In this paper, I am going to argue against views of those concerned about the negative effects of a moral hazard in regards to the safety nets implemented for drug users, and I am going to do so with a libertarian view. In this view, I plan to articulate the positives of the safety nets provided for drug users and the positive effect it could have on our society if we further implemented them. Moral hazard is a term coined to be used in terms of economics, insurance specifically. In short, moral hazard can be defined as the incentive to take steps to guard oneself against consequences being stripped due to a built-in protection against said consequences . In regards to drug use, moral hazard applies when we recognize the safety nets society has implemented for drug users. There is heavy debate circulating of whether said safety nets are of benefit to drug users across the U.S. Specifically, there is concern that they increase drug use by decreasing the incentive to take steps towards addiction recovery. I am going to address the safety nets provided by over the counter naloxone, needle exchange programs, and safe injection sites. Essentially, the concerns for these safety nets are driven by the idea that by providing insurance to their own life, we are making drug use socially acceptable and more obtainable. I wish to provide evidence to counteract those concerns.
OVER THE COUNTER NARCAN
As clearly represented in the chart above, over the years, heroin use has seen a large increase in the U.S. When a person is overdosing on an opioid such as heroin, morphine, codeine, oxycodone, methadone or Vicodin, the drug has attached to the opiate receptors in the user’s brain and begun to affect their ability to breath and remain conscious. Naloxone, specifically the well-known brand Narcan, essentially removes and knocks the opioids away off the opiate receptors of the brain. Taking around an average of 5 minutes to start working, Narcan reverses an overdose, resetting the person's breathing, and allowing the user to live.
As reported by medical professionals, naloxone has not yielded results that would indicate a physical or psychological dependency . That said, when there is a physical or psychological dependency to opioids present for the person consuming naloxone, withdrawal symptoms will arise only minutes after naloxone administration, subsiding after upwards of two hours. Each intake of naloxone works a little differently, heavily depending on both the dose of the naloxone as well as the severity of the user’s opioid dependency. The user is put through withdrawal symptoms including, but not limited to, nausea and vomiting, muscle and stomach cramping, goosebumps, agitation, anxiety, sweats, racing heart, and the craving of more opiates. This observation shows that Narcan removes the ability for users to enjoy the rest of their high after injection of the opioid antagonist. The level of the withdrawal symptoms and the discomfort they produce vary depending on the dependency of the user to the drug.
As referenced in the last paragraph, addiction is an uncomfortable road for any person to find themselves on. Reliance on drugs in order to avoid uncomfortable withdrawal symptoms is so much more than many predict it to be. Recently, controversial opinion pieces have been reaching the mainstream media, producing much controversy on the topic. For example, with an article resulting in over 746 thousand Facebook shares, Brianna Lyman of Fordham University shared her thoughts about how drug addiction is not a disease. Specifically, she states in her article,
“I’ve watched enablers cosset the addict, consistently making up excuses as to why that person is an addict, why they can’t quit, and best of all; why they have a disease and should be treated as such. But enablers are not the problem, it’s the manipulator -- who is the drug addict.”
Fundamentally, this is a stance many take in order to fight back the safety nets we provide for addicts. People such as Brianna Lyman see treatment for addiction as enabling those addicted to consider themselves sick. That said, many people would also believe that someone experiencing the previously mentioned withdrawal symptoms is, if under any other circumstance, in fact, very ill. People tend to label the choice made by users as a reason to discredit their symptoms, illness, and discomfort.
In 2016, John Tommasi, Senior Lecturer of Economics and finance at The University of New Hampshire, reported, “Within the past two years, we have seen a large increase in the number of heroin OD’s in the northeast.” Tommasi goes on to credit this epidemic to the fact that heroin is being laced with the cheaper and more potent drug, fentanyl. In his piece, Tommasi states, “Most heroin addicts would like to quit, and the greater possibility of an OD death would normally be more incentive.” He then counters this statement by introducing the effect naloxone, specifically Narcan, has on the incentive for users to quit. After addressing moral hazard and the effects it has in economics, Tommasi credits Narcan in regards to being a safety net for drug users, to have similar attributes that insurance has regarding economic moral hazard. Tommasi states, “According to WMUR/NH, drug dealers are giving away free Narcan (it’s sold over-the-counter) with every bag of heroin they sell, hence insurance and it takes away a motivation for kicking the habit.” As both a lecturer at a large university and as a police officer, John Tommasi has strong opinions regarding most subjects. In this report, it seems Tommasi’s goals revolved around the want to shed light on the question of whether Narcan, in fact, increases heroin use. He believes that there is reason to believe that there is a relation between the two, but would never want to remove Narcan as an aid to help save lives. That said, many find themselves asking a similar question. People wonder if implementing the insurance of Narcan simply amplifies the idea of moral hazard leading to unsafe actions with the idea that if consequences arise, they can be reversed. If there is the opportunity to reverse the effects of an overdose, it is argued that people will become comfortable within their addiction, no longer attempting to quit their dangerous levels of usage.
Despite these concerns, studies show no relation between naloxone and an increase in heroin usage. After performing Naloxone Distribution and Cardiopulmonary Resuscitation Training for Injection Drug Users to Prevent Heroin Overdose Death: A Pilot Intervention Study, Seal, Karen H., Robert Thawley, Lauren Gee, Joshua Bamberger, Alex H. Kral, Dan Ciccarone, Moher Downing, and Brian R. Edlin of the New York Academy of medicine stated that there was no scientific reasoning to believe the use of naloxone increases drug use. This study consisted of many working parts. In short, the study was used to “investigate the safety and feasibility of training injection drug using partners to perform cardiopulmonary resuscitation (CPR) and administer naloxone in the event of heroin overdose.” The study took place in the months of May and June in 2001. During this time, 12 pairs of injection partners were enlisted from the street life of San Francisco. The pairs underwent a training program revolving specifically around heroin overdose prevention; specifically, CPR training and training to administer naloxone. This study, as well as the results, are vital to understanding the double-sided argument of whether naloxone increases heroin use by implementing moral hazard or not.
While results of this pilot study still have room to be further investigated through retesting the hypothesis, the depth of the study still provides evidence to believe that the safety net provided by naloxone does not necessarily increase users want to take heroin. Specifically, in their report they state,
“Contrary to initial concerns about naloxone distribution, we found decreased heroin use among participants, even though the program did not advocate reduction in drug use, abstinence, or drug treatment. The training program was interactive, capitalizing on participants’ prior overdose experiences and empowering them with additional knowledge and training. This may have increased self-efficacy and motivated participants to decrease drug use despite having the “safety net” of naloxone.”
This conclusion was met through the data gathered following the initial overdose-prevention training. The six months proceeded as follows:
“Following the intervention, participants were prospectively followed for 6 months to determine the number and outcomes of witnessed heroin overdoses, outcomes of participant interventions, and changes in participants’ knowledge of overdose and drug use behavior. Study participants witnessed 20 heroin overdose events during 6 months follow-up. They performed CPR in 16 (80%) events, administered naloxone in 15 (75%) and did one or the other in 19 (95%). All overdose victims survived. Knowledge about heroin overdose management increased, whereas heroin use decreased.”
These findings prove incorrect the stances many hold while opposing the administration of naloxone. Similar to other harm reduction measures/safety nets utilized by drug users, there is a heavy burden of proof placed on researchers attempting to find answers. Said burden of proof is so vital because there is such harsh judgement against those who use drugs.
With research showing that there is no increase in drug use due to the implemented safety net, the concerns of those who oppose the distribution of naloxone are entirely dismantled and proved to be developed through no true evidence for the argument. Therefore, it can be concluded that the use of naloxone does not have a positive correlation regarding heroin use.
NEEDLE EXCHANGE PROGRAMS
Needle exchange programs, also known as syringe service programs (SSPs) are a disease prevention method implemented in order to reduce drug user’s risk of getting and/or transmitting diseases through unsterile needles. Users who utilize said programs vastly reduce their risk of obtaining diseases including, but not limited to, HIV, viral hepatitis, and other blood borne infections. These programs are community-based and have goals to both provide access to free sterile needles and syringes as well as dispose of used syringes.
Similar to the other safety nets mentioned in this paper, before the first implemented program, originally there was a concern that syringe exchange programs were going to remove the incentive to rid of the bad habits associated with drug use. In 2012, NASTAD (National Alliance of State and Territorial Aids Directors) and UCHAPS (Urban Coalition for HIV/Aids Prevention Services) teamed up to create a report on the process, use, and effect of syringe exchange programs. With this platform, they reported that approximately 16% of new human immunodeficiency virus (HIV) infections are obtained through injection drug users, despite the significant overall reduction of HIV cases as time has passed. It is important to recognize that these numbers reduce as syringe exchange programs pop up in different communities.
Throughout this publication, it is noted that these programs were originally implemented entirely out of good faith. This is noted when it states the history of needle exchange programs,
“The history of SSPs (syringe service programs) in the U.S. is primarily the history of SEPs (syringe exchange programs). The first SEPs in the U.S. began in the late 1980s in Boston, Massachusetts; Tacoma, Washington; and San Francisco, California. With a few exceptions, these SEPs were primarily activist-initiated programs without support from governmental sources.”
This shows that without government intervention, there will still be room for society to step in and decide the steps necessary for a better society. Programs such as these can run based on market forces alone, allowing for a safety net that does not affect the negative rights of others.
The overall goal of these programs clearly laid out in studies based on the effectiveness of said programs; reducing the consequences incurred by drug use. NASTAD and UCHAPS have no intention of promoting drug use, but rather, their intentions are highlighted when they specifically address the conditions of drug use. While providing safer avenues for injections, syringe service programs also provide resources to aid in the search for information and counseling revolving around drug use and the possible consequences it may incur. In addition to syringe exchange, education, and counseling, syringe service programs also have been found to supply links to resources including social services, medical care, mental health services, drug abuse treatment, and overdose prevention. These resources are obtained by a mechanism referred to as PCSI, Program Collaboration and Service Integration. PCSI is defined as “a mechanism of organizing and blending interrelated health issues, separate activities, and services in order to maximize public health impact through new and established linkages between programs to facilitate the delivery of services” This mechanism is vital to allowing users to decide for themselves and embrace their rights through their own decision making.
Making these services obtainable allow for drug users to utilize their right to choose the path their life will take. Making resources available such as needle exchange programs, counseling, drug education, social services, medical care, mental health services, drug abuse treatment, and overdose prevention, allows for communities to provide incentive for people and communities to rehabilitate.
SAFE INJECTION SITES
Drug related safe houses, also known as safe injection sites, are locations where safety precautions are known and practiced by the medical professional overseeing injection. Essentially, these locations are legally-sanctioned areas where drug users can do drugs and experience highs under medical supervision. As reported by Julia Guilardi of the Boston Globe media partners,
“A vote of approval from the Massachusetts Medical Society would just be the first step in bringing these (supervised injection) facilities to the Commonwealth. At least one city in the state would have to be willing to host it….specifically, medical society members are eyeing Boston Health Care for the Homeless in the South End, which is home to the Supportive Place for Observation and Treatment (SPOT), which opened last year. In SPOT, patients are supervised by nurses while high, but they are not allowed to use drugs while in the SPOT room.”
Due to research and successful experiments in Europe, safe injection sites are being implemented in the U.S. where the results of said sites will be closely monitored to measure the direct effects on the community of users.
While addressing the facts of the matter and addressing the events that may unfold, Guilardi also addresses the opposition to said events and actions. This is significant because while this is all happening currently, some of the arguments against are arguments that have carried through for years in the debate over drug use. Specifically, Guilardi references the major standpoints of each side of the debate,
“Supporters of supervised injection facilities say the sites would be a new tool for medical professionals to help save lives. Critics, however, question the ethics and legality of such facilities, arguing that they may encourage illegal drug use”
From a medical standpoint, this is the safest way for addicts to get clean supplies and prevent over dose. Many argue that addicts are going to keep doing illegal drugs and that safe injection sites would just give them a safer, and monitored space to do them.
While there are currently official no safe injection sites in the United States, this is not a new concept for humankind. For example, in the 1990’s a safe injection site in Frankfurt Germany was used to experiment the effects said site would have on the drug using community. In this experiment, addicts could come in to this location, called Café Fix, to “shoot up”. As reported by John Tommasi, “They were given free needles (which decreased cases of hep C) and counseling. Over a 10 year period, they achieved the following results: HIV declined by 40%, a decline in robberies of 20%, a decline in court drug cases by 60%, and drug addicts amongst drug users declined from 27% to 9%.” Rather than making drug users apply to a long waiting list to see a social worker, Café Fix in Frankfurt, Germany provided access to social work, yielding amazing results. This specific site was established in 1990. Clearly, this addition to the streets of Frankfurt, Germany worked wonders for the community.
Originally, Café Fix was a mobile program utilized for syringe exchange, and since the start of the program, 2.5 million syringes have been exchanged. As the program evolved, as did the clients. There was a wide range of clients who utilized the facilities including, but not limited to, long term addicts (more than 8 years of drug use), socially-integrated users, the homeless, women using prostitution to finance addiction, addicted foreigners, drug users with children, convicts in a halfway program, people wanted and in hiding, male and female prostitutes, and the youth. This is a vital piece of the project that was Café Fix because it showed all the different needs of all the different kinds of clients.
The goal of Café Fix was to improve basic conditions within the lives of addicts. Specifically, employees were concerned about the nutrition, hygiene, behavior, and medical caretaking of the some 500 to 1,000 clients seeking help each day.
In a report produced by the Council of Europe, the effects of the program are spoken of from a very supportive point of view. Specifically, the symposium produced states that, “’Café Fix’ offers live-saving and life-improving services, in order to keep the clients from deteriorating further. Thus, the possibilities for addicts to decide and act for themselves are maintained and improved.” Also in the symposium, theories opposing the benefits of safe injection sites were disproved by scientific evidence.
“Scientific research about the process of getting free from drug use has sufficiently disproved the theory which claims that drug users will only make an effort to get rid of their addiction when they have sunk into the utmost misery. On the contrary, it is evident that the reintegration releases stabilizing elements in a personality, which can support the process of liberation from the addiction.”
Essentially, pilot programs such as Café Fix have created routes for support for drug users. This support has launched the discovery that strength in support can result in strength when fighting addiction.
APPLYING LIBERTARIANISM WHOLLY
Opiate drug users can incur withdrawal symptoms as few as just a few hours after the last dose, and can last for a week or even longer. These symptoms lead many down the road of pursuing their fix yet again. Many believe that by removing the incentive to kick the dangerous habit is dangerous for users and the environments they effect. The thought is that people will continue to use opiates regularly knowing that there is the security blanket on hand.
John Hospers, a founder of libertarian ideals, states that “Individuals own their own lives. They, therefore, have the right to act as they choose unless their actions interfere with the liberty of others to act as they choose” This statement is largely considered the backbone of libertarianism. Not only is this statement the backbone of libertarianism, it is also a normative theory often applied to the war on drugs being fought across the United States, as well as around the world. Per Hospers, “Government is the most dangerous institution known to man” Minimal government, that is the libertarian goal. This is reflected into the war on drugs when people create opinions that revolve around the lack of laws that should be implemented in regards drug use. A libertarian would argue that users and addicts should not be protected from themselves, but instead, they should be enabled to make their own choices in regards to both their drug usage and their recovery.
In the view of libertarians, the government has no role in creating laws that protect individuals from themselves. The government is expected to limit its power to protecting citizens against the aggression of others. In the eyes of Hospers and other libertarians, a government is expected only to protect human rights of negative nature, just another way of saying rights of non-interference. Negative rights guarantee no interference/the overall right to be left alone. By attempting to control the usage of users and addicts, those taking actions are no longer allowing users and addicts to make their own choices regarding their health.
A libertarian perspective would view naloxone/narcan, safe injection locations, and needle exchange programs all as completely justified as long as they are not directly infringing upon the choices of others. If a free market systems could fuel and drive these programs, then a libertarian would see no wrong doing and would consider them entirely morally sound. The Libertarian National Committee has a very specific platform on the War on Drugs. Considering the Libertarian Party the ‘Party of Principle’, they state the following in regards to the war on drugs:
“The War on Drugs has imprisoned millions of non-violent people. This is unfair to these people and also uses up resources that would be better spent prosecuting and imprisoning people who are violent. The War on Drugs is largely responsible for the militarization of police forces in America. It has pitted police against citizens and this is unfair to both. Police need to be able to focus on protecting the American public from violent offenders and fraud. Lastly, Libertarians believe that it is immoral for the government to dictate which substances a person is permitted to consume, whether it is alcohol, tobacco, herbal remedies, saturated fat, marijuana, etc. These decisions belong to individual people, not the government.”
The Libertarian Party is an evolved reflection of the ideals stated by John Hospers. The above quote comes from the developed ideas of only protecting citizens’ negative rights. By implementing safety nets and improving lives for those using drugs we are not forcing ideals upon them but instead providing resources for them to make their own decisions about the path of their lives.
Overall, with data and statistics backing up the positive influences the safety nets can have on drug users’ drug usage, and the libertarian ideas that support the right to be left alone, it can be concluded that these three safety nets are morally sound. If decided by market forces, due to the morally sound nature of the safety nets, they should continue to be implemented by society.
"All About Narcan." Narcan | Naloxone | The Opiate Antidote to Save a Life. Accessed May 02,
Bazazi, Alexander R., BA, Nickolas D. Zaller, Ph.D., Jeannia J. Fu, BS, and Josiah D. Rich, MD,
MPH. Preventing Opiate Overdose Deaths: Examining Objections to Take-Home Naloxone.Report. John Hopkins University. November 4, 2010. Accessed May 8, 2017. http://muse.jhu.edu/article/400754/pdf.
Guilardi, Julia. "Massachusetts is moving closer to opening a safe injection site for drug users."
Boston.com. April 10, 2017. Accessed May 05, 2017. https://www.boston.com/news/local-news/2017/04/10/massachusetts-is-moving-closer-to-opening-a-safe-injection-site-for-drug-users?event=event51.
"HIV/AIDS." Centers for Disease Control and Prevention. May 17, 2016. Accessed May 07, 2017.
Hospers, John. "What Libertarianism Is." The Libertarian Manifesto, 1973. Accessed February 26,
Libertarian National Committee. "War on Drugs." Libertarian Party. Accessed May 07, 2017. H
Lyman, Brianna. "Stop Calling Your Drug Addiction A Disease." Odyssey. April 24, 2017. Accessed
May 02, 2017. https://www.theodysseyonline.com/stop-calling-drug-addiction-disease.
"Naloxone." Drugs.com. March 2017. Accessed May 06, 2017.
Scofield, Julie M., NASTAD Executive Director, and Marsha Martin, UCHAPS Director. Syringe
Services Program (SSP) Development and Implementation Guidelines for State and Local Health Departments .Publication. NASTAD. August 2012. Accessed May 9, 2017. http://www.uchaps.org/assets/NASTAD-UCHAPS-SSPGuidelines-8-2012.pdf.
Seal, Karen H., Robert Thawley, Lauren Gee, Joshua Bamberger, Alex H. Kral, Dan Ciccarone,
Moher Downing, and Brian R. Edlin. Naloxone Distribution and Cardiopulmonary Resuscitation Training for Injection Drug Users to Prevent Heroin Overdose Death: A Pilot Intervention Study .Report. Journal of Urban Health, New York Academy of Medicine. May 4, 2005. Accessed May 8, 2017. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2570543/pdf/11524_2006_Article_385.pdf.
Tommasi, John. "Does Narcan Increase Heroin Use?" The Economics of Unintended
Consequences & Common Sense. March 2016. Accessed May 02, 2017. http://www.johntommasi.com/blog/archives/03-2016.
Tommasi, John . "Café Fix : Frankfurt, Germany ." Lecture, Business Statistics Class, 10 Garrison
Avenue, Durham, NH, May 5, 2017.
Wichelmann-Werth, Birgit. 'Cafe Fix': A Concept of Outreach Work For Problematic Drug Users in
Western Germany. Council of Europe, 1994. Accessed May 6, 2017. https://play.google.com/books/reader?id=EYqa5WTl6agC&printsec=frontcover&output=reader&hl=en&pg=GBS.PA79.