding of needle-exchange and safe injection facilities. It does require removing legal obstacles to the existence of such programs so they can openly fundraise and operate. 

Many other harm reduction efforts can be undertaken through regulatory reform that does not involve spending taxpayer dollars. For example, the restrictive quotas and regulations the Drug Enforcement Administration imposes on health care practitioners wishing to engage in Medication Assisted Treatment with buprenorphine should be relaxed, so more providers will be willing to engage in MAT and more patients will have access. And the DEA’s restrictions on methadone are archaic and should be modernized, which will allow more patients access to methadone programs, as I have written about here and here. Many state restrictions on methadone treatment need to be relaxed as well. And making naloxone truly over-the-counter will likely reduce its price and certainly increase access to the life-saving drug (public health lawyer Corey S. Davis discussed this point at the conference).

In addition, as I point out in my policy analysis on harm reduction, on a cost-benefit basis, safe-injection sites reduce the rate of HIV and hepatitis, the costs of which are usually borne by Medicaid. They also reduce overdoses, easing the budgetary burden on police and fire departments who are called to respond. One can make a strong argument that permitting government funding of safe injection facilities is a cost-saving measure for government funded Medicaid. If the government already pays for health care for indigents (and many of those with complications of substance abuse disorder are indigent) then this is a more cost-effective way of allocating the taxpayer dollars funding indigent care. 

Many harm reduction advocates see this strategy as a step in the right direction that may gradually change public attitudes towards drug prohibition similar to the way legalization of medical cannabis has made the public more amenable to recreational legalization.

Harm reduction has advocates from across the political and ideological spectrum. Many non-libertarians who support government funding of harm reduction programs unite with libertarians in the cause of ending drug prohibition or at least mitigating some of the harms that result from prohibition. While libertarians certainly prefer an emphasis on smaller government approaches, i.e., removal of legal and regulatory barriers to harm reduction, the idea of government providing these services is probably less coercive and therefore preferable, from a libertarian standpoint, to prohibiting the service entirely.

Also, personally, as a libertarian, I can see government-provided harm reduction as analogous to the government providing aid to refugees from a country with which our government has entered into war. In this case, it’s the government’s War on Drugs that is responsible for so many people dying of overdoses and infections and spreading infectious diseases.