Thursday, April 8, 2010

on double standards, this time my own

One of the readings for today's class was this article on drugs and sex in prison:

Seal DW, Belcher L, Morrow K, Eldridge G, Binson D, Kacanek D, Margolis AD, McAuliffe T, Simms R; Project START Study Group. A qualitative study of substance use and sexual behavior among 18- to 29-year-old men while incarcerated in the United States. Health Education & Behavior 31(6):775-789.

Without going into too much detail, the paper states that drugs are widely available in prison and that people absolutely do them, and it shows that those who use injection drugs do so unsafely, i.e., re-using needles without cleaning them, sharing needles, etc.  While this was all surprising for me to read, what I need to get off my chest is the reaction I found myself having to its policy implications.  Obviously if people are shooting drugs in prison, they should have clean needles made available to them - after all, that's a most reasonable course of action outside of prison.   But the idea didn't immediately sit right.  Ultimately, of course, it seemed like the way to go, but on first read, there was this sense of "Uhhh...Imma have to think about that one" that I can't quite reconcile with the values I thought I had.  I'm not proud of it, but I AM curious about it.  Where does this double standard come from, and why do I, as a harm reduction advocate, have it??  So I started coming up with reasons why availability of clean needles in prison would send a confusing message, and quickly realized that they are identical to the reasons people have for criminalizing and condemning drug use outside of prison - reasons I usually try to talk people OUT of.  For example, prisons are supposed to be sheltered, controlled environments, so admitting that contraband penetrates their walls (built with OUR money) undermines this status.  Well, isn't our country supposed to be a sheltered, controlled environment too, with tons of money going to border control?  Policy ideals and rhetoric are being shattered in both cases, so why do I forgive the real world its porous borders and cry harm reduction, but recoil from accepting drug availability in prisons as a reality to be dealt with?  Or maybe it's the sense of surprise, that I had no idea drug use was so prevalent in prisons, so I'm going to need a minute to sit with this idea.  Well, not everyone was a raver or outreach volunteer or addiction researcher and has been around drug users half their life -- many in the real world probably also have no idea about the actual extent of the problem, and need to be granted some time to come to terms with it and realize its impact.  Or maybe I'm afraid of a sense of spite or disregard on the part of prisoners for rules that they, as part of their punishment, have been required to obey.  But as citizens and productive members of society, people in the real world also have a set of rules and laws to obey -- and I don't necessarily see it as an act of subversion or spite when they break these laws by using drugs.  Or maybe it's because many of the people in prison were sent there for the very purpose of not doing drugs anymore (not that treatment is available there, but that's another story...), so supporting them in doing it anyway is a bit of a slap in the face - but then I'm just another jerk who thinks themself morally superior and wants to teach a lesson and places conditions on reaching out a helping hand.  In the real world, I despise these kinds of attitudes; when it comes to prison, I have them??  I don't know -- there isn't an answer, but it's certainly painful to find limits to one's sense of immediate empathy.

Having thought about it, I'm of course all about supplying needles (and condoms) to people in prison.  But I don't like having observed this side of me that had to give it any thought at all.  On the brighter side, I wonder what proportion of knee jerk reactions to needle exchanges and other harm reduction programs in the real world could be reversed by just giving people a minute to let it percolate and an opportunity to articulate (and potentially realize the folly of) their concerns.

Thursday, April 1, 2010

an oldie but a goodie

I'm stoked to audit a class in the Community Health Sciences Department this quarter.  It is named "Managing Drug Abuse from a Public Health Perspective."  Hello!  It started today, and already I'm energized to learn the language and logic of this approach (in more formal terms than my noodling around drug policy conferences, anyway).

Among the first reading assignments was a paper published in the journal Addiction over a decade ago, titled "Setting goals for drug policy: harm reduction or use reduction?"  The reason I like it is that it describes the philosophies, merits, and policy implications of each approach so much more articulately than I have ever managed to, and it is thought-provoking and challenging while being level-headed and just.  Its main point is that in order to be effective, drug policy needs to define attainable goals (there is a world of goals beyond use reduction), set up reliable measures by which to gauge success (use/harm reduction can be conceptualized in several ways, not all of which go hand in hand), and recognize that with different goals come different policy implications.  It also touches on some sad truths, like the idea that choice of strategy comes down to things like political feasibility (appearing "soft on drugs") and ultimate values (caring about drug-related things like health problems, poverty, crime, etc. versus viewing drug use itself as "bad").  And as far as I can tell, all of the arguments stand to this day.

The end of the paper also states some author opinions that I really liked.
"Our recommendation is that the overall objective be to minimize the harm associated with the production, distribution, consumption and control of illicit substances.  Reducing use should be seen as a principal means of attaining that end.  However, although reducing use is a principal way of reducing harm, it is neither the only way nor a foolproof way." 
"It is our belief that augmenting use reduction with explicit harm reduction goals and admitting the possibility that one might at times be willing to accept higher use if it yields substantially less harmful use, would encourage wiser policies."

It's been over a decade since.  Surely, some harm reduction programs (needle exchanges, etc.) have made great strides, but lots of work remains to be done.  Can we get to it now?

Reference: Caulkins JP, Reuter P. (1997)  Setting goals for drug policy: harm reduction or use reduction? Addiction 92(9), 1143-1150.