In defence of harm reduction…but thank you Carl Hart

by Dr Giulia Zampini

Dr Carl Hart is the first hard scientist I ever heard speaking about currently taking heroin and other drugs recreationally for pleasure in public. This deserves a heartfelt thank you. Pause for a minute and think about what might happen if more people in high-powered positions started talking openly about using drugs and how drugs have had positive effects on their lives.

I know. Huge!

I have been a fan of Carl’s ever since he argued that people with privilege should come out about their drug use. I totally agree with him on this. I also liked his criticism of the psychedelic community for not supporting other drug users more openly and jumping on the bandwagon of a drugs hierarchy, with psychedelics placed at the top. I have discussed both these issues at length with my project partners in a new paper, where we argue that drug hierarchies reinforce social and cultural hierarchies, and that it is class and status that allow some – the privileged – to hide their drug use, while others are publicly shamed and criminalised for it.

I have been reading Hart’s new book Drug Use for Grown-Ups and enjoying the way he has weaved personal experience, anecdotes, and scientific evidence into the book’s narrative, which makes it very compelling. What I find most intriguing about him is that in many ways, he is a symbol of the American dream – he is a huge success story. A black man from the ghetto who rose above his “fate” to reach the top as a leading scientist, he is also a great believer in the liberal values of individual freedom and the pursuit of happiness.

In the book, Hart configures drug use as a part of the individual pursuit of happiness and exercise of freedom, using the pillars of American republicanism including the Constitution, the Declaration of Independence, and the Bill of Rights as documents that inscribe the right to use drugs for all citizens. In Hart’s discussion, responsibility and freedom are weighed according to utilitarian liberal principles, a risk-to-benefit analysis. In fact, many of the statements he makes in the book remind me of liberal philosophy.

Hart makes the argument that fear is a powerful motivator of prohibitions and restrictions in all domains. Fear is also a powerful motivator for people to stay in the closet. Hart bravely defines his not-coming-out for over 20 years as the behaviour of a coward. He draws a parallel between not coming out and behaving like children and emphasises that to adult is to be honest and forthcoming about one’s responsible drug use. In the book, he defines grown-up drug users as

Autonomous, responsible, well-functioning, healthy adults. These individuals meet their parental, occupational and social responsibilities, their drug use is well planned in order to minimize disruptions of life activities. They get ample sleep, eat nutritiously, and exercise regularly. They don’t put themselves or others in physically dangerous situations as a result of their drug use.

He says that this accounts for many drug users worldwide. So far, so good.

I have been thinking about pleasure recently and have come to really appreciate the idea of ‘responsible pleasure’ – much better than ‘guilty pleasure’ perhaps. I don’t disagree with Hart on many of these points, though my non-Americanness makes me uneasy about his likening of the right to use drugs to the right to bear arms.

This is related to the one point of disagreement that I have with Hart, which is around harm.

Hart has argued in the book and elsewhere that we need to abandon harm reduction, linguistically and also as a pursuit, because it forces our focus toward a statistically narrower and negative relationship between people and drugs. I get it, harm reduction is too narrow a concept to encompass the kaleidoscopic nature of drugs and their relationship with people.

I get the reasoning behind the argument. We are OBSESSED with harm to the detriment of pleasure and happiness in our discussions about drugs and people, and in our research agendas.

My question: in order to create a more nuanced narrative that gives pleasure and happiness its proper place, do we have to stop talking about harm and harm reduction?

I don’t think so.

Why is it so hard for people to hold duality in their thinking? Can’t pleasure and harm coexist, as they do in reality?

To me, harm reduction is not just an obsession with the harms of drugs for a marginalised and disadvantaged population; it is so much more. It is a non-judgemental praxis that has allowed people to talk about their drug use, and get help when they needed it most, for decades.

It is also a principle, which needs to exist at least alongside the principles of individual freedom and the pursuit of happiness (though I am sure many people believe harm reduction should take precedence). As a principle, harm reduction is positioned at the very heart of the drug user movement globally.

Without harm reduction, what exactly is going to help us establish limits on our happiness pursuits? What is going to remind us about the potential consequences of our drug consumption not just on ourselves, but on the environment, or on people who depend on the drug trade for survival? Yes, these consequences are made many times worst by prohibition and the war on drugs, and if we had a different model, perhaps the conditions would become less exploitative (though consumption for pleasure within capitalism often has exploitative, harmful consequences). 

The thing is, we don’t have a different model yet, and the harms are real. My view is that harm reduction is a crucial principle in the making of a better world and a better drug policy, and I am not ready to let it go just because it gets used in a narrower sense.

If Hart is a liberal, which I think he is, then his approach should extend to the harm principle, or else how does he understand and define responsibility?

3 thoughts on “In defence of harm reduction…but thank you Carl Hart

  1. I have not yet read Dr Hart’s book, but going by Dr Zampini’s response, I wonder how many drug consumers can afford good sleep, nutritious foods and regular exercise. A sizeable proportion of drug consumers, particularly in the part of the world where I live (sub-saharan Africa), come from the most marginalised sectors of society, and cannot afford these things. Drug harms are amplified by conditions of social marginalisation, so if we jettison harm reduction as Dr Hart suggests how shall we deal with the consequences of drug use in these populations?

  2. Important point you make here. I think Hart’s book mainly deals with the drugs issue in the context of the USA. He recognises the harm of drugs and has studied harm of drugs for many years. I think his frustration comes from the fact that the research agenda globally is dominated by a focus on harm to the detriment of pleasure, which is problematic for our ability to understand the issue in a fuller, more complex manner. I would still recommend reading his work, but also accompany your reading with some other work which centres global harm of the drug trade, for example. – Giulia

  3. Thank you for this interesting article. From the UK my opinion is I agree. We need to have an official review to look at a new model to not only support people but also to highlight that while we continue to isolate and stigmatise drug use the problem will only get worse. We need to reform the UK 1971 Misuse of Drugs Act. After supporting the care of drug users I realised:

    – Prescribing methadone from GP is not supporting client care.
    – Safe drug consumption rooms* maybe a way forward.
    – Therapeutic communities (TCs) are a common form of long-term residential treatment for substance use disorders (SUDs) which work.
    – Drug users should no longer be called “recovering” as there is no end in sight. A different wording should be used.
    – Better fund the police, and social healthcare to support them.
    – Include alcohol, cigarettes and vape in to the reformed Act!

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