Bleach saved Maia Szalavitz’s life. It cleans a used needle of potential infectants, Szalavitz was told by an acquaintance in 1986, information that was a godsend to an injection drug user like herself. So when she was short of clean needles, she knew how to protect herself from catching HIV, which had infected over half of all those who injected drugs in Manhattan at the time.
Her impromptu instructor, a San Francisco outreach worker named Maureen Gammon, who was the girlfriend of one of Szalavitz’s friends, was more than just an introduction to a simple way to keep herself uninfected. The lesson was also her first foray into harm reduction, a philosophy and health practice that equips people who use drugs with the resources needed to safeguard their well-being.
This chance but lifesaving encounter is the window through which readers of Szalavitz’s latest book, Undoing Drugs: The Untold Story of Harm Reduction and the Future of Addiction, are ushered into a past largely unknown to the general public. Published last year, Undoing Drugs is both a history of Anglo-American harm reduction and an argument that harm reduction can “undo” prohibition, the policy criminalizing people who use controlled substances on their own terms and not on those dictated by doctors and regulators. History is a new territory for Szalavitz, but disrupting ingrained assumptions about drugs is her bread and butter: Her previous book, Unbroken Brain, upended conventional theories of the role of brain chemistry in addiction.
Undoing Drugs is the perfect primer for lay audiences living in a country where 93,000 people fatally overdosed in 2020. Szalavitz sets the story straight on a topic that is often misinterpreted, making clear that harm reduction is a formidable social and political movement dating back to the mid-1980s. Together, drug users and health workers utilized militant direct action, mutual aid, and cutting-edge science to fight for drug users’ rights to health and dignity.
Undoing Drugs is also the story of harm reduction’s unlikely wins despite the prohibitionist consensus. For example, as new HIV/AIDS cases rapidly accelerated in the United Kingdom in the 1980s, a network of health workers and researchers based in the city of Liverpool managed to keep such cases close to zero during the late 1980s in Merseyside, the surrounding county, thanks to the principle of syringe exchange, started in 1986 by Allan Parry, and of narcotic maintenance, practiced by Dr. John Marks beginning in 1982.
The Merseyside model demonstrated to the world the promise of these new concepts of “harm reduction,” as local psychologist Russel Newcombe, in a 1987 journal article, dubbed the two key practices repurposed by Parry and Marks. Syringe exchange had already helped stop disease transmission once before, in the Netherlands, where drug-user activist Nico Adriaans pioneered it to combat the spread of hepatitis B in 1981. UK narcotic maintenance was a decades-old practice of indefinitely prescribing heroin, morphine (and later injectable methadone), and sometimes cocaine and amphetamines to prevent withdrawal and stabilize lives. From 1988 to ’89, the clinics led by Marks tested nearly all of their patients for HIV, with not a single case reportedly being found.
The real success of the Merseyside model and the soon-to-follow American harm reduction resources went beyond preventing the spread of HIV/AIDS, Szalavitz argues; they undid what prohibition had spawned. Harm reduction replaced stigma and preventable health issues with what she calls “nonjudgmental compassion.”
Many of Undoing Drugs’ chapters are structured around the “undoing” relationship. For example, one focuses on how syringe exchange undoes needle reuse––as well as the dehumanizing assertion that “addicts” are incapable of caring for themselves. Another chapter focuses on naloxone distribution, traced by Szalavitz to Chicago activists in 2001. Naloxone neurochemically undoes opioid overdose, displacing fentanyl, for example, from brain receptors, resulting in the reversal of suppressed breathing. Its distribution challenges the assumption that fatal overdose is inevitable, demonstrating that tragedy is a choice favored by austerity-focused local governments refusing to meaningfully invest in naloxone’s wider availability.
In addition to her intimate expertise and honed reporting skills, Szalavitz succeeds in clearly demonstrating how harm reduction can undo prohibition’s ills because the current champions of the movement have indeed succeeded in reducing such conditions as HIV infections, opioid-involved overdoses, and problematic consumption. And yet the largest part of the book’s argument, articulated in the very title, Undoing Drugs, is left incomplete, because the harm reductionists themselves have yet to accomplish it.
Here, they have their work cut out for them. “Undoing drugs” means nothing short of negating the belief that there’s a scientifically discernible class of substances liable to hijack the brain. It also necessitates the category’s replacement with an understanding that its branding is arbitrary and its harms conditioned by the socioeconomic environment engineered by the state and its interests. Practically, users, not white coats or cops, must be centered as the primary agents in determining the material character and social distribution of psychoactive substances—that is to say, the potency and formulation of them, as well as the issue of who can receive them and through which means of delivery. The task is to make the social construction of “drugs” work for the people who actually use them.
To understand how harm reduction can undo the concept of drugs, look no further than the start of the federal prohibition of nonmedical opiates and cocaine with the passage of the Harrison Narcotics Tax Act of 1914. The construction of what we call drugs is found to be entangled with the rise and fall of what would become harm reduction’s most promising and yet neglected tool: narcotic maintenance, the practice from which the US movement grew, and one that came to be ignored in favor of syringe exchange.
Narcotic maintenance took off in the mid-1910s to meet the needs of consumers no longer able to purchase retail heroin or cocaine. The reason was the Harrison Act, which established what the historian David Herzberg describes as the medical profession’s “legal monopoly on narcotics” in February 1915, forcing consumers to seek an official prescription for the morphine, heroin, or cocaine previously purchasable at a store––or turn to the newly minted illicit market.
Ironically, the conditions that provoked narcotic maintenance’s rise would also facilitate its downfall, Szalavitz briefly notes. As narcotic prescriptions continued and a national panic ensued, jurists fiercely debated the legality of doctors and pharmacists providing drugs to so-called “habitual users” for maintenance and not an eventual “cure.” During this time, the notion of illicit drugs was established in contradistinction to legally available prescription medicine. But as long as narcotic maintenance prevailed, the meaning of “drug use” was fungible: A medicinal substance could still be prescribed to function as a drug.
In 1919, this interchangeability was thrown out and replaced by a hard-and-fast divide, cementing “drugs” as the stark antithesis to “medicine.” In Webb v. United States, a Supreme Court majority declared that prescribing a substance to keep “habitual users” “comfortable” was not a “legitimate medical purpose,” the criterion for lawful prescribing. “Medicine,” “patient,” and “doctor” became mutually exclusive from “drugs,” “junkie,” and “peddler.”
The Webb ruling also provoked the formal establishment of dozens of so-called narcotic clinics by city governments for patients cut off from care, as providers were quickly arrested for prescribing the now-illegal substances. Once more, prohibition unleashed its reactionary forces: Federal agents smeared the work of this diverse patchwork of clinics with cherry-picked data. Instead of the fungible logic of maintenance, the “medicine-drug divide”—another term of Herzberg’s—came to prevail among key public health figures once supportive of narcotic clinics, indicative of the increasingly hostile political terrain. Ever since the last narcotic clinic closed in 1923, no formal heroin or cocaine maintenance program has been able to flourish in the United States, with the few doctors that attempted one, such as Dr. Thomas P. Ratigan Jr., facing aggressive prosecution and incarceration.
Prohibition’s early history was shaped by the mutually antagonistic and contradictory relationship between the concept of drugs and the practice of narcotic maintenance. The former compelled the shuttering of dozens of clinics offering the latter. Likewise, narcotic maintenance threatened the coherence of prohibition’s classification regime, demonstrating that the only thing stopping a medicine from being a “drug,” or a drug from being a “medicine,” was the decision to regard the same substance as belonging to either one or the other politically constructed category.
Szalavitz recognizes how the “medicine-drug divide” serves to undergird prohibition and limit the physician’s prescription pad. But she only explores it at length in relation to an inadvertent casualty: opioid prescribing for pain treatment. Beginning around 2013, the availability of opioid analgesics was drastically reduced as practitioners forcibly tapered prescriptions and refused to provide new ones because of the increasing legal prosecution that they faced. In part, the backlash was driven by the Drug Enforcement Administration’s campaign of fearmongering and the Center for Disease Control and Prevention’s 2016 prescribing guidelines, instigating a paranoia that pain patients who needed opioids simply to function were actually diverting the medicines into the illicit market or using them on their own terms, not the prescribers’—justifications that Szalavitz notes date back to the crackdown on narcotic maintenance.
By neglecting to engage more meaningfully with the history of narcotic maintenance, Szalavitz misses an opportunity to explore historical harm reduction strategies that troubled the distinction between medicine and narcotic maintenance regimes with the same depth and detail as she explored strategies that operated under a more clear division. HAT (heroin-assisted treatment) was developed in the 1990s by Swiss researchers who found that by providing regular users with measured, supervised daily access to medicinal-grade heroin, participants in these clinical trials, known as PROVE, enjoyed drastic improvements in their physical and mental health. Homelessness in the trial group was entirely eliminated, and housing situations were “rapidly improved and stabilised.” Criminalized income dropped dramatically as permanent employment doubled, and unemployment and criminalized activity were cut in half. Illicit heroin and cocaine use was “rapidly and markedly” reduced. Similar evidence supporting HAT’s efficacy has continued to grow in the 20 years since the PROVE study. As of 2018, there are more than 50 such clinics across seven Western European countries and Canada.
Szalavitz’s concentration on practices successfully implemented in the United States may have obscured HAT’s recognition. In June 1998, a two-day conference was hosted in New York City to strategize a multicity HAT clinical trial, including in Baltimore, Md. Unfortunately, the effort was buried by a swift backlash, one that included the likes of former Baltimore mayor Kurt Schmoke, a liberal interested in drug decriminalization. For whatever reason, the activists did not push ahead. Since then, pilot programs have been proposed in the 2010s by state lawmakers from New Mexico and Nevada, but the legislation never advanced far enough to enjoy a floor vote.
Reviewing a wider stretch of the history of narcotic maintenance could have helped Szalavitz clarify the road ahead for harm reduction in Undoing Drugs. But she does gesture toward one current example of the tradition she left unexplored as a promising strategy to end the ever-escalating rate of overdose deaths. Canada’s “safe supply” movement is demanding the expansion of maintenance prescribing, including hydromorphone (Dilaudid)––already available thanks to the activism of HAT pilot patients since 2011—as well as stimulants like Ritalin. Safe supply was officially inaugurated by the British Columbia provincial government’s 2020 clinical guidelines in response to the Covid-19 pandemic and the soaring overdose death toll, and it is now being expanded thanks to new funding by Canada’s federal government. Unlike HAT, safe supply marks a return by advocates to narcotic maintenance’s principle of providing indefinite prescriptions to support patients’ self-determined pattern of consumption with no expectation of its eventual cessation.
While American harm reductionists can learn much from their northern neighbor, ranging from the innovative model of heroin compassion clubs to the Drug User Liberation Front’s insurgent strategy of handing out free safer drugs, they will need to chart their own course to meet the unparalleled challenges of struggling for drug user liberation from within the heart of the global drug war. Transnational collaborations with contemporary movements and the production of new social movement histories—perhaps one tracing the largely forgotten campaigns for heroin maintenance by US advocates in the 20th century—can lead the country’s drug-user activists and harm reductionists forward.
To truly win what these movements are after—systems guaranteeing drug users’ health, dignity, and self-determination—past failures like narcotic maintenance must be regarded as sites of transformative possibility. Clearly, the programs that have been successfully implemented are not enough. This is the significance of Undoing Drugs: Harm reductionists should learn from past successes to revisit what has failed.