essay about selling drugs

Selling Illegal Drugs: Psychological Reasons Essay

Introduction.

One fundamental question that comes to one’s mind is why people sell illegal drugs. However, one must note that selling of illegal drugs is a human behavior. This is a behavior, which is socially unacceptable because illegal drugs have harmful effects on their users. Generally, there are motivations and thoughts, which drive such behaviors in people. Psychology should help us to understand why people engage in selling illegal drugs. In addition, one ought to understand the role of the environment in such cases. This is antisocial personality behavior and disregard for social norms, which starts from a person’s mind.

The Situation of Selling Illegal Drugs

Drugs are important in alleviating illnesses and discomfort in people. However, there are certain regulated drugs, which are harmful to users because they cause severe health problems and addiction. As a result, authorities have banned such drugs. Nevertheless, illegal drugs find their ways in the streets. The society is aware of the prevalence of selling of illegal drugs. Majorities who sell and abuse illegal drugs are mainly youths.

Selling of illegal drugs is an act of antisocial behavior, which is socially unacceptable. Such people do not follow a set of laws, which provide order in society. Instead, they display behaviors, which do not conform to norms, and they tend to be aggressive and dishonest. The focus of individuals who sell drugs has been self-centered. The tendency to reject the expected behaviors in society originates from one’s own mind and motivations. People who sell drugs define laws, authorities, and establish their norms, which reflect criminal tendencies.

Selling illegal drugs also make such people to be aggressive and repulsive toward others because selling of illegal drugs is deviant behavior in society. It is important to understand the role of the mind and environments and their impacts on people who sell drugs. From psychological perspectives, one can understand thought processes, motivations, and intentions of people who engage in selling illegal drugs. Selling illegal drugs is usually a copied behavior that may have environmental influences based on societal norms. At the same time, it would also be important to explore the role of hereditary in such cases.

Analysis of the social, cultural, and spiritual influences on the individual’s behavior and his or her ethics

Social influences have significant impacts on behaviors of individuals who sell drugs. Such influences affect one’s thoughts, behaviors, and actions. Society and social groups are responsible for shaping illegal activities of people who engage in selling illegal drugs. In most cases, disorganized societies are responsible for antisocial behaviors among individuals. People who engage in selling illegal drugs could be from broken homes, crime zones, and unstable families, which highly influence their social behaviors and criminal conducts. Social groups may introduce a person to a culture of selling illegal drugs. A bad culture in which one grows up has a critical role in the development of a person’s antisocial behaviors and deviant tendencies like selling illegal drugs. For instance, if one associates with a bad company, it would influence him or her, and the persona may learn the group’s undesired behaviors.

People who sell illegal drugs may also have spiritual views and claim assert they do not have any controls on their behaviors or thought. Instead, they get such powers from unknown worlds. Overall, one must note that a person who sells illegal drugs may disregard ethical concepts of good or bad and choose his or her own lifestyle (Chen and Risen, 2010).

The reciprocal relationship between behavior and attitudes

People tend to focus on portraying their desired behaviors and act in a similar manner to reflect such attitudes and thinking. In this case, a person who believes in selling illegal drugs and aggression would only champion such behaviors and actions, and he or she will likely to believe in their influences. Myers shows that behaviors and attitudes have reciprocal relationships (Myers, 2010). In other words, one can think of being aggressive and act in a manner that would affect the way he or she thinks. Behaviors have the ability to project one’s thoughts and attitudes, which influence the subsequent action, particularly when one believes that he or she is responsible for his or her actions.

A person who sells illegal drugs knows that he or she causes social disorder through deviant and antisocial behaviors. Moreover, the person also knows the negative effects of illegal drugs on users. Rationalization in such people may result into ethical dilemma about the need to project good deeds and behaviors against harming others and society. Any changes in such people, to make their behaviors and attitudes consistent, result in lessening cognitive dissonance. This should create congruence between behaviors and beliefs.

Using cognitive dissonance theory to rationalize selling illegal drugs

In some cases, a person’s actions may conflict with his or her attitudes. This may lead to a change of attitudes for consistency with actions. A person who sells illegal drugs may justify his or her behavior by changing his attitudes and claim that selling illegal drugs was justified in his or her situation when faced with cognitive dissonance. The person may claim that he can only sell illegal drugs in his or her status, and this is a decision that supports his attitude toward selling drugs and being antisocial. The person believes that selling illegal drugs is important and acceptable in his or her situation. However, when he or she relieves cognitive dissonance, the person would wish to change his or her attitude and support the desired behavior (Van Veen, Krug, Schooler and Carter, 2009). This is a rationalization process.

When the person begins to rationalize his or her behavior, he or she would realize that selling illegal drugs does not improve his or her situation. Instead, it only creates unacceptable behaviors and outcomes in society. The feeling of revulsion and guilt with one’s self may make the person to change his or her behaviors (Fointiat, 2004). In addition, the person may change his attitude later if he or she faces the same situation.

Social, cultural, and spiritual influences may affect one’s behaviors and attitudes. As a result, an individual may begin to rationalize his or her behaviors and attitudes in order to establish congruence. However, this may not be the case, as it creates discomfort. Cognitive dissonance makes the person to rationalize his or her behaviors and actions in order to lessen the tension as a way of accommodating such behaviors. This is a process of attempting to justify an act of selling illegal drugs and antisocial behaviors. As a result, cognitive dissonance will help the person to establish congruence between his or her attitudes and behaviors, and lessen inner conflicts.

Chen, K., and Risen, L. (2010). How choice affects and reflects preferences: Revisiting the free-choice paradigm. Journal of Personality and Social Psychology, 99 (4), 573-594.

Fointiat, V. (2004). I know what I have to do, but…When hypocrisy leads to behavioral change. Social Behavior and Personality, 32 , 741-746.

Myers, D. (2010). Social psychology (10th ed.). New York, NY: McGraw Hill.

Van Veen, V., Krug, K., Schooler, W., and Carter, S. (2009). Neural activity predicts attitude change in cognitive dissonance. Nature Neuroscience, 12 (11), 1469-1474. Web.

• Mental Disorders: Effects and Components
• What Is Strauss Syndrome?
• Cognitive Dissonance and Reduction Strategies
• Organizational Diagnostic Models: Congruence Model
• Cognitive Dissonance and How to Deal With It
• Post Traumatic Stress Disorder: Joseph Wolpe Treatment Theory
• Mental Disorders: Diagnosis and Statistics
• Psychoanalytic Theory: Understanding the Persistent Deviant
• Mood and Addictive Disorders in Psychology
• Clinical Diagnosis and Treatment
• Chicago (A-D)
• Chicago (N-B)

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Seeing The Humanity Of People Who Sell Drugs

Spotlights like this one provide original commentary and analysis on pressing criminal justice issues of the day. You can read them each day in our newsletter, The Daily Appeal. In 2014, Morgan Godvin’s best friend, Justin DeLong, experienced a fatal drug overdose. She had sold him the heroin he used. The next night, police officers raided […]

Spotlights like this one provide original commentary and analysis on pressing criminal justice issues of the day. You can read them each day in our newsletter,  The Daily Appeal .

In 2014, Morgan Godvin’s best friend, Justin DeLong, experienced a fatal drug overdose. She had sold him the heroin he used. The next night, police officers raided her apartment and placed her under arrest. She was 24, and her mother had died of an overdose three months earlier. Federal prosecutors charged Godvin with “delivery resulting in death” for her friend’s overdose, a charge that she was told carried a 20-year minimum sentence. She ended up pleading guilty to conspiracy to distribute heroin and spent the next five years in prison.

Last month, in  a commentary  in the Washington Post, Godvin laid out how misguided the government’s response to her friend’s death was and how it failed to recognize the overlap between those who use drugs and those who sell them. “To purchase heroin, you have to know someone who has it, or know someone who knows someone who does. Friends and acquaintances formed our network. The vast majority of heroin dealers I met were not in it to make money. They simply supported their own habit by selling to people they knew who were also addicted. The archetypal predatory drug dealer is a myth. For many, a sale is not about ruthless profit; it is about survival.”

But as the overdose crisis has taken hundreds of thousands of lives in recent years, prosecutions like Godvin’s have become increasingly common. Several states have enacted laws akin to the laws under which she was prosecuted or have made their existing laws harsher.

This week, the Drug Policy Alliance delivered a comprehensive rebuttal to this policy response and the worldview that drives it. In a  new report , the organization calls for an end to the broad demonization of and harsh penalties for people selling drugs. It is necessary, the report says, to “rethink the ‘drug dealer.’” The authors note: “Policymakers in the United States increasingly recognize that drug use should be treated as a public health instead of a criminal issue.” Yet, “the softening of public opinion has not extended to people involved in drug selling or distribution, as politicians on both sides of the aisle have made clear.”

The impulse to conceive of people who sell drugs as a category distinct from people who use them is both misguided and counterproductive, the report states. “Politicians and prosecutors who say they want a public health approach to drug use, but harsh criminal penalties for anyone who sells, are in many cases calling for the imprisonment and non-imprisonment of the very same people.”

In 2012, over 80 percent of those arrested for distribution offenses in Chicago tested positive for drug use. In New York and Sacramento it was over 90 percent. Moreover, the laws criminalizing drug sales are written so broadly that people arrested with drugs for their own use are frequently charged as dealers.

The narrative of the dangerous drug dealer also has a long history. It is “a deeply racialized narrative in which illegal drug use is driven by drug sellers (often portrayed as people of color) who push drugs on vulnerable people (often white people) to get them hooked.”

Writing for The Appeal this week, Zachary Siegel  reviews the report’s prescribed reforms , which include the repeal of drug-induced homicide laws; calling on progressive prosecutors to decline to prosecute certain sale and distribution-related offenses; and radically reducing the number of arrests police treat as drug sale and distribution.

While advocating for a number of “incremental reforms,” the Drug Policy Alliance remains committed to fundamental changes to how drug use and drug markets are  viewed. “As we consider new approaches for people who use, we also need to explore options for addressing drug sales outside the criminal justice system,” Lindsay LaSalle, managing director of public health law and policy at the Drug Policy Alliance  told The Appeal . “We need a radical shift away from supply side interventions and must truly examine both the demand for drugs and the economic and structural reasons why people may be selling drugs.”

Ultimately, the distinctions between drug buyers and sellers draws on the same zero-sum instinct—the desire to sort people into opposing categories—as seen in conversations about victims versus offenders and people charged with nonviolent crimes versus those charged with violent crimes. In the discussions of reforms that help free people charged with nonviolent versus those charged with violent crimes, there is the constant risk of presenting one group as deserving at the expense of the other. In the conversations about victims and offenders there is a systemic unwillingness to recognize that many of those who commit harm have themselves been harmed. And for those who have suffered, it seems too often as though the state’s recognition of one’s humanity comes only in the form of the criminal legal system trying to find someone to blame and punish—however irrelevant an exercise that might be.

In her commentary, Godvin points out the lack of support available to her friend while he lived and the massive law enforcement resources mobilized in his name after he died. “Society offered no compassionate resources to Justin while he was alive—only a dozen arrests and a prison sentence, none of which helped him overcome addiction.” But “the federal government poured resources into convicting five people for his accidental overdose—me, my roommate who sold me my heroin, his dealer and that man’s two dealers—sentencing us to 60 total years in prison for Justin’s death.” That enormous amount of incarceration changed nothing. “The flow of heroin in our city, Portland, continued without a moment’s interruption. In the years after the trial, the  rate of fatal heroin overdoses  in Oregon even increased.”

Kellogg School of Management at Northwestern University

Policy Jul 6, 2015

The economics of the illegal drug market, an argument for sentencing dealers based on the purity of their product..

Manolis Galenianos

Rosalie Liccardo Pacula

Nicola Persico

What does the illegal drug market look like to an economist?

This research recently won Kellogg’s Stanley Reiter Best Paper Award.

This is what the Kellogg School’s Nicola Persico set out to learn. A better understanding of the key features of the market for illicit drugs, he reasoned, could lead to more effective policies and enforcement practices.

Persico, a professor of managerial economics and decision sciences at the Kellogg School, developed a new model of the drug market that accounts for the fact that buyers do not know a drug’s purity before purchasing it, as well as the fact that they cannot contest sales of impure drugs.

The model provides a fuller picture of the drug market, and it includes some surprising implications. For one, police presence may actually increase buyer loyalty to specific sellers. And if policymakers choose to impose more lenient sentences on sellers of impure drugs, overall demand for drugs could decrease.

A Problem of Highest Priority

The United States’ war on drugs is tremendously costly —not only in terms of money spent, but also with regard to police manpower, legal proceedings, and long-term incarceration. “Illegal drugs arguably represent the number-one law enforcement issue in the U.S.,” Persico says, “so figuring out how to make progress in this area is very important.”

Persico’s previous work on racial profiling by police brought him to a criminology conference where drug scholar Peter Reuters discussed the issue of price dispersion in the illicit-drug market—that is, how drugs of the same type sold for very different prices in different places and at different times.

That observation got Persico thinking about the drug market in general: How did its structure differ from markets for legal products and services? Which economic models explained it best? And, importantly, what implications for policy and enforcement could be derived from a better understanding of the drug market?

Beyond Supply and Demand

Past efforts to characterize the drug market relied on standard supply-and-demand models. “It’s Econ 101,” Persico says. “The demand curve slopes down and the supply curve slopes up, and where they meet is the equilibrium point, or market-clearing price.” He acknowledges that this basic model has virtue, but wished to take a “Drug Market 2.0” approach, as he called it, to gain a better understanding of market structure and dynamics.

“If there’s a lot of police enforcement, buyers take more risk switching sellers because the next seller could be an undercover police officer.”

Part of that approach was the recognition that while illicit drugs share some economic qualities with agricultural commodities like coffee, drugs sell at a much higher price. And, more importantly, drug transactions are not enforceable through the legal system.

Persico and coauthors Manolis Galenianos of Royal Holloway College and Rosalie Liccardo Pacula of RAND Corporation used Drug Enforcement Administration information on drug transactions (heroin, cocaine, and others) in the U.S. from 1981 to 2003. The data the DEA supplied came from informants, undercover agents, and technicians, and included price, location, and purity of the drugs. An additional data set provided information on those arrested for buying and using drugs, and included demographics, number of dealers transacted with, difficulty locating dealers, and price paid.

Preliminary data analysis highlighted the unenforceability issue in a big way. “We saw the price dispersion, as expected, but also that about 5–10 percent of the transactions were completely fake ,” Persico said. “Those transactions—‘rip-offs’—involved no drug content at all, but buyers paid the same average amount for the product as they did for real drugs.” For example, 8.2 percent of all heroin transactions were rip-offs. “If someone sells me coffee that’s actually dirt, I can take them to court,” Persico says. “I can’t do that with heroin or cocaine.”

If you are buying an illegal drug, you only learn its purity after the sale is made. Why does that matter? “The inability to know the quality of drugs before purchase, combined with the unenforceability, means the drug market is always on the brink of collapse, as there will be incentive on the part of sellers not to make good on the product quality expected,” Persico says. Recognizing this “moral hazard” on the sellers’ part is critical for understanding the drug market—and addressing it more effectively.

Buy, Sell, Repeat

One question raised by Persico’s line of thinking was how the drug market could continue to exist in the first place—and even flourish—given the incentive for rip-offs. He believed there was a simple explanation: repeated interactions between the same buyers and sellers.

To explore this mechanism, the researchers turned to labor economics models pioneered by former Northwestern University economics professor and Nobel Prize winner Dale Mortensen —models originally developed to understand when and why workers switched from one employer to another. “The labor models assume that quality of the work—or the ‘product’—is consistent,” Persico says, “but that’s not a fair assumption in the drug market.” So the researchers adapted their model to account for the reality that a drug buyer will not be able to know the product quality when dealing with a seller for the first time.

When the researchers included the moral-hazard component in the models, they could see that having buyers who repeatedly patronize the same seller helps keep the market sustainable. In other words these frequent shoppers keep their dealers honest by discouraging rip-offs. For example, 76 percent of frequent heroin users reported buying drugs most recently from their regular dealer. “Where quality can’t be enforced by courts, the only thing that keeps it at a reasonable level is repeated interactions,” Persico says.

On this point, Persico speculates that greater police presence—including the undercover variety—actually makes repeated interactions more likely, thus increasing drug purity. “If there’s a lot of police enforcement, buyers take more risk switching sellers because the next seller could be an undercover police officer,” he says.

And that helps keep the drug market going.

Better Enforcement Means Lesser Enforcement

Out of Persico’s research emerges a logical but controversial enforcement recommendation: less harsh sentences for those selling less pure drugs.

Using tougher penalties for drug convictions has not reduced drug affordability; cocaine and heroin prices have fallen significantly, despite stronger enforcement. Less harsh sentencing for sellers of impure drugs will result, theoretically, in a higher proportion of rip-offs, because such sellers will spend less time in jail and face less deterrence than their pure-drug-selling counterparts. A higher rate of rip-offs would, the model shows, encourage more buyers to exit, leveraging the moral hazard to erode demand for illicit drugs.

Carrying this logic to the limit, Persico believes there should be zero penalty for a 100 percent-impure drug sale. “If someone’s selling sugar under the pretense of selling cocaine, let’s celebrate this guy!” he says. “The penalty should be for the actual amount of illicit substance sold, not the amount purportedly sold—let the punishment fit the actual crime.”

Persico’s enforcement suggestion potentially addresses an important social issue as well, given that those incarcerated for drug offenses tend to be from minority and low-income populations. “A more lenient sentencing policy would get people out of jail faster, save taxpayer money, and keep the percentage of rip-offs higher,” he says. “Who could be against that?”

Persico acknowledges the challenge of implementing his policy suggestion. “It’s not clear if the government would take our sentencing recommendation seriously,” he says.

Drug markets will continue to evolve. Some markets, like that for marijuana, have even moved from illicit to legal in some US states . The key takeaway from Persico’s research, then, is that to address any drug market and develop effective policies related to it, we first have to understand its dynamics and unique features.

That is a prescription well worth following.

John L. and Helen Kellogg Professor of Managerial Economics & Decision Sciences; Director of the Center for Mathematical Studies in Economics & Management; Professor of Weinberg Department of Economics (courtesy)

About the Writer Sachin Waikar is a freelance writer based in Evanston, Illinois.

Galenianos, Manolis, Rosalie Liccardo Pacula, and Nicola Persico. 2012. “A Search-Theoretic Model of the Retail Market for Illicit Drugs.” Review of Economic Studies . 79(2): 1239–1269.

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Understanding the Demand for Illegal Drugs (2010)

Chapter: 1 introduction, 1 introduction.

A merica’s problem with illegal drugs seems to be declining, and it is certainly less in the news than it was 20 years ago. Surveys have shown a decline in the number of users dependent on expensive drugs (Office of National Drug Control Policy, 2001), an aging of the population in treatment (Trunzo and Henderson, 2007), and a decline in the violence related to drug markets (Pollack et al., 2010). Still, research indicates that illegal drugs remain a concern for the majority of Americans (Caulkins and Mennefee, 2009; Gallup Poll, 2009).

There is virtually no disagreement that the trafficking in and use of cocaine, heroin, and methamphetamine continue to cause great harm to the nation, particularly to vulnerable minority communities in the major cities. In contrast, there is disagreement about marijuana use, which remains a part of adolescent development for about half of the nation’s youth. The disagreement concerns the amount, source, and nature of the harms from marijuana. Some note, for example, that most of those who use marijuana use it only occasionally and neither incur nor cause harms and that marijuana dependence is a much less serious problem than dependence on alcohol or cocaine. Others emphasize the evidence of a potential for triggering psychosis (Arseneault et al., 2004) and the strengthening evidence for a gateway effect (i.e., an opening to the use of other drugs) (Fergusson et al., 2006). The uncertainty of the causal mechanism is reflected in the fact that the gateway studies cannot disentangle the effect of the drug itself from its status as an illegal good (Babor et al., 2010).

The federal government probably spends $20 billion per year on a wide array of interventions to try to reduce drug consumption in the United States, from crop eradication in Colombia to mass media prevention programs aimed at preteens and their parents. 1 State and local governments spend comparable amounts, mostly for law enforcement aimed at suppressing drug markets. 2 Yet the available evidence, reviewed in detail in this report, shows that drugs are just as cheap and available as they have ever been.

Though fewer young people are starting to use drugs than in some previous years, for each successive birth cohort that turns 21, approximately half have experimented with illegal drugs. The number of people who are dependent on cocaine, heroin, and methamphetamine is probably declining modestly, 3 and drug-related violence has appears to have declined sharply. 4 At the same time, injecting drug use is still a major vector for HIV transmission, and drug markets blight parts of many U.S. cities.

The declines in drug use that have occurred in recent years are probably mostly the natural working out of old epidemics. Policy measures— whether they involve prevention, treatment, or enforcement—have met with little success at the population level (see Chapter 4 ). Moreover, research on prevention has produced little evidence of any targeted interventions that make a substantial difference in initiation to drugs when implemented on a large scale. For treatment programs, there is a large body of evidence of effectiveness and cost-effectiveness (reviewed in Babor et al., 2010), but the supply of treatment facilities is inadequate and,

perversely, not enough of those who need treatment are persuaded to seek it (see Chapter 4 ). Efforts to raise the price of drugs through interdiction and other enforcement programs have not had the intended effects: the prices of cocaine and heroin have declined for more than 25 years, with only occasional upward blips that rarely last more than 9 months (Walsh, 2009).

STUDY PROJECT AND GOALS

Given the persistence of drug demand in the face of lengthy and expensive efforts to control the markets, the National Institute of Justice asked the National Research Council (NRC) to undertake a study of current research on the demand for drugs in order to help better focus national efforts to reduce that demand. In response to that request, the NRC formed the Committee on Understanding and Controlling the Demand for Illegal Drugs. The committee convened a workshop of leading researchers in October 2007 and held two follow-up meetings to prepare this report. The statement of task for this project is as follows:

An ad hoc committee will conduct a workshop-based study that will identify and describe what is known about the nature and scope of markets for illegal drugs and the characteristics of drug users. The study will include exploration of research issues associated with drug demand and what is needed to learn more about what drives demand in the United States. The committee will specifically address the following issues:

What is known about the nature and scope of illegal drug markets and differences in various markets for popular drugs?

What is known about the characteristics of consumers in different markets and why the market remains robust despite the risks associated with buying and selling?

What issues can be identified for future research? Possibilities include the respective roles of dependence, heavy use, and recreational use in fueling the market; responses that could be developed to address different types of users; the dynamics associated with the apparent failure of policy interventions to delay or inhibit the onset of illegal drug use for a large proportion of the population; and the effects of enforcement on demand reduction.

Drawing on commissioned papers and presentations and discussions at a public workshop that it will plan and hold, the committee will prepare a report on the nature and operations of the illegal drug market in the United States and the research issues identified as having potential for informing policies to reduce the demand for illegal drugs.

The committee drew on economic models and their supporting data, as well as other research, as one part of the evidentiary base for this

report. However, the context for and content of this report were informed as well by the general discussion and the presentations in the workshop. The committee was not able to fully address task 2 because research in that area is not strong enough to give an accurate description of consumers across different markets nor to address the questions about why markets remain robust despite the risks associated with buying and selling. The discussion at the workshop underscored the point that neither the available ethnographic research nor the limited longitudinal research on drug-seeking behavior is strong enough to inform these questions related to task 2. With regard to task 3, the committee benefitted considerably from the paper by Jody Sindelar that was presented at the workshop and its discussion by workshop participants.

This study was intended to complement Informing America’s Policy on Illegal Drugs: What We Don’t Know Keeps Hurting Us (National Research Council, 2001) by giving more attention to the sources of demand and assessing the potential of demand-side interventions to make a substantial difference to the nation’s drug problems. This report therefore refers to supply-side considerations only to the extent necessary to understand demand.

The charge to the committee was extremely broad. It could have included reviewing the literature on such topics as characteristics of substance users, etiology of initiation of use, etiology of dependence, drug use prevention programs, and drug treatments. Two considerations led to narrowing the focus of our work. The first was substantive. Each of the topics just noted involves a very large field of well-developed research, and each has been reviewed elsewhere. Moreover, each of these areas of inquiry is currently expanding as a result of new research initiatives 5 and new technologies (e.g., neuroimaging, genetics). The second consideration was practical: given the available resources, we could not undertake a complete review of the entire field.

Thus, we decided to focus our work and this report tightly on demand models in the field of economics and to evaluate the data needs for advancing this relatively undeveloped area of investigation. That is, this area has a relatively shorter history of accumulated findings than the more clinical, biological, and epidemiological areas of drug research. Yet it is arguably better situated to inform government policy at the national level. A report on economic models and supporting data seemed to us more timely than a report on drug consumers and drug interventions.

The rest of this chapter briefly lays out some concepts that provide a basis for understanding the committee’s work and the rest of the report.

Chapter 2 presents the economic framework that seems most useful for studying the phenomenon of drug demand. It emphasizes the importance of understanding the responsiveness of demand and supply to price, which is the intermediate variable targeted by the principal government programs in the United States, namely, drug law enforcement. Chapter 3 then examines changes in the consumption of drugs and assesses the various indicators that are available to measure that consumption. Chapter 4 turns to the program type that most focuses specifically on reducing drug demand, the treatment of dependent users. It considers how well these programs work and how the treatment system might be expanded to further reduce consumption. Finally, Chapter 5 presents our recommendations for how the data and research base might be built to improve understanding of the demand for drugs and policies to reduce it.

PROGRAM CONCEPTS

A standard approach to considering drug policy is to divide programs into supply side and demand side. This approach accepts that drugs, as commodities, albeit illegal ones, are sold in markets. Supply-side programs aim to reduce drug consumption by making it more expensive to purchase drugs through increasing costs to producers and distributors. Demand-side programs try to lower consumption by reducing the number of people who, at a given price, seek to buy drugs; the amount that the average user wishes to consume; or the nonmonetary costs of obtaining the drugs. This approach has value, but it also raises questions.

The value of this framework is that it allows systematic evaluation of programs. A successful supply-side program will raise the price of drugs, as well as reduce the quantity available, while a demand-side program will lower both the number of users and the quantity consumed, as well as eventually reducing the price. As noted above, this report is primarily focused on improving understanding of the sources of demand.

There are two basic objections to this approach. First, some programs have both demand- and supply-side effects. Since many dealers are themselves heavy users, drug treatment will reduce supply, just as incarceration of drug dealers lowers demand. Second, there is a collection of programs that do not attempt to reduce demand or supply; rather, their goal is to reduce the damage that drug use and drug markets cause society, which are generally referred to as “harm-reduction” programs (Iversen, 2005; National Institute on Drug Abuse, 2010). 6 Nonetheless, the classifi-

cation of interventions into demand reduction and supply reduction is a very helpful heuristic for policy purposes, as well as being written into the legislation under which the Office of National Drug Control Policy operates.

What determines the demand for drugs? Clearly, many different factors play a role: cultural, economic, and social influences are all important. At the individual level, a rich set of correlates have been explored, either in large-scale cross-sectional surveys (such as the National Survey on Drug Use and Health and the National Household Survey on Drug Abuse) or in small-scale longitudinal studies (see, e.g., Wills et al., 2005). Below we briefly summarize the complex findings of those studies.

Less has been done at the population level. It is known that rich western countries differ substantially in the extent of drug use, in ways that do not seem to reflect policy differences. For example, despite the relatively easy access to marijuana in the Netherlands, that nation has a prevalence rate that is in the middle of the pack for Europe, while Britain, despite what may be characterized as a pragmatic and relatively evidence-oriented drug policy, has Europe’s highest rates of cocaine and heroin addiction (European Monitoring Center for Drugs and Drug Addiction, 2007). There is only minimal empirical research that has attempted to explain those differences. Similarly, there is very little known about why epidemics of drug use occur at specific times. In the United States, for example, there is no known reason for the sudden spread of methamphetamine from its long-term West Coast concentration to the Midwest that began in the early 1990s. There are only the most speculative conjectures as to the proximate causes.

A DYNAMIC AND HETEROGENEOUS PROCESS

The committee’s starting point is that drug use is a dynamic phenomenon, both at the individual and community levels. In the United States there is a well-established progression of use of substances for individuals, starting with alcohol or cigarettes (or both) and proceeding through marijuana (at least until recently) possibly to more dangerous and expensive drugs (see, e.g., Golub and Johnson, 2001). Such a progression seems to be a common feature of drug use, although the exact sequence might not apply in other countries and may change over time. For example, cigarettes may lose their status as a gateway drug because of new restrictions on their use. 7 Recently, abuse of prescription drugs has emerged as a possible gateway, with high prevalence rates reported for youth aged 18-25;

however, because of limited economic research on this phenomenon, this report’s focus is on completely illegal drugs.

At the population level, there are epidemics, in which, like a fashion good, a new drug becomes popular rapidly in part because of its novelty and then, often just as rapidly, loses its appeal to those who have not tried it. For addictive substances (including marijuana but not hallucinogens, such as LSD), that leaves behind a cohort of users who experimented with the drug and then became habituated to it.

An important and underappreciated element of the demand for illegal drugs is its variation in many dimensions. For example, the demand for marijuana may be much more responsive to price changes than the demand for heroin because fewer of those who use marijuana are drug dependent (Iversen, 2005; National Institute on Drug Abuse, 2010). Users who are employed, married, and not poor may be more likely to desist than users of the same drug who are unemployed, not part of an intact household, and poor. There may be differences in the characteristics of demand associated with when the specific drug first became available in a particular community, that is, whether it is early or late in a national drug “epidemic.”

There are also unexplained long-term differences in the drug patterns in cities that are close to each other. In Washington, DC, in 1987 half of all those arrested for a criminal offense (not just for drugs) tested positive for phencyclidine, while in Baltimore, 35 miles away, the drug was almost unknown. Although the Washington rate had fallen to approximately 10 percent in 2009 (District of Columbia Pretrial Services Agency, 2009), it remains far higher than in other cities. More recently, the spread of methamphetamine has shown the same unevenness: in San Antonio only 2.3 percent of arrestees tested positive for methamphetamine in 2002; in Phoenix, the figure was 31.2 percent (National Institute of Justice, 2003). These differences had existed for more than 10 years.

The implication of this heterogeneity is that programs that work for a particular drug, user type, place, or period may be much less effective under other circumstances, which substantially complicates any research task. It is hard to know how general are findings on, say, the effectiveness of a prevention program aimed at methamphetamine use by adolescents in a city where the drug has no history. Will this program also be effective for trying to prevent cocaine use among young adults in cities that have long histories of that drug?

This report does not claim to provide the answers to such ambitious questions. It does intend, however, to equip policy officials and the public to understand what is known and what needs to be done to provide a more sound base for answering them.

Arseneault, L., M. Cannon, J. Witten, and R. Murray. (2004). Causal association between cannabis and psychosis: Examination of the evidence. British Journal of Psychiatry, 184 , 110-117.

Babor, T., J. Caulkins, G. Edwards, D. Foxcroft, K. Humphreys, M.M. Mora, I. Obot, J. Rehm, P. Reuter, R. Room, I. Rossow, and J. Strang. (2010). Drug Policy and the Public Good . New York: Oxford University Press.

Carnevale, J. (2009). Restoring the Integrity of the Office of National Drug Control Policy. Testimony at the hearing on the Office of National Drug Control Policy’s Fiscal Year 2010 National Drug Control Budget and the Policy Priorities of the Office of National Drug Control Policy Under the New Administration. The Domestic Policy Subcommittee of the House Committee on Oversight and Government Reform. May 19, 2009. Available: http://carnevaleassociates.com/Testimony%20of%20John%20Carnevale%20May%2019%20-%20FINAL.pdf [accessed August 2010].

Caulkins, J., and R. Mennefee. (2009). Is objective risk all that matters when it comes to drugs? Journal of Drug Policy Analysis , 2 (1), Art. 1. Available: http://www.bepress.com/jdpa/vol2/iss1/art1/ [accessed August 2010].

District of Columbia Pretrial Services Agency. (2009). PSA’s Electronic Reading Room—FOIA. Available: http://www.dcpsa.gov/foia/foiaERRpsa.htm [accessed May 2009].

European Monitoring Center for Drugs and Drug Addiction. (2007). 2007 Annual Report: The State of the Drug Problem in Europe. Lisbon, Portugal. Available: http://www.emcdda.europa.eu/publications/annual-report/2007 [accessed May 2009].

Fergusson, D.M., J.M. Boden, and L.J. Horwood. (2006). Cannabis use and other illicit drug use: Testing the cannabis gateway hypothesis. Addiction, 6 (101), 556-569.

Gallup Poll. (2009). Illegal Drugs . Available: http://www.gallup.com/poll/1657/illegal-drugs.aspx [accessed April 2010].

Golub, A., and B. Johnson. (2001). Variation in youthful risks of progression from alcohol and tobacco to marijuana and to hard drugs across generations. American Journal of Public Health, 91 (2), 225-232.

Iversen, L. (2005). Long-term effects of exposure to cannabis. Current Opinion in Pharmacology, 5 (1), 69-72. Available: http://www.safeaccessnow.org/downloads/long%20term%20cannabis%20effects.pdf [accessed July 2010].

National Institute of Justice. (2003). Preliminary Data on Drug Use & Related Matters Among Adult Arrestees & Juvenile Detainees 2002 . Washington, DC: U.S. Department of Justice.

National Institute on Drug Abuse. (2010). NIDA InfoFacts: Heroin . Available: http://www.drugabuse.gov/infofacts/heroin.html [accessed August 2010].

National Research Council. (2001). Informing America’s Policy on Illegal Drugs: What We Don’t Know Keeps Hurting Us. Committee on Data and Research for Policy on Illegal Drugs, C.F. Manski, J.V. Pepper, and C.V. Petrie (Eds.). Committee on Law and Justice and Committee on National Statistics. Commission on Behavioral and Social Sciences and Education. Washington, DC: National Academy Press.

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Office of National Drug Control Policy. (2001). What America’s Users Spend on Illegal Drugs 1988–2000 . W. Rhodes, M. Layne, A.-M. Bruen, P. Johnston, and L. Bechetti. Washington, DC: Executive Office of the President.

Pollack, H., P. Reuter., and P. Sevigny. (2010). If Drug Treatment Works So Well, Why Are So Many Drug Users in Prison? Paper presented at the meeting of the National Bureau of Economic Research on Making Crime Control Pay: Cost-Effective Alternatives to Incarceration, July, Berkeley, CA. Available: http://www.nber.org/chapters/c12098.pdf [accessed August 2010].

Trunzo, D., and L. Henderson. (2007). Older Adult Admissions to Substance Abuse Treatment: Findings from the Treatment Episode Data Set . Paper presented at the meeting of the American Public Health Association, November 6, Washington, DC. Available: http://apha.confex.com/apha/135am/techprogram/paper_160959.htm [accessed August 2010].

Walsh, J. (2009). Lowering Expectations: Supply Control and the Resilient Cocaine Market. Available: http://www.eluniversal.com.mx/graficos/pdf09/wolareportcocaine.pdf [accessed August 2010].

Wills, T., C. Walker, and J. Resko. (2005). Longitudinal studies of drug use and abuse. In Z. Slobada (Ed.), Epidemiology of Drug Abuse (pp. 177-192). New York: Springer.

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Despite efforts to reduce drug consumption in the United States over the past 35 years, drugs are just as cheap and available as they have ever been. Cocaine, heroin, and methamphetamines continue to cause great harm in the country, particularly in minority communities in the major cities. Marijuana use remains a part of adolescent development for about half of the country's young people, although there is controversy about the extent of its harm.

Given the persistence of drug demand in the face of lengthy and expensive efforts to control the markets, the National Institute of Justice asked the National Research Council to undertake a study of current research on the demand for drugs in order to help better focus national efforts to reduce that demand.

This study complements the 2003 book, Informing America's Policy on Illegal Drugs by giving more attention to the sources of demand and assessing the potential of demand-side interventions to make a substantial difference to the nation's drug problems. Understanding the Demand for Illegal Drugs therefore focuses tightly on demand models in the field of economics and evaluates the data needs for advancing this relatively undeveloped area of investigation.

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Dark web, not dark alley: why drug sellers see the internet as a lucrative safe haven

Associate Professor in Criminology, Swinburne University of Technology

Vice Chancellor’s Senior Research Fellow, Social and Global Studies Centre, RMIT University

Disclosure statement

James Martin receives funding from the Australian Institute of Criminology, who funded this particular study, as well as the National Health and Medical Research Council.

Monica Barratt receives funding from Australian (National Health and Medical Research Council, the Australian Institute of Criminology, the National Centre for Clinical Research into Emerging Drugs) and international (US National Institutes of Health, NZ Marsden Fund) funders. She has recently conducted commissioned research for the NSW Coroner's Office, the WA Mental Health Commission and the Victorian Department of Health and Human Services. Monica also volunteers for not-for-profit harm reduction organisations: The Loop Australia and Bluelight.org

RMIT University provides funding as a strategic partner of The Conversation AU.

Swinburne University of Technology provides funding as a member of The Conversation AU.

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More than six years after the demise of Silk Road, the world’s first major drug cryptomarket , the dark web is still home to a thriving trade in illicit drugs.

These markets host hundreds, or in some cases thousands, of people who sell drugs, commonly referred to as “vendors”. The dark web offers vital anonymity for vendors and buyers, who use cryptocurrencies such as Bitcoin to process transactions.

Trade is booming despite disruptions from law enforcement and particularly “exit scams”, in which market admins abruptly close down sites and take all available funds.

Read more: Explainer: what are drug cryptomarkets?

Why are these markets still seen as enticing places to sell drugs, despite the risks? To find out, our recent study surveyed 13 darknet drug vendors, via online encrypted interviews.

They gave us a range of reasons.

More profitable

First, selling drugs online is safer and more profitable than doing it offline:

Interviewer: So you still sell on DNMs [darknet marketplaces], and prefer that to offline. Correct? Respondent: YES. Selling offline is borderline stupid. You can make so much more money online, the risks [in selling outside cryptomarkets] aren’t even remotely worth it.

Both of these claims correspond with previous research showing that the dark web is perceived to be a safer place to buy and sell drugs.

Regarding profits, darknet vendors do not have to limit their trading to face-to-face interactions, and can instead sell drugs to a potentially worldwide customer base.

Read more: Explainer: what is the dark web?

Less violent

Encryption technologies allow vendors to communicate with customers and receive payments anonymously. The drugs are delivered in the post, so vendor and customer never have to meet in person.

This protects vendors from many risks that are prevalent in other forms of drug supply, including undercover police, predatory standover tactics where suppliers may be robbed, assaulted or even killed by competitors, and customers who may inform on their supplier if caught.

Other risks, such as frauds perpetrated by customers and exit scams, were considered inevitable on the dark web, but also manageable.

Some respondents said that being protected from physical risk on the dark web is not only a benefit for existing drug suppliers, but may also make the activity attractive to people who would not otherwise be willing to sell drugs.

While some of our respondents had previously sold drugs offline, others were uniquely attracted to the perceived safety and anonymity of the dark web:

I hadn’t ever thought about selling drugs in any capacity because I dislike violence and it just seemed impossible to be involved in selling drugs in “real life” without running into some sort of confrontation pretty quickly… I was always too scared and slightly nerdy to do that and never really contemplated it seriously until the dark web.

More customer-focused

Some vendors told us the feeling of safety and control lets them focus on providing a more courteous service to their customers or “clients”:

I try to provide the best products and service I can, when someone has a problem or claims [their order was] short on pills (as long as they have ordered from me before) I usually take them at their word.

This is a stark contrast with perceptions of the street trade, which some of our respondents perceived not only as “small-time”, but also rife with danger and potential violence:

The street trade is a mess. I wanna provide labelled products, good advice and service, like a real business. Not sit in a shitty car park selling $10 bags from a car window all day.

Read more: Australia emerges as a leader in the global darknet drugs trade

Not just about profit

Dark web vendors also pointed out the various non-material benefits of their work. These included feelings of autonomy and emancipation from boring work and onerous bosses, as well as excitement and the thrill of transgression. One respondent described it as:

Exhilarating … and nerve-wracking. Seemed so alien. “Drugs? Online? In the post? Naaaah surely not.” Plus if I’m honest, my inner reprobate buzzes from it. The rush of chucking a grand’s worth of drugs into post boxes… unreal, man.

Interviewees rationalised their participation in the dark web drugs trade in a variety of ways. These included pointing out the relative safety and medicinal benefits of some illicit drugs, and the dangers associated with drug prohibition .

Let’s face it, a LOT of people like getting high… It’s human nature, but to ban it and make it criminal so that it’s hard to get, then you get poison and people die… I can tell you that the use of darknet protects users from buying products that during traditional prohibition would likely kill much more people. It also takes drugs off the street, reducing some violent crime.

These insights help us understand why the dark web is increasingly attractive, not only to consumers of illicit drugs but to the people who supply them.

For those who are averse to confrontation, and who are sufficiently tech-savvy, the dark web offers an alternative to the risk and violence of dealing drugs offline.

• Illicit drugs
• Cryptocurrency
• Drug dealing
• Black markets

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Home — Essay Samples — Social Issues — Peer Pressure — Drugs: Causes and Effects

Drugs: Causes and Effects

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Practices of care among people who buy, use, and sell drugs in community settings

• Gillian Kolla   ORCID: orcid.org/0000-0002-5743-7153 1 &
• Carol Strike 1  

Harm Reduction Journal volume  17 , Article number:  27 ( 2020 ) Cite this article

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Popular perception of people who sell drugs is negative, with drug selling framed as predatory and morally reprehensible. In contrast, people who use drugs (PWUD) often describe positive perceptions of the people who sell them drugs. The “Satellite Sites” program in Toronto, Canada, provides harm reduction services in the community spaces where people gather to buy, use, and sell drugs. This program hires PWUD—who may move into and out of drug selling—as harm reduction workers. In this paper, we examine the integration of people who sell drugs directly into harm reduction service provision, and their practices of care with other PWUD in their community.

Data collection included participant observation within the Satellite Sites over a 7-month period in 2016–2017, complemented by 20 semi-structured interviews with Satellite Site workers, clients, and program supervisors. Thematic analysis was used to examine practices of care emerging from the activities of Satellite Site workers, including those circulating around drug selling and sharing behaviors.

Satellite Site workers engage in a variety of practices of care with PWUD accessing their sites. Distribution of harm reduction equipment is more easily visible as a practice of care because it conforms to normative framings of care. Criminalization, coupled with negative framings of drug selling as predatory, contributes to the difficultly in examining acts of mutual aid and care that surround drug selling as practices of care. By taking seriously the importance for PWUD of procuring good quality drugs, a wider variety of practices of care are made visible. These additional practices of care include assistance in buying drugs, information on drug potency, and refusal to sell drugs that are perceived to be too strong.

Our results suggest a potential for harm reduction programs to incorporate some people who sell drugs into programming. Taking practices of care seriously may remove some barriers to integration of people who sell drugs into harm reduction programming, and assist in the development of more pertinent interventions that understand the key role of drug buying and selling within the lives of PWUD.

Research examining drug selling (frequently referred to as “drug dealing”) has found that it is a common income generation strategy among people who inject drugs, particularly among people who report daily drug use [ 1 , 2 ]. In fact, the category of “drug seller” or “drug dealer” itself is somewhat fluid, with many people who use drugs (PWUD) moving into or out of low-level drug selling depending on circumstance and economic necessity [ 3 , 4 , 5 ]. When examining the relationship between PWUD and people who sell drugs, PWUD often describe high levels of trust when buying from their “regular” drug seller [ 6 , 7 ], and consider a long and trusted relationship with the person selling them drugs as a source of protection against overdose [ 8 , 9 , 10 ]. PWUD frequently cite buying from a trusted or known drug seller as a harm reduction strategy that they engage in [ 8 , 9 , 10 , 11 ]; despite this, harm reduction programming and research has been slow to engage with people who sell drugs directly.

With few exceptions, harm reduction programs have focused on their clients as consumers of drugs, and little attention has been paid to the ways in which people who engage in drug selling—often the very same people—could be integrated into harm reduction efforts. In the context of the North American overdose crisis, multiple interventions have been scaled up including overdose education and naloxone distribution programs, overdose prevention and supervised consumption sites, and drug checking programs [ 12 , 13 , 14 , 15 ]. While there has been some interest in how people who sell drugs might be integrated into drug checking interventions as part of the response to the overdose crisis [ 6 ], the integration of people who sell drugs into other areas of harm reduction programming remains underexplored, and may hold promise as a way to address continuing high overdose death rates.

In this paper, we present and analyze qualitative data from interviews and ethnographic observations of the Satellite Site program—a low-threshold, peer-led harm reduction program operating within community spaces—frequently apartments—where people gather to buy, use, and sell drugs. The Satellite Site program hires PWUD to be Satellite Site workers (SSW), who are chosen because they are well-known in their communities, and want to work as a type of community-based harm reduction worker. To do so, they are trained to offer harm reduction services to other PWUD in their social networks, and work primarily from their own homes. The Satellite Sites become community access points for harm reduction equipment and information, overdose education, and naloxone distribution, and, in some sites, monitoring of drug consumption [ 16 , 17 ]. One of the unique elements of the Satellite Site program is that it works directly with people who may move into and out of drug selling; the result is that some of the SSWs are people who sell, or allow drugs to be sold within their sites. The Satellite Site program is an example of a safer environment intervention [ 18 , 19 ], where people who use and sometimes sell drugs are employed to deliver harm reduction equipment and education to their peers. The program aims to improve the health of PWUD by altering the socio-spatial relations within these closed spaces in the community where people gather to use drugs. In this paper, we focus on the practices of mutual aid and support—or practices of care—that were observed within the Satellite Sites. These practices of care circulate in the harm reduction work that occurs between SSWs and their clients, and were also observed during instances of drug selling and sharing. The existence of practices of care surrounding drug selling troubles popular conceptions of drug selling as always or solely predatory or deviant [ 20 , 21 , 22 ], and offers insights into how people who sell drugs might be integrated into harm reduction programs more broadly.

Drug selling and harm reduction

Focusing on drug selling within harm reduction programming is not a new idea. A key early example of this is provided by Grove [ 23 ], who argued that “real harm reduction” must focus on the key concerns of PWUD, which frequently revolve around availability of drugs, how to find enough money to buy good-quality drugs, and how to avoid detection by the police. “Real harm reduction” focuses on the harms caused to PWUD by drug prohibition, particularly the harms stemming from an unregulated drug market with no quality control or method of verifying the potency and composition of drugs, and where the risk of arrest and incarceration is ever present. These are major problems for PWUD, and Grove critiqued early public health interventions for completely ignoring them while also attempting to justify harm reduction by focusing solely on its ability to prevent HIV transmission among PWUD [ 23 ]. Highlighting that “drug use is profoundly normal”, Grove traces how prohibition and criminalization not only fail to dissuade drug use, but are also social policies that accentuate the harms associated with drug use [ 23 ]. He also highlights the drug user organizing that led to “shooting galleries” being early spaces of harm reduction, where PWUD are able to use drugs off the street and where they do not have to hurry to attempt to avoid law enforcement [ 23 ].

While many key components of public health interventions for PWUD (such as needle and syringe distribution programs) started out as survival strategies among PWUD, their uptake and operationalization by public health authorities (who may have little to no connection with communities of PWUD) can lead to services that are not accommodating nor reflective of the needs of people who use drug [ 24 ]. A prime example of this is the way in which public health interventions have almost completely ignored drug buying and selling except to prohibit it within formal programs and service offerings. Due to criminalization, drug selling represents a particularly contentious issue to be managed for organizations providing services to PWUD, necessitating an institutional focus on rules and regulations. This includes rules that prohibit the sharing or selling of drugs, or—within the context of supervised consumption services—that specify particular methods of drug administration and whether people can receive assistance with injections [ 25 , 26 ]. This focus on the enforcement of rules and regulations can alienate and exclude PWUD from accessing much-needed harm reduction services [ 25 , 27 , 28 ]. Unsanctioned and peer-run services that are designed to be “low-threshold” and function with fewer rules (or with behavioral guidelines that emerge organically from communities of PWUD) may attract more marginalized service users who would otherwise choose not to access or be excluded from accessing services [ 25 , 26 , 28 , 29 , 30 ].

The difficulties in ensuring that the institutional rules and regulations that surround the delivery of harm reduction services are low threshold and reflect the local culture among PWUD are amplified in any attempt to work with people who sell drugs, despite the frequent acknowledgment that engaging in low-level drug selling is common for people with high frequency or daily drug use [ 1 , 2 ]. Alternate framings of drug selling remain rare. Research has documented how PWUD frequently engage in “helping” and mutual aid behaviors—such as procuring and sharing drugs with each other—that are technically drug distribution or trafficking offences under drug laws [ 31 , 32 ]. Previous research has also documented how the mutual aid that emerges from social ties between PWUD can be protective in cases where people cannot secure an adequate supply of drugs for themselves, and must rely on other PWUD to supply them with opioids as they attempt to avoid opioid withdrawal [ 33 , 34 ]. Programs that formally and explicitly engage with people who sell, share, or exchange drugs (activities that are frequently and often interchangeably referred to as “drug dealing”) in pursuit of harm reduction or public health goals are rarely documented. Framings of people who sell or supply drugs as predatory and morally reprehensible remain popular and enduring [ 20 , 35 ]. This renders it difficult to explore the practices of mutual aid and support—or practices of care—that surround drug selling and sharing in communities of PWUD.

Practices of care in harm reduction

This paper explores the practices of care that SSWs engage in as part of their harm reduction work, with a focus on the practices of care that circulate around drug selling. Drawing on Foucault’s ethics as well as more recent work on pleasure in drug use [ 36 ], Duff examines how “drug users cultivate and sustain practices of care in contexts of social and economic disadvantage” [ 37 ], (p83). Here, “practices of care” refers both to the practices used by PWUD to care for the self within larger social and economic contexts that remain hostile to drug use, as well as the ways in which people care for others, emphasizing the often relational character of practices of care [ 37 ]. Research on the practices of care surrounding drug use has emerged from a concern that the experience of pleasure has been neglected in research on illicit drug use [ 38 , 39 ]. Instead, a focus on the risks and harms associated with drug use has reinforced the “pathologizing tendencies” of research on drug use, with drug policy and programming reflecting this view of drug use as almost exclusively harmful [ 36 , 40 ]. In contrast, “thinking with” pleasure in drug use may provide a way to counter this tendency towards pathologization, allowing for examinations of the pragmatic ways people use drugs to manage illness or pain, and to experience pleasurable sensations and states of consciousness, in addition to the oft-documented negative effects of drug use [ 38 , 41 ]. Nuancing drug use in this way may hold potential to counter stigma and moral judgment against PWUD, and open space to explore how practices of care circulate among PWUD [ 37 ].

Much of the concern with care stems from the work of feminist scholars in science and technology studies, and stems from the feminist concern with devalued labor [ 42 ]. Here, the concept of “care” carries multiple and often interwoven meanings, including care as indicative of paying attention to something in a careful or watchful manner, “caring about” as a state of being emotionally attached to something, and “caring for” as a way of providing for or looking after someone as part of a social relationship [ 43 , 44 , 45 , 46 ]. We focus on “practices of care” to reflect care as an active practice, a moment of active “doing” of care that engages practitioners in their worlds [ 42 , 43 ]. However, it is also important to note that care is a contested concept, and that practices of care are not neutral or uniformly positive acts of affection or attachment [ 46 ]. Instead, the concept of care is constrained by uneven and asymmetrical power relations that dictate which practices of care are worthy of attention and to “count” as care [ 46 ]. Practices of care are often embroiled in a complex politics that determines which practices, people, and phenomena are recognized as caring or worthy of care and which are excluded from recognition or analysis [ 43 ]. Acknowledging this contested “politics of care” highlights how attention to care is selective, where some lives and phenomena are included and attended to, while others are neglected and excluded from consideration or analysis—particularly those marginalized by drug use and related social inequities [ 43 , 47 ]. Focusing on “real harm reduction” [ 23 ] by listening to the expressed needs of PWUD around the centrality of drug buying in their lives, and developing interventions that take seriously the practices of care among people who sell drugs, provides recognition of the practices of care among a marginalized group of people that are frequently ignored.

Practices of care in harm reduction proliferate, yet have only recently begun to be described as such. Examining the practices of care among PWUD builds off research that has repeatedly documented the mutual aid among PWUD. This includes the ways that PWUD (whether formally employed as “peer workers” or not) support others within harm reduction programs and overdose prevention sites, with more recent research exploring their experiences reversing overdoses in housing and community settings [ 17 , 47 , 48 , 49 , 50 , 51 ]. Practices of care range from the provision of sterile injection equipment to the administration of naloxone to reverse a life-threatening opioid overdose. For example, Fraser describes the “ethos of community care” that inspires people to maintain large supplies of sterile injection equipment on hand so that they can engage in secondary distribution of this equipment—a practice of care—to people in need [ 52 ]. Similarly, the way in which the expansion of take-home naloxone programs has allowed new practices of care to develop between a person administering naloxone and a person who is overdosing, has been explored to describe how people will use naloxone to gently reverse overdose, in an attempt to avoid the harms of precipitated withdrawal from more forceful naloxone administration [ 47 ].

Increased attention is being paid to how a strong focus on risk and harm in research on drug use may obscure the wide variety of drug use experiences [ 37 , 38 , 40 ]. However, such nuance is lacking when examining drug selling. People who sell drugs are routinely framed not only as uncaring, but as actively predatory towards others [ 20 , 21 , 22 ]. Many studies of drug selling and drug markets focus on the aggression, theft, and violence that can occur around drug selling and buying within unregulated drug markets [ 3 , 53 , 54 ]. Without ignoring the existence of these important issues, we attempt to broaden the discussion of what constitutes “care” within harm reduction practice by exploring the variety of practices of care that people are engaging in related to drug selling and drug sharing. Starting with Grove’s insight that “real harm reduction” must attend to the primacy of drug buying and selling in the lives of PWUD [ 23 ], in this paper we explore the practices of care that surround drug procurement, buying, and selling. Exploring the practices of care that exist among people who use and sell drugs opens the possibility for a reconceptualization of some aspects of drug selling more generally, and for imagining a place for the broader participation of people who sell drugs in harm reduction programs specifically.

This research was conducted with the “Satellite Site” program, implemented in Toronto, Canada. The Satellite Site program started informally in 1999, as an outgrowth of a peer-developed and peer-run harm reduction program operating inside a community health center. The founder of the program, who ran the harm reduction program at the community health center and who openly identified as a person who injected drugs, began to provide home delivery of sterile injection equipment to increase access for community members outside the hours of operation at the community health center. Noticing that many people maintained communal spaces where people gathered to use illicit drugs, he began asking the people running these spaces if they wanted to keep extra harm reduction supplies around for others who might need them; this was the beginning of the Satellite Site program [ 16 ]. The Satellite Sites were based on a secondary syringe exchange model, where PWUD would distribute sterile injection equipment obtained from formal harm reduction programs to other people who inject drugs out in the community [ 55 , 56 , 57 ]. Since he was familiar with the sites and had spent time observing their operation firsthand, the program founder was able to choose Satellite Sites deliberately, and was able to assess potential Satellite Site workers for their suitability and privilege choosing spaces that were already engaged in high-volume needle and syringe distribution and disposal. Due to his close connections with the community, the program founder was also able to verify that the people running the sites were interested in working within a harm reduction philosophy and were not formally associated with any criminal organizations. He also ensured that SSWs were well-connected to the community health center so that they could provide referrals to the center for healthcare and social service needs. In 2010, the Satellite Site program adopted a more formal model when the program received external funding [ 16 ]. This allowed for the SSWs—who were previously in a volunteer role—to be employed as paid staff, receiving a modest salary of $250 a month and cellular telephone. During the study period, there were 9 Satellite Sites in operation, and each distributed and disposed of, on average, approximately 1500 needles and syringes a month.

Data collection

A community-based research approach was used to guide the data collection in this ethnographic study. The lead author was well-known to SSWs due to previous involvement in an evaluation of the program [ 16 ], as well as work on other research projects in the community health center. An advisory group consisting of key members of the program, including the program founder, the Satellite Site coordinator, and several SSWs met regularly with the lead author to provide guidance on research design, data collection and recruitment, and on the interpretation of the data. Research ethics board approval was obtained from the researchers’ institution.

SSWs were invited by the lead author to participate in site visits and/or one-on-one semi-structured interviews. SSWs who expressed interest in participating provided informed consent for observations at their site prior to the first visit. The consent process included a discussion of how they could opt out of site visits, ask the researcher to leave at any time, or withdraw from the study completely. As part of the consent process, SSWs were asked to inform any Satellite Site clients who were at the site at the time of a visit about the research study using a short script. Ethnographic observation at the Satellite Sites occurred over a period of 7 months, from September 2016 to March 2017. In total, 57 observation visits were conducted. Sampling was guided by the sequential approach described by Small [ 58 ]. Visits occurred once or twice a week, and averaged an hour (with visits ranging from 15 min to 2 h in length). They generally occurred in the evenings, with visits held on different days to capture variations in operations between weeknights and weekends. Days and times of observation visits were arranged in advance by the Satellite Site coordinator, an employee of the community health center responsible for supervision of the Satellite Site program who regularly visited the sites as part of their job responsibilities and who was present during all site visits. SSWs were provided a $20CDN honorarium at each visit. Field notes on observations were recorded immediately after leaving sites, and expanded upon in detail the following day, using principles outlined by Emerson et al. [ 59 ]. An observation guide was used to highlight major areas of attention, and focused on instances of drug use observed (including the buying, selling, preparation, and consumption of drugs), any instances of violence or aggression, interventions by police or paramedics, and interactions between SSWs and clients where harm reduction interventions occurred, including the following: equipment distribution, harm reduction education, naloxone distribution, overdose education, overdose intervention, and provision of information and referrals to health or social services. All field notes were anonymized using pseudonyms, with names of participants and locations of Satellite Sites never recorded in field notes due to the criminalized nature of activities being observed.

Seven Satellite Sites were visited on a regular basis. Two of these Satellite Sites were in privately owned apartment buildings, and five were located in subsidized social housing complexes. The closest Satellite Site was located 2 km from the sponsoring community health center, and the farthest was located 11 km away. The SSWs running these seven sites included six individuals and one couple; three men and five women, all between the ages of 45 and 70 years old who injected drugs regularly (although their drugs of choice varied), and who received much of their income from government social assistance programs.

One-on-one, semi-structured interviews were also conducted to complement the information gathered during observation visits. SSWs were interviewed twice; once prior to the beginning of observation visits in the Satellite Sites, and once following the completion of visits. In the first interview, they were asked about general issues relating to their work as a SSW, such as how they became part of the program, challenges they faced, and benefits of being a SSW. The second interview was used to expand on issues and themes that emerged from the observation visits. Clients and supervisory staff were each interviewed once only. Clients were recruited from the Satellite Sites, where the researcher would discretely approach them to determine interest in participating in a confidential interview in a spare room in the Satellite Site (if available), or at another location (e.g., a coffee shop or community health center). They were asked about the experience of visiting the Satellite Site, and their use of other health or harm reduction services. Community health center staff were also interviewed; staff were all involved in different aspects of administering or supervising the Satellite Site program. They were asked about institutional factors associated with running the program, such as challenges faced in implementation or program expansion. All interview participants gave verbal informed consent to be interviewed, and were offered $20CAD honorarium.

In total, 15 participants were interviewed, including five SSWs, four Satellite Site clients, and six staff members from the community health center who administered and worked in supervisory roles over the program. Two of the SSWs who were interviewed were men, and three were women, and all were between the ages of 51 and 70 years old. They all injected drugs regularly, with four injecting daily, and four lived in subsidized housing complexes, with the remaining SSWs living in a privately owned apartment building. For Satellite Site clients who participated in formal interviews, three out of four were male, between 20 and 30 years of age, with the fourth participant in the 50–60-year age range. One client was homeless, with the remaining three living in subsidized community housing.

Data analysis

Data analysis was guided by a theoretical approach that aimed to foreground the ways in which a marginalized group of people engage in harm reduction work in community settings, with a focus on how structural and social forces shape actions that are often viewed (and framed) as individual-level risk behaviors [ 60 , 61 , 62 ]. This approach shaped the focus on care as a practice, and on the ways that practices of care were being actively enacted by SSWs in their work with PWUD in the Satellite Sites. Field notes and interview data were analyzed using an iterative process guided by thematic analysis [ 63 ]. Beginning in the early stages of participant observation, field notes were coded for key themes. As data collection progressed and interviews were conducted, emergent themes were grouped by category. The ways in which SSWs engaged in thoughtful practices of care within their work was identified in subsequent iterations of coding as a major analytic trajectory. Later iterations of data analysis refined this analysis by focusing on the interactions between drug selling and acts of care. Dedoose qualitative data analysis software was used for data management and coding. In the excerpts below, all participants are identified by pseudonyms only, and potentially identifying details have been altered.

Drug selling and practices of care

The Satellite Site program integrates the distribution of harm reduction materials directly into the spaces in the community where people are already gathering to buy and use drugs, and helps make sterile drug injection and unused inhalation equipment more widely available in these community settings. During the observations for this study, people were repeatedly observed visiting Satellite Sites to get harm reduction supplies and to make use of the sterile equipment available. No instances of needle or syringe sharing were noted. Clients of the sites recognized the health-related benefits of the widespread availability of sterile injection equipment at the Satellite Sites. As one client indicated: “It's probably allowed me to avoid certain health complications. Like, I don't have Hep C, right? I don't have HIV or anything like that. So that's a positive” (interview with Satellite Site client 1). This client also stated that he had never accessed a formal harm reduction program, and accessed all his injection equipment at a Satellite Site where drugs were being sold. This speaks to the long history of secondary distribution within harm reduction, where PWUD maintain a reserve of harm reduction materials to distribute to people who may not otherwise be accessing formal harm reduction programs [ 55 , 64 , 65 ]. Secondary distribution has been well-documented even in jurisdictions where it is illegal, as continues to be the case in Australia [ 66 ]. The distribution of harm reduction materials—including the stockpiling of large amounts of equipment by PWUD for friends, family, and community members to use—has been described as a practice of care for others [ 52 ]. The Satellite Site program formalizes this practice of care to further the public health goal of improving access to sterile injection equipment, as this is a key public health intervention to reduce the transmission of bloodborne infections [ 67 ].

Satellite Sites are not required to allow either drug use or drug selling within their sites: SSWs decide for themselves how they wish to run their sites. The Satellite Site program goes beyond the traditional public health focus on the distribution of harm reduction equipment and moves towards “real harm reduction” by acknowledging the ways that buying, using, and sometimes selling drugs are intertwined within the lives of PWUD [ 23 ]. Unlike traditional harm reduction programs located in community organizations or health centers where drug use and drug buying, selling, and sharing are not allowed, the Satellite Site program is designed to be located in places in the community where these activities are already taking place. The program recognizes that while access to sterile equipment for drug use is important for PWUD, it is not necessarily their top priority. The following field note is from a Satellite Site run by Phil, a man in his 50’s who injects heroin and also engages in small-scale heroin selling to friends and acquaintances who live in his apartment building. It illustrates the benefits of co-locating harm reduction equipment within the spaces where people are buying and using their drugs:

There is a knock at the door, and Phil walks over, opening the door a crack. He speaks quietly for a moment to the person at the door, before letting a woman in. Phil asks her what she needs, and she quietly says, “Can I get some kits, and a point [of heroin] too?” He goes into the kitchen, grabs an empty grey plastic bag, and passes it to her, gesturing to the stack of plastic drawers holding all the harm reduction supplies. She opens the top drawer, takes a bunch of injection kits (that contain sterile needles, cookers, filters, water, and tourniquets), and then grabs a handful of crack pipes, putting them all in the bag. Phil heads to the bed, and, sitting on the edge, he pulls out a scale and a tiny Ziploc bag. The woman sits on the floor in front of him, watching intently as Phil shakes a little bit of heroin powder onto a small square of paper that he’s placed on the scale. He’s going slow, tipping powder out of the baggie, carefully weighing the drugs out. Once he gets to the right number on the scale, he looks up at her, and she nods, before he carefully folds up the little piece of paper. She passes him some money, says thanks, and nods a goodbye at us. (Field note 2016-11-19)

Increasing access to sterile injection equipment within the spaces where people are buying and using their drugs can facilitate the important public health goal of preventing transmission of HIV and hepatitis C. Additionally, combining the provision of sterile injection equipment with drug purchasing can enable small practices of care in the lives of people who may not be accustomed to receiving care around their drug use.

Another example of a practice of care occurs when SSWs use their personal knowledge of drug potency and translate it into harm reduction education. Adrienne is a long-time harm reduction worker in her 50’s, and runs a Satellite Site out of her apartment. Her clients are mostly friends and family members, and she knows their drug use habits very well. She injects opioids but does not sell them, and mobilizes her personal experience to attempt to prevent overdose among clients:

They [client] will say, 'Oh, what's the junk like?' And I'll say 'I don't know. Which one did you get?' and they’ll show me: 'This one’. And I can tell them, ‘Be careful, it's a little strong. You can always do more'. But also, they know, ‘Don't worry’, you know, ‘I'll keep an eye on you’. (Interview with SSW 8)

Here, Adrienne references both her knowledge of drug potency and her ability to intervene in case an overdose occurs. The Satellite Site program formalizes overdose response as a practice of care by providing SSWs with training in overdose intervention and equipping the sites with naloxone kits that could be used onsite or distributed to their clients [ 17 ]. For clients who use the Satellite Sites, the combination of harm reduction services and quick intervention in case of overdose created a feeling of safety:

I like that it's a place that's safe and you know nothing's going to happen to you. And shit, Adrienne [the SSW] has all the supplies and everything. For example, like, when people overdose, she has everything ready. And she’s actually used it [naloxone]. (Interview with Satellite Site client 2)

The Satellite Sites were developed as a way of building on the practices of care that exist between PWUD surrounding the distribution of sterile needles and syringes. In the context of the overdose crisis, SSWs also mobilize practices of care to improve overdose prevention and response in the community.

Drug potency, overdose, and practices of care

Over the period of field work for this study, the contamination of the illegal heroin supply with illicitly produced fentanyl and fentanyl analogs translated into an increase in the frequency of overdoses within Canada; this increase in overdose was also seen within the Satellite Sites [ 17 , 68 ]. There are strong indications that fentanyl and its analogs are entering the drug supply chain early, likely in source countries [ 69 , 70 ]. Those involved in street-level drug selling are low on the supply chain and often unaware of the content or potency of the drugs they are selling. The following field notes describe how Tommy—a SSW who also sells heroin—engages in a practice of care related to overdose prevention:

I arrive at Tommy’s place with Sonia, who is looking to buy some heroin from him. After knocking for almost 10 minutes, Tommy finally answers the door. He is clearly very intoxicated, sedated. His speech is disconnected, and he is walking slowly around his apartment running a hand through his hair, barely able to keep his eyes open. “I think I was totally unconscious. I did some dope, Sam brought some new dope over, and it was crazy. You know me, I’m no lightweight, but it just knocked me out. And I only had half a point! That stuff is crazy strong.” Hearing this story, Sonia pipes up and says, “Hey, Tommy, could I get a bit of that from you? I’ve got 40 bucks. I’ll take some of that good stuff that knocked you out. I can take that off your hands, if you want.” Tommy shakes his head, and says, “No way! There’s no way I’m selling that – it’s too strong. Maybe it’s cut with fentanyl, but it doesn’t feel heavy like fentanyl – it had the smooth, gradual start like good junk. But it’s really too strong. That could kill someone, and I don’t want to be responsible for that.” He takes a dime bag out of his pocket, and takes out a small chunk of beige heroin, putting it on the table. It looks a bit like silly putty, and he takes a kitchen knife from the table and cuts a small chunk off the end, saying, “But don’t worry, this stuff is good too.” (Field note, 2016-12-14)

This field note complicates the simplistic narratives that portray people who sell drugs as reckless and indifferent to the wellbeing of their clients. Here, Tommy is troubled by the strength of the heroin he has just consumed, and is unwilling to sell it to Sonia, as he worries that it might cause a fatal overdose. This field note points to the potential benefits of integrating people who sell drugs into harm reduction programs within the context of the current opioid overdose crisis.

Mutual aid, drug procurement, and practices of care

The example in the field note above is an illustration of a practice of care in relation to drug selling. However, the heavy stigma surrounding drug selling can make it difficult to recognize this and other common practices of care that circulate around drug buying and selling. Common, normative narratives frame people who sell or procure drugs in almost exclusively negative terms, as reckless, predatory, and unconcerned about their clients [ 20 , 21 ]. The fieldwork for this study challenges this portrayal: PWUD were frequently observed engaging in mutual aid and practices of care to assist each other with drug procurement, which is sometimes referred to as social supply. In social supply, drug transactions within social networks are facilitated either at cost as a means of reinforcing social ties, or at a small markup to compensate the seller for their effort, risk, or to allow them to finance their own use [ 31 , 71 ]. Helping other people to procure drugs is very common; however, these acts are nonetheless drug trafficking offences. SSWs would frequently engage in these types of social supply or “helping” behaviors, despite the risk of arrest. During observation visits, a form of mutual aid was frequently observed where clients and SSWs pooled their money and arranged to “pick up” from a drug seller:

SSW: And I pick up for people too, so. By me picking up, I'm usually, you know, I'm in and out, in and out, in, I'm surprised I haven't got nabbed yet, knock on wood. (laugh) Interviewer: And what's in it for you for picking up for them? SSW: It depends. From the dealers, I get, you know, some extra. From the people themselves, they'll throw me something. I usually go if I'm making money. (laugh) If I'm not making money, I don't want to go. (laugh) I mean, it's not a lot of money but it helps.” (Interview with SSW 7)

Pooling money for a pickup was mutually beneficial, both from an economic perspective as the people putting in money would receive a better deal, and because assisting with these transactions helped sustain and cement social relationships. There is also risk involved in providing this help due to criminalization. These helping behaviors are complex, as they comprise elements of assisting others to procure drugs and self-interest in acquiring free drugs.

Additionally, some SSWs were observed helping their clients to negotiate the vagaries of drug markets that lack formal dispute resolution procedures. For example, Sandra, a SSW who did not formally sell drugs, explains how she would often help to procure drugs for Satellite Site clients who were unable to buy drugs due to disputes or unpaid debts with drug sellers:

Service users know that I do have a good rapport with dealers, and good credit. So sometimes, that will come up, like, you know, 'Oh, well, you get it and then I'll pay you’. (Interview with SSW 10)

The Satellite Site program was built around the practices of care surrounding harm reduction equipment distribution within communities of PWUD. By recognizing the importance of drug buying and selling in the lives of PWUD, the practices of care circulating between SSWs and their clients around drug procurement can be rendered visible. Revealing the diversity of relationships and arrangements that surround drug selling may contribute to decreasing the pathologization associated with this often stigmatized practice (37, 47). The following field note from a busy Satellite Site provides an example of how social supply networks function, and how a SSW was motivated to assist in the procurement of drugs out of a desire to provide assistance to community members:

It’s Saturday night and we are at Bobby’s place, sitting in the living room with the TV on in the background. It’s been busy, with people coming in and out all night, picking up both injection kits and crack smoking kits. There is a knock on the door, and Bobby comes back with Stella. She says hello to me, as we hadn’t seen each other in a while. She turns to Bobby and somewhat sheepishly says, “Bobby, can I ask a favour? Would you mind getting some crack for me, a 40 piece? Your guy, it’s good stuff?” Tom perks up, and answers, “Oh yeah, it’s good. It’s a little grainy right now, like, it’s not big rocks, but it’s good.” Stella, looking visibly relieved, replies, “Okay, would you mind? My guy, he usually comes to me, he delivers. But he’s not working right now. And I know someone else, but we have to meet on the street. And I hate that. I hate standing out on the street, waiting, not knowing if there are cops around. I get so nervous, I hate it. And I feel like the guy I’m seeing now, that he’s shorting me. Maybe it’s just paranoia, but it seems like the bags are getting smaller and smaller.” Stella hands $40 to Bobby, and he gets up, heading towards the door to his apartment, saying, “No problem, I’ll be right back.” Stella and I make small talk and watch TV while we wait. About 10 minutes later, Bobby comes back, and hands her a little baggie. Stella looks at it quickly, saying, “Thanks. This is 40?” She’s looking closely at the rocks in the bag, and I can tell that she is unsure about the quantity, and probably wondering if she is getting ripped off. Bobby replies to her, “Yeah, this is good stuff. See what I mean, it’s a little grainy? But that’s the same stuff I had earlier. It’s good. Do you need pipes?” Stella, still looking at the bag, and probing it with her nail, replies, “Yeah, that would be great, thanks.” Tom packs up a bag of new crack pipes, filters, and push-sticks for her to take. (Field note 2016-11-12 )

The importance of ensuring an adequate supply of good quality drugs, while also avoiding getting ripped off and being criminalized for drug use is highlighted as a key concern within “real harm reduction” [ 23 ]. However, it is not frequently attended to within drug policy or harm reduction research, despite the prominent role it plays in the lives of PWUD. In the field note above, Tom is making it possible for Stella to avoid a situation that was clearly causing her great stress and anxiety, by procuring drugs for her. Stella’s expressed fears of getting ripped off and of encountering police (and by extension, being criminalized for her drug use) are frequent among PWUD. Attending to the primacy of safety during drug procurement is not a traditional concern of public health-oriented harm reduction activities. This is partly due to normative framings of drug use as negative and dangerous, which can make it difficult to see acquiring, procuring, or selling drugs as a practice of care, since drug use is almost exclusively framed as dangerous and having no potential of positive benefits for the person using them [ 37 ]. Validating these acts of mutual aid as practices of care opens the possibility of integrating interventions around drug selling into harm reduction programming.

The findings from this ethnographic research document the practices of care occurring around drug buying, using, and selling within a community-based harm reduction program staffed by SSWs—some of whom are actively engaged in drug selling alongside their harm reduction roles. Common portrayals of PWUD, and particularly people who sell drugs, as solely predatory, lacking in self-control, or as careless obscure the practices of care that were observed in this study. These negative portrayals also make it difficult to integrate these practices of care—and the people who sell drugs who practice them—into public health programming to facilitate harm reduction goals. Harm reduction programs are well-placed to work with people who sell drugs due to their philosophy of meeting PWUD “where they’re at,” of integrating PWUD within program development and delivery, and of highlighting the health harms associated with the criminalization of drug use. Our findings suggest that there is potential to expand the relevance and reach of harm reduction programming by recognizing the practices of care that occur around drug selling, and integrating them into harm reduction. The criminalization of behaviors that we observed as common among people who use drugs (such as buying drugs together, buying for another person, and pooling money to buy and share a larger quantity of drugs) contributes to the difficulty in making visible the practices of care circulating within drug buying and selling. The criminalization of drug selling has also rendered these behaviors highly stigmatized. While the idea of integrating PWUD into harm reduction programming and service delivery in the response to the overdose crisis is not new [ 50 ], there has been little formal integration of people who sell drugs into harm reduction programming. Highlighting these practices of care has the potential to remove barriers that hinder the integration of people who use and sell drugs into harm reduction programming, and to develop public health interventions that take seriously the key role of drug buying and selling within the lives of PWUD.

Some of the practices observed in this study are easily recognizable as “care” (e.g., the provision of equipment for drug use and intervention when overdoses occur) because they align with traditional framings of affective care work as a form of looking after another, or “caring for” someone [46)]. These practices of care are already well-established and practiced within harm reduction programming, particularly in harm reduction programming that utilize “peer” workers [ 50 , 72 ]. Offering harm reduction equipment in the same location as drug selling allows for more widespread dissemination of sterile injection equipment, a key public health strategy in reducing the transmission of HIV and hepatitis C. In association with drug selling, these more traditional practices of care lead to increased trust and help facilitate harm reduction education and equipment distribution.

However, other practices we identified are frequently overlooked as “care” because they are often associated with criminal acts (e.g., assistance in procuring or buying drugs, the provision of information on drug potency, or refusing to sell drugs that are deemed to be too strong). Our results underline how behaviors such as buying drugs together, buying for another person, and pooling money to buy and share a larger quantity of drugs are common within the social networks of PWUD. Despite their frequency, as well as their role in decreasing and sometimes preventing overdose, these behaviors are nonetheless heavily criminalized as drug distribution or trafficking under current drug laws. The criminalization of commonplace behaviors contributes to alienating people who use and sell drugs from the health and social service system, and results in missed opportunities to engage people who are selling drugs in potentially beneficial public health interventions [ 1 , 54 ]. There is potential to expand the relevance and reach of harm reduction programming by recognizing the practices of care associated with drug buying and selling, and integrating them into formal harm reduction programming. The Satellite Site program recognizes and builds upon the practices of care that SSWs are already engaging in within their communities (such as secondary syringe distribution). The inclusion of people who sell drugs in formal roles within harm reduction programming is not only a recognition that they are already engaging in practices of care within their communities, but can contribute to shifting the possibilities of care by “contingently co-producing different capacities for, and subjects of, care” [ 73 ] (p 433). This is particularly the case in the context of the overdose crisis in North America; our finding that SSW transmit important information on drug potency to their clients highlights an important potential role within harm reduction programming for people who sell drugs in the transmission of information on drug potency within social networks.

A key feature of the Satellite Sites is that the drug selling sometimes occurring within them is not seen as a liability, but is utilized to achieve public health goals like increasing access to sterile equipment for drug use. Secondary distribution programs have long been used to increase the reach of more formal harm reduction programs [ 55 , 56 , 57 ]. By situating a harm reduction intervention directly in the spaces where drugs are being bought, used, and sold, the Satellite Site program operationalizes Grove’s insight that the key concerns of PWUD revolve primarily around how to find and purchase good quality drugs [ 23 ]. The program then extends this insight by training PWUD who may move into and out of drug selling as peer harm reduction workers. In doing so, the Satellite Sites provide an example of how to reduce the structural barriers faced by PWUD that impede access to health and social services by providing convenient access to sterile injection equipment directly within the environments where drugs are sold. Importantly, this program also recognizes and formalizes the practices of care surrounding secondary distribution that are already occurring within communities of PWUD [ 52 ]. Similar to calls for exploring the potential integration of people who sell drugs into drug checking interventions [ 6 ], our findings suggest that an expanded recognition of what “counts” as care to encompass the practices of care that circulate around drug selling can be mobilized within harm reduction programs in an attempt to address the overdose crisis. Provision of information on drug potency and integration of people who sell drugs into drug checking interventions represent a promising area for expansion for harm reduction programming. It acknowledges a potential role of people who sell drugs in addressing overdose risk from the wide variations in the composition of the opioid supply. Additionally, people who sell drugs represent an avenue for reaching “hidden” populations of PWUD, who are unconnected to formal harm reduction programs or other health services.

Mobilizing PWUD as peer workers within harm reduction programming and in response to the overdose crisis is an important strategy to expand service delivery and improve engagement with harm reduction services [ 50 ]. However, there is a strong need to ensure that this care work is not downloaded onto peer and community harm reduction workers in ways that may reinforce existing marginalization [ 17 , 47 ]. Scholars have highlighted the potential for care work to be exploited and/or exploitative, particularly since care work is traditionally devalued, as it is frequently gendered, unpaid, and associated with groups experiencing marginalization [ 42 , 43 ]. Criminalization of drug use and drug selling contributes to the marginalization of PWUD as they take on work within harm reduction, which has led to documented inequities in stipends, salaries, and access to benefits, contingent work, and lack of job protections [ 50 , 72 ]. Harm reduction workers—even those who sell drugs—must be adequately compensated for their labor, and provided with proper supports to address the grief and negative emotional impacts associated with providing frontline services during the overdose crisis [ 17 , 50 ].

Care must be taken when attempting to extrapolate the findings from this study to other geographical settings, as not all environments or contexts would be amenable to this type of intervention. For example, ethnographic research in Montreal, Canada, exploring “piaules” (the local term for “crack houses”) found that these spaces were closely tied to and often operated by criminal organizations, rendering the integration of harm reduction programming into them very difficult [ 74 ]. The Satellite Sites, by contrast, are run out of private apartments by individuals who are not associated with any criminal organization. As mentioned earlier, the founder of the Satellite Site program was very deliberate and took great care in the selection of the Satellite Sites. He used both his familiarity with the community settings where people gathered to use drugs and his in-depth knowledge of harm reduction practices to choose potential Satellite Sites. An in-depth examination of the local norms within the spaces where drugs are used and sold in the community, in partnership with PWUD who are knowledgeable about the local context, is necessary prior to the development of any programming that aims to integrate people who sell drugs into harm reduction service delivery.

The increased prevalence of fentanyl in the illicit opioid market in most parts of North America has led to a massive increase in overdose deaths in the USA and Canada [ 68 , 70 , 75 ]. It also constitutes a changing risk environment for PWUD [ 76 ], where the presence of fentanyl in the illicit opioid supply is disrupting the ways in which both PWUD and people who sell drugs attempt to keep themselves and others safe from overdose [ 69 , 70 ]. Available information suggests that this contamination is happening far up the supply chain, and not primarily among street or low-level drug sellers [ 69 ]. Findings from this study suggest that there is strong potential to integrate low-level drug sellers—particularly those who know their clients well and are already engaging in practices of care towards them—in harm reduction programming. PWUD have already been integrated into community based initiatives that equip them to intervene quickly when overdose occurs [ 17 , 50 , 77 ]. Expansion to formally engage some people who sell drugs in overdose response initiatives, transmission of information on drug potency, or in drug checking interventions [ 6 ] may provide additional avenues for capitalizing on existing practices of care among people who sell drugs, and addressing the opioid overdose crisis at the community level.

Availability of data and materials

The datasets generated and analyzed during the current study are not publicly available given the sensitive nature of the research topic, as they contain confidential information that could compromise participant confidentiality and consent.

Abbreviations

People who use drugs

Satellite Site worker

Hepatitis C

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Acknowledgements

We would like to thank the study participants, Satellite Site workers, and program staff members for their assistance and time, as well as for their willingness to share their perspectives with us. Patricia Erickson, Maritt Kirst, and Jooyoung Lee provided supervision of this dissertation project, and their comments on early drafts of this manuscript are gratefully acknowledged.

GK was supported during this research by a CIHR Banting and Best Doctoral Research Award and a Canadian Network on Hepatitis C (CanHepC) doctoral fellowship.

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GK is the primary author; she designed the study, conducted qualitative and ethnographic data collection and analysis, and drafted and edited the manuscript. CS supervised the study design, provided guidance on data collection and analysis, and reviewed and commented on drafts of the paper. Both authors read and approved the final manuscript.

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Kolla, G., Strike, C. Practices of care among people who buy, use, and sell drugs in community settings. Harm Reduct J 17 , 27 (2020). https://doi.org/10.1186/s12954-020-00372-5

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I mpact of Drugs on Society

The trafficking and abuse of drugs in the United States affect nearly all aspects of our lives. The economic cost alone is immense, estimated at nearly $215 billion. The damage caused by drug abuse and addiction is reflected in an overburdened justice system, a strained healthcare system, lost productivity, and environmental destruction.

The Demand for Illicit Drugs

NSDUH data show that in 2008, 14.2 percent of individuals 12 years of age and older had used illicit drugs during the past year. Marijuana is the most commonly used illicit drug, with 25.8 million individuals 12 years of age and older (10.3%) reporting past year use. That rate remains stable from the previous year (10.1%) (see Table B1 in Appendix B). Psychotherapeutic s 4 ranked second, with 15.2 million individuals reporting past year "nonmedical use" in 2008, a decrease from 16.3 million in 2007. In 2008, approximately 5.3 million individuals aged 12 and older reported past year cocaine use, 850,000 reported past year methamphetamine use, and 453,000 reported past year heroin use.

Rates of drug use vary by age. Rates are highest for young adults aged 18 to 25, with 33.5 percent reporting illicit drug use in the past year. Nineteen percent of youth aged 12 to 17 report past year illicit drug use. Finally, 10.3 percent of adults aged 26 and older report past year illicit drug use. These rates are relatively stable when compared with 2007 rates.

In 2008, approximately 2.9 million individuals tried an illicit drug or used a prescription drug nonmedically for the first time, representing nearly 8,000 initiates per day. More than half of these new users (56.6%) report that marijuana was the first illicit substance that they had tried. Other past year illicit drug initiates report that their first drug was a psychotherapeutic drug used nonmedically (29.6%), an inhalant (9.7%), or a hallucinogen (3.2%). By drug category, marijuana and pain relievers used nonmedically each had an estimated 2.2 million past year first-time users. Also identified frequently as the first drug used by initiates were tranquilizers (nonmedical use--1.1 million), ecstasy/MDMA (0.9 million), inhalants (0.7 million), cocaine (0.7 million), and stimulants (0.6 million). Methamphetamine appears to be fading in popularity among initiates. In 2008, an estimated 95,000 individuals tried methamphetamine for the first time--a 39 percent decrease from the 2007 estimate (157,000) and a 70 percent decrease from the 2004 estimate (318,000).

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The Consequences of Illicit Drug Use

The consequences of illicit drug use are widespread, causing permanent physical and emotional damage to users and negatively impacting their families, coworkers, and many others with whom they have contact. Drug use negatively impacts a user's health, often leading to sickness and disease. In many cases, users die prematurely from drug overdoses or other drug-associated illnesses (see text box ). Some users are parents, whose deaths leave their children in the care of relatives or in foster care. Drug law violations constitute a substantial proportion of incarcerations in local, state, and federal facilities and represent the most common arrest category.

Impact on Health and Health Care Systems

Drug use and abuse may lead to specialized treatment, ED visits (sometimes involving death), contraction of illnesses, and prolonged hospital stays.

In 2008, NSDUH estimated that 7 million individuals aged 12 and older were dependent on or had abused illicit drugs in the past year, compared with 6.9 million in 2007. The drugs with the highest dependence or abuse levels were marijuana, prescription pain relievers, and cocaine. The number of individuals reporting past year marijuana abuse or dependence was 4.2 million in 2008, compared with 3.9 million in 2007; the number of individuals reporting past year prescription pain reliever abuse or dependence was 1.7 million in both 2007 and 2008; and the number of individuals reporting past year cocaine abuse or dependence was 1.4 million in 2008, compared with 1.6 million in 2007.

Many individuals who become dependent on illicit drugs eventually seek treatment. The Treatment Episode Data Set (TEDS) provides information regarding the demographics and substance abuse patterns of treatment admissions to state-licensed treatment facilities for drug dependence. In 2007, there were approximately 1.8 million admissions to state-licensed treatment facilities for illicit drug dependence or abuse. The highest percentage of admissions reported opiates as the primary drug of choice (31%, primarily heroin) followed by marijuana/hashish (27%), cocaine (22%), and stimulants (13%). Although approaches to treatment vary by drug, more than half of the admissions were to ambulatory (outpatient, intensive outpatient, and detox) facilities rather than residential facilities. (See Table B2 in Appendix B for data on admissions for specific drugs.)

Individuals often experience adverse reactions to drugs--including nonfatal overdoses--that require them to go to the hospital. In 2006, the Drug Abuse Warning Network (DAWN) reported that of 113 million hospital ED visits--1,742,887 (1.5%)--were related to drug misuse or drug abuse. An estimated 31 percent of these visits involved illicit drugs only, 28 percent involved CPDs, and 13 percent involved illicit drugs in combination with alcohol. When drug misuse or abuse plays a role in these ED visits, the most commonly reported substances are cocaine, marijuana, heroin, and stimulants (typically amphetamines or methamphetamine).

A 2007 DAWN survey of 63 metropolitan areas found an average of 12.1 deaths per 100,000 persons related to drug use . 5 Rates of drug-related deaths range from 1.1 per 100,000 in Sioux Falls, South Dakota, to 26.1 per 100,000 in the New Orleans area. DAWN also records the number of drug-related suicide deaths. In 2007, the number of drug-related suicides per 100,000 persons ranged from less than one in several jurisdictions (including Chicago, Dallas-Fort Worth, and Minneapolis) to 6.2 per 100,000 in Fargo, North Dakota. To put these statistics in perspective, the Centers for Disease Control and Prevention (CDC) reports other nonnatural death rates as follows: Motor vehicle accidents, 15.1 per 100,000; nontransport accidents (e.g., falls, accidental drownings), 24.4 per 100,000; suicide, 11.1 per 100,000; and homicides, 6.2 per 100,000.

The consequences of drug use usually are not limited to the user and often extend to the user's family and the greater community. According to SAMHSA, combined data from 2002 to 2007 indicate that during the prior year, an estimated 2.1 million American children (3%) lived with at least one parent who was dependent on or abused illicit drugs, and 1 in 10 children under 18 lived with a substance-addicted or substance-abusing parent . 6 Moreover, the U.S. Department of Health and Human Services estimated in 1999 that substance abuse was a factor in two-thirds of all foster care placements.

Many states have enacted drug-endangered children laws to protect children from the consequences of drug production, trafficking, and abuse. Typically associated with methamphetamine production, drug-endangered children are exposed not only to abuse and neglect but also to fires, explosions, and physical health hazards such as toxic chemicals. In 2009, 980 children were reported to the El Paso Intelligence Center (EPIC) as present at or affected by methamphetamine laboratories, including 8 who were injured and 2 who were killed at the laboratories. These statistics do not include children killed by random gunfire associated with drug activity or who were physically or sexually abused by a "caretaker" involved in drug trafficking or under the influence of drugs.

Impact on Crime and Criminal Justice Systems

The consequences of illicit drug use impact the entire criminal justice system, taxing resources at each stage of the arrest, adjudication, incarceration, and post-release supervision process. Although drug courts and diversion programs in many jurisdictions have helped to alleviate this burden (see text box ), substance abuse within the criminal justice population remains widespread.

The most recent annual data from the Federal Bureau of Investigation (FBI) show that 12.2 percent of more than 14 million arrests in 2008 were for drug violations, the most common arrest crime category. The proportion of total drug arrests has increased over the past 20 years: in 1987, only 7.4 percent of all arrests were for drug violations. Approximately 4 percent of all homicides in 2008 were drug-related, a percentage that has not changed significantly over the same 20-year period.

The characteristics of populations under correctional supervision reflect these arrest patterns. According to the Bureau of Justice Statistics (BJS), 20 percent of state prisoners and 53 percent of federal prisoners are incarcerated because of a drug offense. Moreover, 27 percent of individuals on probation and 37 percent of individuals on parole at the end of 2007 had committed a drug offense.

The drug-crime link is also reflected in arrestee data. In 2008, the Arrestee Drug Abuse Monitoring (ADAM) II program found that the median percentage of male arrestees who tested positive in the 10 ADAM II cities for any of 10 drugs, including cocaine, marijuana, methamphetamine, opioids, and phencyclidine (PCP), was 67.6 percent, down slightly from 69.2 percent in 2007. Other data reflect the link as well. In 2002, a BJS survey found that 68 percent of jail inmates were dependent on or abusing drugs and alcohol and that 55 percent had used illicit drugs during the month before their offense. In 2004, a similar BJS self-report survey identified the drug-crime link more precisely: 17 percent of state prisoners and 18 percent of federal prisoners had committed their most recent offense to acquire money to buy drugs. Property and drug offenders were more likely than violent and public-order offenders to commit crimes for drug money.

Impact on Productivity

Premature mortality, illness, injury leading to incapacitation, and imprisonment all serve to directly reduce national productivity. Public financial resources expended in the areas of health care and criminal justice as a result of illegal drug trafficking and use are resources that would otherwise be available for other policy initiatives.

There is a great loss of productivity associated with drug-related premature mortality. In 2005, 26,858 deaths were unintentional or undetermined-intent poisonings; in 2004, 95 percent of these poisonings were caused by drugs. Although it is difficult to place a dollar value on a human life, a rough calculation of lost productivity can be made based on the present discounted value of a person's lifetime earnings.

There are also health-related productivity losses. An individual who enters a residential drug treatment program or is admitted to a hospital for drug treatment becomes incapacitated and is removed from the labor force. According to TEDS data, there were approximately 1.8 million admissions to state-licensed treatment facilities for illicit drug dependence or abuse in 2007. Productivity losses in this area alone are enormous. Health-related productivity losses are higher still when lost productivity associated with drug-related hospital admissions (including victims of drug-related crimes) is included.

The approximately one-quarter of offenders in state and local correctional facilities and the more than half of offenders in federal facilities incarcerated on drug-related charges represent an estimated 620,000 individuals who are not in the workforce. The cost of their incarceration therefore has two components: keeping them behind bars and the results of their nonproductivity while they are there.

Finally, there is productivity lost to drug-related unemployment and drug-related absenteeism. According to the 2008 NSDUH, 19.6 percent of unemployed adults may be defined as current users of illicit drugs. Based on population estimates from the same study, this translates into approximately 1.8 million unemployed individuals who were current drug abusers. Further, approximately 8 percent of individuals employed full time and 10.2 percent of individuals employed part-time were current users of illicit drugs. Individuals who are employed but have chronic absenteeism resulting from illicit drug use also accrue substantial lost productivity.

Impact on the Environment

The environmental impact of illicit drugs is largely the result of outdoor cannabis cultivation and methamphetamine production. Many of the chemicals used to produce methamphetamine are flammable, and the improper storage, use, and disposal of such chemicals that are typical among methamphetamine producers often lead to fires and explosions at clandestine laboratories. Additionally, the process used to produce methamphetamine results in toxic chemicals--between 5 and 7 pounds of waste per pound of methamphetamine--that are typically discarded improperly in fields, streams, forests, and sewer systems, causing extensive environmental damage.

Currently, there are no conclusive estimates regarding the nationwide cost of methamphetamine production site remediation because many of the methamphetamine laboratories and dumpsites in the United States are undiscovered due to their clandestine locations. However, in California alone, from January through December 10, 2009, the California Department of Toxic Substance Control responded to and cleaned up 232 laboratories and dumpsites at a cost of $776,889, or approximately $3,349 per site.

Outdoor cannabis cultivation, particularly on public lands, is causing increasing environmental damage. Grow site operators often contaminate and alter watersheds, clear-cut native vegetation, discard garbage and nonbiodegradable materials at deserted sites, create wildfire hazards, and divert natural water courses. For example, cultivators often dam streams and redirect the water through plastic gravity-fed irrigation tubing to supply water to individual plants. The high demand for water often strains small streams and damages downstream vegetation that depend on consistent water flow. In addition, law enforcement officials are increasingly encountering dumpsites of highly toxic insecticides, chemical repellants, and poisons that are produced in Mexico, purchased by Mexican criminal groups, and transported into the country for use at their cannabis grow sites. These toxic chemicals enter and contaminate ground water, pollute watersheds, kill fish and other wildlife, and eventually enter residential water supplies. Moreover, the National Parks Conservation Association (NPCA) reports that while preparing land for cannabis cultivation, growers commonly clear the forest understory, which allows nonnative plants to supplant native ones, adversely affecting the ecosystem. They also terrace the land--especially in mountainous areas--which results in rapid erosion.

Limited research on the environmental impact of the improper disposal of pharmaceutical s 7 indicates that contamination from dissolved pharmaceutical drugs is present in extremely low levels in most of the nation's water supply. The harm to aquatic life and the environment has not been determined, and according to the Environmental Protection Agency, scientists have found no evidence of adverse human health effects from the minute residue found in water supplies. Nonetheless, as a precaution based on environmental research to date, the ONDCP and the Food and Drug Administration suggest that consumers use take-back programs to dispose of unused prescription drugs (see text box in Vulnerabilities section).

4 . Non medical use of prescription-type psychotherapeutics includes the nonmedical use of pain relievers, tranquilizers, stimulants, and sedatives but excludes over-the-counter drugs. 5 . DAWN defines drug-related deaths as deaths that are natural or accidental with drug involvement, deaths involving homicide by drug, and deaths with drug involvement when the manner of death denoted by the medical examiner is "could not be determined." 6 . Data include alcohol dependence or alcohol abuse. 7 . The research also included antibiotics, steroids, and more than 100 pharmaceuticals.

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We Can Prevent Overdose Deaths if We Change How We Think About Them

I ’ve been living in recovery from opioid use disorder for eight and a half years, and this might be a weird thing to say about addiction, but I feel lucky—like I dodged a bullet. I was addicted to opioids in Florida throughout the early 2000s, during the heyday of pill mills that flooded the streets with powerful pharmaceuticals like OxyContin. I say I’m lucky because this was just before the drug supply turned into a toxic sludge of potent fentanyl analogues, mysterious tranquilizers, and deadly counterfeit pills. Sometimes I wonder what it would be like if I were using today. The chances of my survival in these dire conditions would be slim to none.

There’s a saying that “dead people can’t recover,” and I know it’s true. In 2022, an average of 300 Americans died from an overdose every single day. That’s an average of 109,680 human souls. We’re losing far too many people to drugs because America has yet to fully commit to a culture, policy, and strategy focused on overdose prevention.

One of the hardest parts about being an activist is getting people to care about problems that appear distant and far away. It’s all too human to perceive danger as striking someone else, somewhere else. We saw this play out with the COVID-19 pandemic. But we’ve long seen this play out with the overdose crisis in America. In 2017, the federal government declared overdoses a “public health emergency,” and ever since, the death rate has steadily ticked up and up. This was in large part due to the three waves of the “opioid epidemic” and the greed of the Sackler family that peddled OxyContin.

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However, calling this an “opioid epidemic” is to mislabel and misunderstand the actual root of the problem we face: Overdose deaths are preventable; we just haven’t had the tools to efficiently do it—until now. Many users die alone in their homes, apartments, cars, in gas station bathrooms, or on the street. Families and entire communities have been shattered by loss. In a fog of pain, grief, and anger, we’re also losing the plot. The focus of drug policy right now should be on preventing as many fatal overdoses as possible. Instead, America is once again trapped in a disastrous drug war that focuses on punishment and retribution over the goal of saving lives.

Read More: What 3 Grieving Dads Want You to Know About America's Fentanyl Crisis

The very word “fentanyl” evokes scary visions of chemical warfare and “weapons of mass destruction.” The fury of living through so much loss has elevated a reactionary tendency to harshly criminalize drug use and reinforce lengthy mandatory minimum sentences. Politicians like Donald Trump, for instance, want to execute drug sellers. During his 2024 presidential campaign announcement, Trump said , “We’re going to be asking everyone who sells drugs, gets caught selling drugs, to receive the death penalty for their heinous acts.” Members of congress and dozens of states are moving toward with enacting harsher drug penalties, despite decades of evidence that severe punishments do little to deter drug use or drug dealing. The rhetoric has gotten so hot that lawmakers have introduced proposals to authorize military force against drug traffickers in Mexico, turning a metaphorical drug war into a literal war of bombing and invasion. Fear, anger, and political expediency are causing us to repeat failed strategies of the past.

But now is not the time to reach for easy answers and give into dark impulses. Instead, we must double down on overdose prevention using a public health and harm reduction framework to equip people who use drugs with practical tools and spaces that destigmatize the life-saving information they need for their journeys to find safety and community.

As someone who has lost well over three dozen people I loved and cared about to overdose deaths, I know how valuable these tools can be. Most of my friends died alone. Many of them were scorned because they returned to drug use. They weren’t offered compassion when they sought healthcare support. Some of them died after being released from jail on a simple possession charge. All of them would have benefitted from the wide availability of harm reduction services such as syringe exchange programs, free naloxone, drug checking equipment that screens for fentanyl analogues, and safer use spaces—without shame, and without judgement. Consistent data from Harvard’s Recovery Research Institute has shown that harm reduction works and is rooted in evidence.

If we don’t correct our current course, we’ll be stuck in this vicious cycle that leaves millions of people sick, alone, and at risk of fatally overdosing.

On March 29, the FDA approved the first-ever over-the-counter (OTC) naloxone product. In July, they approved a second OTC naloxone product. While this is welcome news and a substantial leap forward, the pricing of these products (averaging between $35-$65 per unit ) is still out of reach for everyday Americans who need quick access to the lifesaving overdose reversal medication.

Read More: A Promising Way to Help Drug Users Is ‘Severely Lacking’ Around the World, Report Says

Naloxone should be free. It must be available and accessible everywhere—and for everyone, without any barriers. Most life-saving medical devices are uncontroversial and ubiquitous. It’s time we think about naloxone and overdose reversal the same way we think about EpiPens, defibrillators, vaccines, and testing. Nobody thinks the mere presence of an EpiPen encourages people severely allergic to peanuts to kick back and crush a bag of pistachios for fun. Unlike peanut allergies, addiction remains highly stigmatized. Some are under the false impression that naloxone “encourages” more risky drug use because they view addiction through a moral lens, not a healthcare challenge. This distorted logic, along with Big Pharma profiteering, hinders broad access to naloxone.

While changing policy and regulations is no small thing, changing cultural outlooks is something else entirely. The social scientist and historian Nancy Campbell called naloxone a “technology of solidarity.” For naloxone to work, someone has to be there to administer it to the person who is overdosing. With the recent expansion of naloxone access, it’s on all of us to step up and be ready to save a life. Instead of punishing and scorning those who are struggling, we must do the harder thing and actually show people that they are not alone.

Overdose prevention strategies also require tailored approaches to their culture and geography. Cities and urban centers where substance use is more concentrated can benefit from overdose prevention centers. More than 100 of these centers operate around the world in more than 60 cities. But America only has two that operate legally. The first sanctioned centers on U.S. soil opened in New York in 2021, and they’ve already rescued 1,000 people from fatal overdoses. Just two centers barely meet the demand. A New York City Health Department study found that opening four centers in the city would save up to 130 lives per year while saving $7 million in health care costs. It’s time for other major cities to follow New York’s lead.

Rural areas need a different kind of help covering vast distances. Traveling across the country, I’ve witnessed innovative grassroots overdose prevention solutions in rural towns that operate mobile harm reduction programs. A key tenet of harm reduction is “meeting people where they’re at.” In this case, that means literally. Big vans equipped with naloxone, clean syringes, HIV testing, drug checking, and perhaps most crucially, warm and kind people, are driving around throughout the week to deliver life-saving health care to people who have no other way to access it. Sadly, these programs are operating on shoestring budgets in extremely hostile political climates. Policymakers and communities must stand up and defend these frontline workers who are sacrificing their freedom for doing what they know is right.

You might’ve heard that harm reduction has failed. You might’ve heard that cities like San Francisco and Portland have gone all in on “radical” harm reduction strategies and implemented “pie-in-the-sky” policies like drug decriminalization, and all they have to show for it is death, despair, and abysmal outcomes. The truth is that no American city, not even the supposedly liberal strongholds like San Francisco, have fully committed to a focused strategy of overdose prevention and recovery support. Cutting social and housing services, refusing to reduce skyrocketing rents, all the while ramping up militarized policing is not radical harm reduction. In fact, these half-measures are actively contributing to crisis levels of overdose fatalities.

While politicians and sensational media outlets play up apocalyptic disaster porn, they never mention the success of states like Rhode Island. Rhode Island decided to double-down on overdose prevention and though it’s taken some time, it’s finally starting to pay off. Fentanyl and its potent analogues hit the small state early and hard. For several years, overdose deaths ticked up and up. But something changed. The number of fatal overdoses did not increase from 2021 to 2022. Then, there was a 13% drop in overdose deaths in the second half of 2022. How did they pull it off?

Rhode Island committed fully and firmly to effective overdose prevention strategies. Despite media backlash, they held strong when the going got tough—even when they weren’t sure if it would work. The state implemented mobile outreach programs that distributed harm reduction supplies, increased the availability of naloxone, expanded access to medication assisted treatment for opioid use disorder in jails and prisons, supported six community centers that offer peer-based recovery support services, and created a new evidence-based drug prevention curriculum for schools. Moving forward, Rhode Island will be opening overdose prevention centers like those in New York, which will ensure their fatal overdose trend reversal continues far into the future.

American drug policy is at an inflection point. For the first time in my life, overdose prevention is gaining acceptance as our culture of tough love and zero tolerance is slowly losing credibility. The basic problem we face today is that too many people are dying in isolation, alone in the shadows. The best thing we can do right now is show up for each other, offer compassion to those who are struggling, and stop politicizing something that isn’t political—saving as many lives as possible, with every tool we have at our disposal.

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Understanding Drug Use and Addiction DrugFacts

Many people don't understand why or how other people become addicted to drugs. They may mistakenly think that those who use drugs lack moral principles or willpower and that they could stop their drug use simply by choosing to. In reality, drug addiction is a complex disease, and quitting usually takes more than good intentions or a strong will. Drugs change the brain in ways that make quitting hard, even for those who want to. Fortunately, researchers know more than ever about how drugs affect the brain and have found treatments that can help people recover from drug addiction and lead productive lives.

What Is drug addiction?

Addiction is a chronic disease characterized by drug seeking and use that is compulsive, or difficult to control, despite harmful consequences. The initial decision to take drugs is voluntary for most people, but repeated drug use can lead to brain changes that challenge an addicted person’s self-control and interfere with their ability to resist intense urges to take drugs. These brain changes can be persistent, which is why drug addiction is considered a "relapsing" disease—people in recovery from drug use disorders are at increased risk for returning to drug use even after years of not taking the drug.

It's common for a person to relapse, but relapse doesn't mean that treatment doesn’t work. As with other chronic health conditions, treatment should be ongoing and should be adjusted based on how the patient responds. Treatment plans need to be reviewed often and modified to fit the patient’s changing needs.

Video: Why are Drugs So Hard to Quit?

What happens to the brain when a person takes drugs?

Most drugs affect the brain's "reward circuit," causing euphoria as well as flooding it with the chemical messenger dopamine. A properly functioning reward system motivates a person to repeat behaviors needed to thrive, such as eating and spending time with loved ones. Surges of dopamine in the reward circuit cause the reinforcement of pleasurable but unhealthy behaviors like taking drugs, leading people to repeat the behavior again and again.

As a person continues to use drugs, the brain adapts by reducing the ability of cells in the reward circuit to respond to it. This reduces the high that the person feels compared to the high they felt when first taking the drug—an effect known as tolerance. They might take more of the drug to try and achieve the same high. These brain adaptations often lead to the person becoming less and less able to derive pleasure from other things they once enjoyed, like food, sex, or social activities.

Long-term use also causes changes in other brain chemical systems and circuits as well, affecting functions that include:

• decision-making

Despite being aware of these harmful outcomes, many people who use drugs continue to take them, which is the nature of addiction.

Why do some people become addicted to drugs while others don't?

No one factor can predict if a person will become addicted to drugs. A combination of factors influences risk for addiction. The more risk factors a person has, the greater the chance that taking drugs can lead to addiction. For example:

• Biology . The genes that people are born with account for about half of a person's risk for addiction. Gender, ethnicity, and the presence of other mental disorders may also influence risk for drug use and addiction.
• Environment . A person’s environment includes many different influences, from family and friends to economic status and general quality of life. Factors such as peer pressure, physical and sexual abuse, early exposure to drugs, stress, and parental guidance can greatly affect a person’s likelihood of drug use and addiction.
• Development . Genetic and environmental factors interact with critical developmental stages in a person’s life to affect addiction risk. Although taking drugs at any age can lead to addiction, the earlier that drug use begins, the more likely it will progress to addiction. This is particularly problematic for teens. Because areas in their brains that control decision-making, judgment, and self-control are still developing, teens may be especially prone to risky behaviors, including trying drugs.

Can drug addiction be cured or prevented?

As with most other chronic diseases, such as diabetes, asthma, or heart disease, treatment for drug addiction generally isn’t a cure. However, addiction is treatable and can be successfully managed. People who are recovering from an addiction will be at risk for relapse for years and possibly for their whole lives. Research shows that combining addiction treatment medicines with behavioral therapy ensures the best chance of success for most patients. Treatment approaches tailored to each patient’s drug use patterns and any co-occurring medical, mental, and social problems can lead to continued recovery.

More good news is that drug use and addiction are preventable. Results from NIDA-funded research have shown that prevention programs involving families, schools, communities, and the media are effective for preventing or reducing drug use and addiction. Although personal events and cultural factors affect drug use trends, when young people view drug use as harmful, they tend to decrease their drug taking. Therefore, education and outreach are key in helping people understand the possible risks of drug use. Teachers, parents, and health care providers have crucial roles in educating young people and preventing drug use and addiction.

Points to Remember

• Drug addiction is a chronic disease characterized by drug seeking and use that is compulsive, or difficult to control, despite harmful consequences.
• Brain changes that occur over time with drug use challenge an addicted person’s self-control and interfere with their ability to resist intense urges to take drugs. This is why drug addiction is also a relapsing disease.
• Relapse is the return to drug use after an attempt to stop. Relapse indicates the need for more or different treatment.
• Most drugs affect the brain's reward circuit by flooding it with the chemical messenger dopamine. Surges of dopamine in the reward circuit cause the reinforcement of pleasurable but unhealthy activities, leading people to repeat the behavior again and again.
• Over time, the brain adjusts to the excess dopamine, which reduces the high that the person feels compared to the high they felt when first taking the drug—an effect known as tolerance. They might take more of the drug, trying to achieve the same dopamine high.
• No single factor can predict whether a person will become addicted to drugs. A combination of genetic, environmental, and developmental factors influences risk for addiction. The more risk factors a person has, the greater the chance that taking drugs can lead to addiction.
• Drug addiction is treatable and can be successfully managed.
• More good news is that drug use and addiction are preventable. Teachers, parents, and health care providers have crucial roles in educating young people and preventing drug use and addiction.

For information about understanding drug use and addiction, visit:

• www.nida.nih.gov/publications/drugs-brains-behavior-science-addiction/drug-abuse-addiction

For more information about the costs of drug abuse to the United States, visit:

• www.nida.nih.gov/related-topics/trends-statistics#costs

For more information about prevention, visit:

• www.nida.nih.gov/related-topics/prevention

For more information about treatment, visit:

• www.nida.nih.gov/related-topics/treatment

To find a publicly funded treatment center in your state, call 1-800-662-HELP or visit:

• https://findtreatment.samhsa.gov/

This publication is available for your use and may be reproduced in its entirety without permission from NIDA. Citation of the source is appreciated, using the following language: Source: National Institute on Drug Abuse; National Institutes of Health; U.S. Department of Health and Human Services.