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The Politics of Addiction Last year, 64,000 Americans died from drug overdoses, a 22 percent increase from 2015. In the United States, death by overdose is now the leading cause of death for people under fifty, killing more people than car accidents or firearm homicides. Last October, President Trump officially declared the opioid crisis a “public health emergency,” and, a week later, his appointed commission released its report of recommendations. The document includes some important suggestions, such as removing legal roadblocks to overdose-reversal drugs and expanding access to medication-assisted treatment options. But the commission completely overlooked supervised injection facilities. Perhaps SIFs weren’t overlooked so much as consciously avoided. For most American policymakers, allowing addicts to use drugs in a legally sanctioned space is unthinkable. George W. Bush’s former drug czar described Insite’s operation as “state-sponsored suicide.” As hyperbolic as that description may seem, in the US it’s a fairly common way of characterizing harm-reduction strategies for addiction. Even needle-exchange programs (NEPs) — which have unquestionably been shown to lessen the transmission of disease — continue to face resistance. The most predictable opponents are conservative figures like Mike Pence, who shut down needle exchanges in Indiana on the grounds that drug use is morally wrong — with deadly results. But a less obvious logic is also at work, one that pushes even those most supportive of addicts away from proven harm-reduction practices. The United States’ dominant understanding of successful addiction treatment is remarkably narrow: addicts need to stop using drugs. The abstinence model, enshrined in twelve-step programs like Alcoholics Anonymous and Narcotics Anonymous, has cornered the rehabilitation market for decades. In contrast, harm reduction meets addicts as they are by giving them clean needles, or a safe space to use, or medications to assuage withdrawal symptoms — an approach that seems incompatible with the twelve-step movement’s focus on abstinence. Jane Nickels, the Public Relations Manager for Narcotics Anonymous, asserts that an addict combating dependence through medication-assisted treatment is “not clean.” Conservatives like Pence demand abstinence because they see drug use as an immoral and irresponsible choice that the addict must reject. But organizations like NA, ostensibly built to serve addicts, arrive at the same conclusion: the only route to “true” recovery is complete abstinence. But abstinence doesn’t work for most addicts, especially when it’s presented as the only option. This is particularly true for long-term opiate addicts and alcoholics, who suffer dangerous withdrawal symptoms when they try to stop using. Elsewhere in the world, SIFs, needle exchanges, and medication-assisted treatment have become points of transition: ways of caring for vulnerable addicts and possibly opening a path to recovery. When viewed through the lens of total abstinence, however, harm reduction looks quite different. Critics see it as an obstacle to recovery because it enables continued drug use. The American fixation on abstinence makes effective harm reduction impossible to implement. Anti-drug conservatives and ostensibly pro-addict twelve-steppers might have different reasons for extolling living clean, but the negative consequences for addicts — disease, overdose, and death — are the same.