Commentary
If supply-oriented drug policy is broken, can harm reduction help fix it? Melding disciplines and methods to advance international drug-control policy

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Abstract

Critics of the international drug-control regime contend that supply-oriented policy interventions are not just ineffective, but, in focusing almost exclusively on supply reduction, they also produce unintended adverse consequences. Evidence from the world heroin market supports their claims. The balance of the effects of policy is yet unknown, but the prospect of adverse consequences underlies a central paradox of contemporary supply-oriented policy. In this paper, we evaluate whether harm reduction, a subject of intense debate in the demand-oriented drug-policy community, can provide a unifying foundation for supply-oriented drug policy and speak more directly to policy goals. Our analysis rests on an extensive review of the literature on harm reduction and draws insight from other policy communities’ disciplines and methods. First, we explore the paradoxes of supply-oriented policy that initially motivated our interest in harm reduction; second, we consider the conceptual and technical challenges that have contributed to the debate on harm reduction and assess their relevance to a supply-oriented application; third, we examine responses to those challenges, i.e., various tools (taxonomies, models, and measurement strategies), that can be used to identify, categorize, and assess harms. Despite substantial conceptual and technical challenges, we find that harm reduction can provide a basis for assessing the net consequences of supply-oriented drug policy, choosing more rigorously amongst policy options, and identifying new options. In addition, we outline a practical path forward for assessing harms and policy options. On the basis of our analysis, we suggest pursuing a harm-based approach and making a clearer distinction between supply-oriented and supply-reduction policy.

Introduction

Critics of the international drug-control regime contend that supply-oriented policy interventions are not just ineffective, but they also produce unintended adverse consequences. Research suggests their claims have merit. Paoli, Greenfield, and Reuter (2009), for example, find that lasting local reductions in opium production are possible, albeit rare; however, unless global demand shrinks, the production will shift elsewhere, with little or no effect on the aggregate supply of heroin and, potentially, at some economic, political, and social cost to exiting and newly emerging suppliers (see also, Dorn, 1992, Friesendorf, 2007, Nadelmann, 1989, Seccombe, 1995). Thailand, which all but ceased opium production with the help of a decades-long, politically and financially backed development strategy (Renard, 2001), might argue it is better off without opium production than with, even if that production migrated elsewhere. A country forced to abandon production rapidly, absent a viable development strategy, might feel differently as might the new source country. The net consequences of the international drug-control regime and related national, regional, and local drug-control policies are as yet unknown. In this paper, we consider whether “harm reduction,” a subject of intense and sometimes acrimonious debate in the demand-oriented drug-policy community, can provide a unifying foundation for supply-oriented policy and speak more directly to policy goals.

We ask: “If supply-oriented drug policy is broken, can harm reduction help fix it?” The naïve response is an emphatic “yes.” The term “harm reduction” holds intuitive and perhaps innate appeal. But harm reduction is not simply the reduction of harm – whatever that means – and, even if it were, the transfer of this term from demand-oriented to supply-oriented drug policy would present real conceptual and technical challenges. A less naïve response is “maybe.” Whether harm reduction can help fix supply-oriented drug policy will depend partly on the nature of the policy's brokenness, the strengths and weaknesses of a harm-based approach, and the specific approach in question.

Our evaluation unfolds as follows. First, we explore the paradoxes of supply-oriented drug policy that initially motivated our interest in harm reduction. Second, we consider the sources of discord in the debate on harm reduction. The literature suggests that conceptual and technical challenges, some more immediately relevant to supply-oriented policy than others, have contributed to the discord. Third, we examine a number of responses to those challenges. Various tools – taxonomies, models, and measurement strategies – have emerged from the literature to identify, categorize, and assess harms. We also examine tools from other disciplines. Each tool suggests a means to address one or more of the apparent challenges of a supply-oriented application. Fourth, armed with a better understanding of the brokenness of supply-oriented policy, the technical and conceptual challenges of harm reduction, and possible means of invoking a harm-based approach, we offer reasons for forging ahead.

We also outline a practical path forward. It harnesses the intuitive appeal of harm reduction, drawing insight from the aforementioned policy tools, and provides a foundation for evaluating the net consequences of supply-oriented drug policy and choosing amongst policy options. Ultimately, we find support for taking a harm-based approach and for reintroducing a clearer distinction between “supply-oriented policy” and “supply-reduction policy.”

Section snippets

Supply-oriented drug-policy paradoxes

As recently as the early 20th century, the terms “supply-oriented policy” and “supply-reduction policy” would have meant two different things. Supply-reduction measures constituted a subset of a larger package of supply-oriented drug controls; initially, these controls were more regulatory than prohibitive (see McAllister, 2000, Paoli et al., in press, Senate of Canada, 2002). In the late 20th and early 21st centuries, supply-oriented policy and supply-reduction policy have become virtually

Sources of discord

Hunt et al. (2003, n.p.) trace the debate on harm reduction to the late 1980s, citing concerns about the role of injecting drug use and needle sharing in the transmission of HIV/AIDS as having prompted the development of harm reduction policies and programmes. An anonymous reviewer of this paper described harm reduction as a “once radical stance for public health policy” that intended to be “contentious, righteous and resistant,” suggesting that the intensity of the debate derives naturally

Conceptual and technical responses

Faced with an array of conceptual and technical challenges, the drug-policy community has developed various tools to identify, categorize, and assess drug-related harms, especially as they pertain to drug use. Efforts to address supply-side and criminal harms, more generally, are less prevalent; however, the national-security community has developed a widely used risk-management process that warrants notice.

Should we forge ahead?

Our review of conceptual and technical challenges – and responses – leads us to consider whether harm reduction holds promise for supply-oriented drug policy. The answer depends on which “version” of harm reduction one invokes.

In developing a harm-based approach to supply-oriented drug policy, we propose an amalgam of MacCoun, Caulkins, and Reuter's “harm reduction” and Weatherburn's “harm minimization.” We would treat harm reduction as an objective—not as a set of policies, programmes, or

A practical path forward

The literature on harm reduction suggests at least three possible analytic approaches: the first focuses on the harms of activities; the second focuses on the harms of policies; the third considers both. Preferring the third, we propose a practical path forward (see Fig. 4) that marries the objective of harm reduction with elements of national security's risk assessment and supports systematic policy evaluation.

Step 1 combines the stages of the 5-step risk-management process that constitute

Concluding remarks

In this paper, we have identified a central paradox of contemporary supply-oriented drug policy, evaluated the strengths and weaknesses of a harm-based approach to policy-making and analysis, and proposed a practical path forward. We suggest a two-step process, consisting of both a harm and a policy assessment. Paoli et al. (2010) have begun to test and refine elements of this process in the Belgian context and we look forward to undertaking harm and policy assessments in “messier” venues, such

Acknowledgements

We wish to thank our many enthusiastic colleagues, including Robert MacCoun, Peter Reuter, and John Walsh for encouraging our efforts. In addition, we are especially grateful to five anonymous reviewers who generously offered their diverse and thought-provoking perspectives and to our editors for helping us to reconcile and respond to five sets of review comments – the final product is much stronger for their input. Lastly, we thank Andries Zoutendijk and Annie Cosgrove-Davies for their

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