Healing Not Harm: Imagining Beyond Carceral Approaches to Care
By Ajetha Nadanasabesan
While working as a community health worker at a harm reduction clinic in Washington D.C., I had the privilege of working with a patient whose experiences had a lasting impact on me. This patient was enrolled in our medication assisted treatment (MAT) program, where he was choosing to manage his opioid use with Suboxone. He was a long-term patient of the clinic who was doing well, rarely missed appointments, and often brightened the clinic with his warm smile. One day, when clinic finished and he had not shown up we had a feeling something was wrong. Our suspicions were confirmed when we learned he had been stopped by the police and searched without a clear reason, an unfortunately common experience for Black men living in the United States. Despite having his medication legally prescribed he was arrested for carrying Suboxone out of its original packaging. His experience highlights the intersecting systemic issues of drug policy, addiction treatment, incarceration and racism. By criminalizing individuals for carrying suboxone, even when legally prescribed, this encapsulates how the legal system is not structured to support healing but instead to perpetuate the punishment of marginalized communities. This patient’s experience illustrates not only the policing of addiction but also how Black and Brown individuals disproportionately face criminalization even when trying to care for their health.
This harmful policing of drug use is a direct consequence of the War on Drugs, a policy framework with lingering negative impacts today. Initiated by President Nixon in the 1970s, the War on Drugs prioritized punitive measures over public health interventions as a solution to addiction. This framework harmfully institutionalized the idea of drug use as a criminal issue rather than a health one. The War on Drugs disproportionately targeted Black and Brown communities contributing to mass incarceration and exacerbated health inequities. Punitive drug policy remains in place today as police make more arrests for drug possession than any other crime, with an arrest made every 25 seconds for simply possessing drugs for personal use. Despite policymakers' claims that drug laws are meant to limit illicit drug use, reducing addiction and making communities safer, they have little evidence to show for these claims. If the goal was reduced harms from drugs, these policies have collectively been an abject failure, as evidenced by the devastating rise of opioid related deaths in recent years.
Since the opioid epidemic was declared a public health emergency in 2017, 454,464 lives have been lost due to opioid related deaths. Furthermore, research shows that opioid-related deaths have risen by 67% between 2017-2023. The staggering number of lives lost demonstrates the continued failure of policies that prioritize incarceration over public health solutions for individuals who use drugs, whether they are struggling with addiction or not.
Policymakers and correctional officials often argue that jails and prisons offer a place where individuals can receive addiction medicine and mental health support. In practice, this could not be further from the truth. While every person who uses drugs does not want or need treatment, they should have access to evidence based treatment if so desired. This is decidedly not the case for many incarcerated individuals. Of the 3,000 local jails across the United States less than two-thirds screen people for opioid use, and only about half provide medication for those experiencing withdrawal. As a result, these individuals are at greater risk for the harmful consequences of untreated withdrawal, including severe dehydration and electrolyte imbalances, both of which can lead to complications such as kidney failure, seizures, and cardiac arrhythmias. While typically not viewed as fatal, opioid withdrawal in jails has proven to be just that, given the too often abusive and negligent conditions. Opioid withdrawal can also exacerbate mental health conditions like depression and anxiety, further increasing the risk of suicide, which is the leading causing of death in jails across the United States. Even more jarring is the limited availability of medication-assisted treatment (MAT) with suboxone or methadone, the most effective treatments for OUD. MAT is only available to less than one in four incarcerated individuals struggling with OUD.
Ultimately, research overwhelmingly shows that incarceration is not only an ineffective solution to the opioid crisis but is in fact contributing to overdose deaths. Overdose is the leading cause of death in individuals recently released from prisons and the third leading cause of death for individuals in jail custody. Incarceration contributes to overdose deaths due to limited access to MAT, naloxone, tolerance loss while incarcerated, and disrupting access to healthcare and social support. This poses the urgent need to utilize public health and patient centered approaches in addressing addiction.
Dedicated organizations and community organizers have responded to this need by embracing harm reduction to support and care for individuals who use drugs. Harm reduction is an evidence-based approach that focuses on minimizing the harmful consequences of substance use rather than prioritizing abstinence. Harm reduction holds the complexity of substance use, recognizing that drug use exists on a spectrum that therefore requires a more individualized
patient-centered approach to care. Harm reduction is a powerful strategy because it acknowledges that individuals who are struggling with addiction are often simultaneously facing systemic issues such as homelessness, poverty, mental health issues and trauma. These intersectional issues will never be solved through incarceration, only exacerbated. Harm reduction is more humane than punitive approaches to addiction and more effective. It has been proven to reduce overdose deaths, improve access to treatment, and lower the risk of disease transmission, while helping dismantle systemic barriers individuals may be facing.
Ultimately, to address the opioid crisis and continuous systemic failures of our current punitive approach, we must imagine more compassionate and effective models of care that prioritize patients’ health and well-being. This involves a comprehensive approach providing housing support, peer education, and community-based harm reduction resources, many of which are already being carried about by community organizers. One emerging solution is the implementation of supervised injection sites in the US, where individuals can use substances under medical supervision. These sites, which already exist in over 100 locations in 67 cities worldwide have been proven to prevent overdose and injection related infections. As of 2021, two supervised injection sites opened in New York City, marking a shift towards the acceptance of harm reduction. Despite common misconceptions, supervised injection sites are not encouraging drug use or promoting crime but instead are about providing a safe environment to promote individual agency and reduce harm associated with drug use. Supervised injection sites are a lifesaving intervention and offer a bridge to recovery and supportive services for participants who are interested in treatment. By embracing abolitionist principles that call for the redistributing of funds away from the ineffective and harmful carceral system and into harm reduction programs, housing support, and healthcare services, the root causes of much problematic substance use can be addressed.
