Biden quietly making a radical shift in opioid policy
In dealing with the opioid crisis, the Biden administration is quietly embracing “harm reduction” — a controversial approach that could save thousands of lives but create a political firestorm because it appears to be giving up and accepting illegal drug use as normal.
Harm reduction is a blanket term for interventions that are designed not to stop people from using drugs but simply to reduce their negative effects, including supervised injection sites, syringe exchanges, safe smoking kits, fentanyl test strips and the widespread availability of Narcan, a drug that reverses overdoses.
Although it makes little effort to trumpet it, “the Biden administration has made harm reduction the centerpiece of its effort to address the opioid crisis,” said Andrew Kolodny, who chairs the psychiatry department at Maimonides Medical Center in New York City.
David Herzberg, a historian of drug policy at the University of Buffalo, said Biden is making “deep and fundamental changes to a bedrock element of American policing culture that has been around for over a century.
"It’s amazing. As a historian you almost never get to say that something is brand new. But this is new,” he said.
But it’s “a drastic change in position,” according to 14 Republican U.S. senators who complained about it in a letter to the president. Harm reduction is “radicalized, illegal, and dangerous,” they claimed, adding that “the grave consequences of enabling and normalizing the consumption of illicit drugs” include “an increase in crime, discarded needles, and social disorder in the surrounding neighborhoods.”
The government’s official drug strategy includes harm reduction as part of a multi-faceted approach that also emphasizes drug treatment and prosecution of trafficking. But this is the first time that the government has thrown its full weight behind treating drug abuse not just as a criminal or individual psychological problem but as a public health issue.
Biden isn’t talking about it much, however, because of the political danger that it sounds like encouraging or at least normalizing the use of heroin and similar drugs, which are still prohibited under federal law and can result in a year in prison for first-offense simple possession.
An example of political controversy occurred in February when the administration announced a $30 million grant for harm-reduction programs that included “safe smoking kits” designed to reduce the spread of HIV and hepatitis, which led the Washington Free Beacon to run an article headlined “Biden Admin to Fund Crack Pipe Distribution to Advance ‘Racial Equity.’”
Although the newspaper later admitted that there was no evidence that crack pipes would be included in the kits, a Republican National Committee official tweeted the story, Fox News host Tucker Carlson repeated it and Senators Marco Rubio and Joe Manchin introduced a bill to outlaw the practice anyway.
As a result of dust-ups like this, Biden is likely waiting until after the midterm elections to publicly further his agenda, Herzberg said.
This could include a highly controversial move by the Department of Justice to allow supervised injection sites where users can take illegal drugs under medical supervision to prevent overdoses.
Eight days before Biden took office, the DOJ won a lawsuit to stop such sites from opening in Philadelphia. But in February of this year it reversed course, announcing that it is “evaluating supervised consumption sites, including discussions with state and local regulators about appropriate guardrails for such sites, as part of an overall approach to harm reduction.”
Several such sites are now operating in New York City and the federal government has made no effort to stop them. Once the midterms are over, the DOJ will likely announce that it won’t interfere with any such sites in much the same way that it currently doesn’t interfere with states that have legalized marijuana, said Alex Kreit, director of the Center on Addiction Law & Policy at Northern Kentucky University.
The sites may be helpful in inner cities where there is a large homeless population, Kolodny said, but not in other areas where drug users are unlikely to commute to a site multiple times each day to shoot up. “The mayor of Ithaca, New York wanted to set one up but it makes no sense there,” Kolodny said.
Safe injection sites are the most politically unpopular form of harm reduction, according to Herzberg. Last month California Governor Gavin Newsom, a Democrat who is widely reputed to have presidential ambitions, vetoed such a program.
“This definitely signals that he was concerned about how this might play out in the media,” said Jeannette Zanipatin, California director for the Drug Policy Alliance.
Another hot-button issue is fentanyl test strips that are designed to reveal whether the highly dangerous drug has been mixed with heroin. The Biden administration has announced that programs receiving federal grant money can use it to buy test strips, but a number of states outlaw them as drug paraphernalia.
Texas lawmakers rejected a bill to legalize the strips last year, and Florida rejected a similar measure this year. But lawmakers in Georgia, New Mexico and Wisconsin recently approved them. Alaska health officials are giving them out for free, and Pennsylvania’s attorney general announced that he won’t charge people for possessing them even though they’re illegal in the state.
In the eastern half of the U.S., though, where powder heroin is common and can easily be mixed with fentanyl, it may be too late. “Almost all the dope you can buy is going to have fentanyl in it, so it’s pointless to keep testing,” said Kolodny.
Black-tar heroin is more common in the West and is harder to mix with fentanyl, so the test strips are more useful there, Kolodny said. “And they make sense for cocaine, which can also be mixed with fentanyl,” he added.
Other harm reduction measures are less politically toxic. Although it was controversial for a long time, the overdose-reversing drug Narcan is now widely accepted and Biden’s drug czar, Rahul Gupta, is in talks with the FDA about making it an over-the-counter medication.
Syringe exchange programs, designed to reduce HIV and hepatitis, are also less divisive. There are now more than 400 such programs spread across 43 states (all but Alabama, Delaware, Kansas, Mississippi, Nebraska, South Dakota and Wyoming).
And every state except Kansas, Texas and Wyoming now has a “Good Samaritan” law that provides at least some protection from prosecution for people who summon emergency help for a fellow drug user’s overdose.
Still, the basic concept of harm reduction is in some ways a political third rail because it divides people who believe that drug use is immoral and should never be encouraged from people who see drugs as just another activity and want to reduce the dangers, said Herzberg.
The principal argument against harm reduction is that it might be well-intentioned but it amounts to enabling drug use. “I'm worried that making drugs more accessible is what this administration calls drug control,” Iowa Senator Charles Grassley complained at a hearing in June.
The political problem is that neither side wants to have a frank debate on which approach is best because both sides are afraid they’ll lose, Herzberg said. So “the two sides talk past each other” and there are delicate dances around each of the harm-reduction measures.
Overall, “the Biden administration is being the bravest federal administration on drug policy just by making any moves at all” toward harm reduction, Herzberg believes.
But Kreit said that one reason the issue is coming to the fore now is that politicians in both parties have moderated their views from the early days of the drug war, when even Biden himself was a hard-liner who complained on national TV that Republicans were “not tough enough” on the issue. The shift is due to the scale of the current opioid epidemic, the success of harm reduction policies in other countries and the fact that harsh mandatory minimum sentences have proven to be ineffective in solving the problem, he said.
Recently Republicans such as Chris Christie and Rand Paul have labeled the drug war a failure, and in 2014 some 49 House Republicans backed a bill to prevent the federal government from interfering with states that allow medical marijuana.
While some Republicans are publicly opposing harm reduction to score political points, they’re unlikely to “go to the mat” and make sustained legislative efforts to block the policy, Kreit believes.
Herzberg thinks that an unlikely coalition may now be forming in favor of harm reduction consisting of Black communities that have been ravaged by the illegal drug trade, a white working class devastated by prescription painkillers and affluent liberals who are more likely to see addiction as a medical problem than a moral fault.
Getting the policy right is critical because drug overdoses are skyrocketing: There were more than 107,000 overdose deaths in the U.S. last year, up more than 50% since 2019. By comparison, there were only 350,000 COVID deaths in the U.S. in 2020, a figure that includes many people who had COVID but died of other causes.
Kolodny said that harm reduction measures can save lives but the ultimate solution is long-term funding of treatment programs. It’s fine to throw a few billion dollars at the problem on a one-time basis, he said, but “states aren’t going to build treatment facilities unless there’s a long-term commitment.
"What are you going to do, build a facility and then fire everyone the next year if you get less funding? You need a long-term commitment,” he said.