As jurisdictions around the country start to examine and redress the harms of police violence and incarceration, activists and professionals in addiction treatment and harm reduction urge that such steps also take the drug war into consideration, including the punitive models of treatment that are rooted to the carceral system.
“From the moment that [substance addiction] was declared a public health issue, it should have been talked about that people who use drugs should not be met with punitive measures; should not be arrested; should not … as a matter of fact … even be forced to enter a treatment program,” said Dinah Ortiz, a harm reduction activist and member of the leadership committee of North Carolina Urban Survivors Union.
One-fifth of people who are incarcerated in the United States are behind bars for a drug charge—including 120,000 yearly who haven’t been convicted. Added to that, more than a million remain under carceral control through probation or parole after being charged for drugs. Drug overdose deaths continue to rise, despite billions of dollars being funneled toward increased treatment access and stopping the flow of drugs into the country. Even the police violence that led to the killings of George Floyd and Breonna Taylor this year—and spurred calls for systemic change around the country—were fueled, at least partially, by the drug war.
But, cautioned Sheila Vakharia, deputy director of research and academic engagement at Drug Policy Alliance, “we have to be careful when we make it seem like treatment will solve everything when we know all treatment is not created equal and not all agencies or programs provide the best services possible and there’s a lot of flaws in the current delivery system we have.”
Substance use and the carceral system are deeply linked, and forced treatment is often the solution that is offered when someone who uses drugs has contact with the police. There are more than 3,000 adult and juvenile drug courts in the United States. These programs offer substance treatment in lieu of incarceration, and are utilized for a range of substance issues, from cannabis use to severe opioid or stimulant addiction.
Justine Waldman, medical director of the REACH Project, a harm reduction-oriented treatment provider in New York State, said “rehab and detox have not been shown to save lives, and I don’t think people being forced to talk to somebody helps them make different decisions because they don’t feel in that space that they can really have [honest] conversations.” These programs often rely on unproven addiction treatment modalities, such as 12-step style regimens and talk therapy. Only around half prescribe medications for opioid use disorder. Of those, approximately 9 percent use only naltrexone, an opioid blocker that has a less robust evidence base than opioid agonist medications like methadone and buprenorphine.
“What we know clearly is that just using [buprenorphine] and just using methadone both decrease substance use dramatically and save lives dramatically. I don’t understand why other things like mandatory counseling—which hasn’t been shown to do anything like that—why we are spending so much time and effort on that premise,” Waldman said.
Even for those who are able to engage in an evidence-based modality, drug court programs are notoriously punitive. One drug court participant in San Francisco ultimately chose six months in jail over drug court, after his mandatory treatment provider kicked him out for eating a cookie without permission. It is common practice for participants to be forced to engage in demeaning practices like urinating while being watched. Failure to comply, or failure to adhere to a regimen of total abstinence, often results in periods of incarceration that are sometimes longer than their original sentence would have been.
“There shouldn’t be mandatory treatment of substance use disorders,” Waldman said. “There’s no numbers that show that mandatory treatment of substance use does anything.”
Nicole Reynolds, a member of the North Carolina Urban Survivors Union and a freelance street-based harm reduction outreach specialist in Raleigh, North Carolina, said drug decriminalization is critical to reducing poor outcomes for people who use drugs. “[Decriminalization] drastically reduces the number of people arrested, incarcerated, or otherwise connected to the justice system,” she said. “It alleviates racial and ethnic disparities in the criminal justice system and improves the cost effectiveness of limited public health resources.”
In the United States, Black people are 5.9 times more likely to be incarcerated than white people; Latinxs are 3.1 times more likely. When it comes to nonviolent drug-related arrests, Black and Latinx people are more likely than white people to be booked in jail rather than cited for the initial charge, and also more likely to serve time for the charges. Yet Black and Latinx people are less likely to be referred to treatment diversion programs. In 2018, when overall opioid overdose deaths declined, overdose deaths among Black and Latinx drug users rose.
“We create all these punitive systems through the treatment system that don’t help patients,” observed Shilo Jama, executive director of the People’s Harm Reduction Alliance, a substance user-led harm reduction program based in Seattle. “If the ultimate goal is for the individual to have a healthy, successful life in the way the individual defines that, we need to sit down and talk to patients: what do you want to get out of this, what’s your end goal?”
Vakharia of Drug Policy Alliance said part of the solution rests on increasing access to treatment and making sure that treatment is evidence based.
“We need to think about, how do we make it as easy as possible for people [to begin treatment],” she noted, citing the long wait times that patients often face when attempting to get into treatment. “We know from a national survey of drug users and health that among the two top reasons people don’t start treatment when they think they need it, one is abstinence expectations, and another is that they can’t afford treatment. When we talk about increasing access to treatment, it should be in ways that are financially manageable for people to start getting the help they need.”
Ortiz also emphasized the need for accessible therapeutic services to address trauma. “There’s always a reason why people are using and I think [treatment providers] are focusing a lot on the drugs but not focusing on the root of the cause,” she said. “I think that the best way to start is to offer therapy to all drug users, and it has to be harm-reduction focused and it has to be non-coercive.”
Kevin Moore, a clinical psychologist and administrator at interstate substance use agency Crossroads Treatment Centers, added that there is a significant need for appropriate training and ongoing education. “We need a huge increase in the training of professionals. Right now, what we do is say ‘go to school for X number or years and learn stuff and then when you’re done go do it for three or four more decades.’ [Instead] you need to constantly be re-evaluating and growing and expanding.”
“One of the things we don’t talk enough about is building people’s self-worth out,” Jama said “If you don’t believe in yourself and don’t love yourself, it’s going to be hard to make positive choices.”
Or, as Drug Policy Alliance notes in its principles of substance use disorder treatment, “Treatment must be available on demand. It should be affordable, accessible, and attractive.”