Keith Humphreys is a professor of psychiatry and behavioral sciences at Stanford University and author of the new book Addiction: A Very Short Introduction. Humphreys was a senior policy adviser in the White House Office of National Drug Control Policy under President Barack Obama. He also advises Congress on strategies for dealing with and reducing drug addiction. In a late June email conversation with the Washington Examiner, Humphreys discussed the fentanyl epidemic, “harm reduction,” and many issues surrounding drug addiction and treatment. This is a lightly edited transcript of that conversation.
Washington Examiner: One question that you ask in your book is, “Why is the government involved in drug policy at all?” Why is it?
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Keith Humphreys: There’s an obvious and nonobvious reason. The obvious one is that drugs change human behavior in ways that impinge on the liberty of others (e.g., violence), which even strong libertarians generally acknowledge is a reason for state involvement. The less obvious reason is that addiction compromises individuals’ ability to use their own reason to pursue their personal good. Free markets and free society depend on individual judgment, and addiction compromises that, meaning the state has to step in to help people who cannot help themselves.
Washington Examiner: You are one of the foremost experts on addiction in the world. How does fentanyl stack up to previous drug-related epidemics?
Humphreys: The opioid epidemic that has ravaged the United States for a quarter century, from OxyContin to heroin to fentanyl, is the longest and deadliest illicit drug epidemic in U.S. history, and ranks with the worst in world history.
Washington Examiner: There is some debate over whether or not addiction constitutes a disease. Where do you come down?
Humphreys: I find that when people argue about whether it’s a disease, they are really arguing about other things, such as whether addicted people are responsible for what they do, whether we should treat them or punish them, and whether it’s OK or cruel to be angry at an addicted person for something they did. I approach addiction as a disease, and at the same time, I think addicted people are accountable for the decisions they make, including decisions that result in harm that invoke punishment. I support expanding treatment for everyone who wants it. And I never scold anyone who’s been hurt by an addicted person for being angry (e.g., “How dare you get mad at a sick person?”).
Washington Examiner: What is “harm reduction,” and who has supported it?
Humphreys: At its best, harm reduction is a pragmatic public health strategy that accepts that even when we can’t eliminate substance use, we can make it less damaging to the person and to society. A classic example is designated driver programs. People are still getting drunk, but at least they aren’t killing people with their car. That version of harm reduction has pretty wide support. I have never, for example, met a parent who would not want a paramedic to administer naloxone to their overdosed child, even though that is a classic example of harm reduction.
Where harm reduction gets controversial is in places like San Francisco, where some advocates phrase it as the right of everyone to take as many drugs as they want no matter how much other people are harmed. That’s a corruption of the concept in my opinion, because classically harm reduction values the whole population’s well-being rather than assigning no worth to the lives of people who don’t use drugs.
Washington Examiner: What is the record of harm reduction versus drug addiction treatment?
Humphreys: The science behind harm reduction is weaker than that behind treatment due to the difficulty of running rigorous studies of community interventions. That said, naloxone has been used to reverse hundreds of thousands of opioid overdoses which is clearly a good thing.
Where harm reduction falls short is when it is not coupled with robust prevention and treatment initiatives. If all we do is wait for people to become addicted and then try to make that situation a bit safer, the epidemic never ends. Epidemics end when you prevent fewer people from developing the problem and help those who have it escape their situation.
Washington Examiner: What works and what doesn’t work with needle exchanges?
Humphreys: Needle exchanges work pretty well for reducing the spread of HIV/AIDS, and they also serve as a contact point for other services, like naloxone distribution. They work less well for slowing the spread of hepatitis C because it’s both more prevalent and more transmissible than HIV.
Washington Examiner: You wrote about something at music festivals that people who don’t go to festivals may not be aware of. Many of them have medical “drug tents.” What goes on there, and how is that legal?
Humphreys: A drug tent includes staff and equipment that helps people determine the content of the drugs they have purchased, e.g., whether a pill labeled as an Ativan is actually that or instead is fentanyl. Some of these services are officially blessed by authorities, some are officially opposed, but most exist in a gray area. Sometimes the authorities don’t like the drug tents, but they also don’t like overdoses at music festivals, so they accept the trade-off and pretend it’s not happening.
Washington Examiner: One phrase not in your book was “moral panics.” Have you given any thought to how moral panics shape the way we think about addiction?
Humphreys: I used that concept early in my career as it helps explain why some small but symbolic events (e.g., a single overdose of a famous person) end up driving society kind of crazy. But moral panic has become an overused term in academic circles that is invoked to dismiss legitimate concerns by society, so I didn’t use it in the book. I mean, there is not a moral panic about fentanyl. There’s a rational panic because it’s a terrible problem.
Washington Examiner: Your book is number 724 in Oxford University Press’s long-running Very Short Introductions series. When did you become aware of this series, and how did you come to write a volume for it?
Humphreys: I owe the invitation to my friend and colleague Professor Sir John Strang, who is based in the U.K. and connected me to Oxford University Press. I decided to work with them after I saw some of their books on other topics in regular bookshops in the U.K., i.e., not just in catalogs of books being sold to university libraries. I saw this as a chance to reach a broader audience.
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Washington Examiner: What inclined you toward making a career out of studying addiction?
Humphreys: I got into the field by happenstance. I was flipping burgers and a fellow undergraduate said I could make a bit more money working as a research assistant at the local university, and she was right. That was an addiction study, and if it had been a depression or schizophrenia study my career might have been different. But I am grateful it worked out this way because addiction connects to every challenge society faces — child welfare, family breakdown, employment, crime, infectious disease — so I always feel I have something to add to the ongoing conversation about how to build a better world.
