Pushing the Needle: a Therapeutic Approach to Drug Use and Social Harm

May 21, 2015

IPFW Associate Professor and medical ethicist Abraham Schwab.
Credit Courtesy / Abraham Schwab

A lot has been made recently of the HIV cases in southeastern Indiana. Governor Mike Pence responded to the crisis by allowing the use of a needle exchange program in that part of Indiana. He then extended the needle exchange program because it appeared to be working. He then signed a bill to allow the use of needle exchanges in counties with similar risk for an HIV outbreak. And despite my disagreements with Pence about other health care issues, I’m grateful that ideology was set aside in favor of effective public policy. 

My own recent experience listening to a local DEA agent drove home how significant Pence’s move was. This particular agent seemed to have a punitive approach to drug use: individuals who decide to use drugs should be punished for their poor decision-making. In discussing drug use in Indiana, he attributed increases in the use of heroin to the recent emphasis on limiting prescription painkiller availability. A problem common to the history of drug enforcement, he compared it to a “Whac-A-Mole” game in which emphasis on one area of drug enforcement leads to an uptick in some other area of drug use (For those unfamiliar with the game here’s an amusing adaptation of "Whac-A-Mole" for cats).

His simile may be more apt than intended. In the original “Whac-A-Mole” game, the moles never stop popping up and the game only ends when you stop putting money into the machine. Similarly, it seems, punishing individuals limits the use of that drug, but then, like a mole from a different hole, some other drug gets used. 

Instead of a punitive approach, there is what we can call a therapeutic approach. 

Here, drug use is treated not punished. The emphasis is on finding a strategy that limits the harms produced by drug use, rather than trying to stamp out all drug use entirely. Portugal has been perhaps the best success story of this kind of approach.

"It is possible to hold the view that addiction to drugs is a terrible thing that wastes many lives, while also holding the view that the appropriate public policy response is to treat this as a medical condition."

One concern about the therapeutic approach is that it includes a subtle endorsement of drug addiction. Critics charge that if we do not punish drug use, we are implicitly endorsing it. This concern rests on an oversimplification of the approach. It is possible to view drugs as something to be avoided, but also something to be treated as a medical condition. For example, it’s possible to both believe that it would be better if no one drank to excess (e.g., a fifth in a night), and also that we should treat individuals who do drink to excess as needing help and treatment. In the same way, it is possible to hold the view that addiction to drugs is a terrible thing that wastes many lives, while also holding the view that the appropriate public policy response is to treat this as a medical condition.

The evidence about public policy is in. The punitive approach produces “Whac-A-Mole” drug use, allowing for related social harms (HIV cases in SE Indiana). The therapeutic approach limits social harms by treating drug use rather than simply punishing the drug user.

If our goal is to limit the social harms produced by drug addiction, the therapeutic approach to the problem is the best available alternative, a point recognized by Governor Pence when he allowed the needle-exchange program. If the goal is not to limit social harms but to punish those who have made poor decisions, then the appropriate public policy might be something else.

And so this gets down to a question of values. What do we value more? Punishing those individuals who use drugs? Or limiting the social harms produced by the fact that there are, have been, and shall be drug users?

 

Abraham Schwab is an associate professor of philosophy and a medical ethicist at IPFW.

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