Drug use has been a part of human experience for thousands of years, across every known culture. But for many of us, it’s still surprising to learn that only a small fraction of people who use even “hard” drugs like heroin or methamphetamine—according to US government data, for example, or the United Nations—become addicted.
Still, a lot of us do experience significant drug-related problems, including addiction. Somewhere in the middle is a line where use crosses over into harmful use. But making that distinction isn’t always easy.
If it’s hard for us to make that distinction about our own drug use, the authorities are even worse at doing it for us. When I was growing up in the 1980s, my Saturday morning cartoons were interspersed with “Just Say No” PSAs and anti-drug propaganda made its way into every popular sitcom. Politicians envisaged—and many still do—a “drug-free America.”
But the War on Drugs has caused more damage than drugs themselves ever could. As these policies fill jails, prisons, probation rolls and morgues, the US government’s own data show that, if we take rates of substance use or overdose deaths as our measures of success, drug prohibition has long since failed. As with alcohol prohibition in the 1920s, it’s just made things more dangerous (living in the heart of moonshine country, I’ve heard stories passed down over generations).
Clearly, people experience directly harmful effects from both illegal and legal drugs. But prohibition blurs cause and effect: If there are harms, where do most of them originate? From the drugs themselves? From the laws that increase the dangers around these drugs? Or from somewhere else?
Amid this confusion, working out whether or not your own drug use is a net problem can be extremely tricky.
Substance Use Can Be a Rational Choice
What if I told you that drug use can be a rational choice? It’s a notion I’d once have scoffed at, even while using heroin every day. But the work of some experts backs this idea.
Neuropsychologist and Influence columnist Dr. Carl Hart, for example, has carried out studies in which patients display seemingly rational behavior when offered something else of value, such as small sums of cash, in lieu of their preferred drug (crack cocaine or methamphetamine). In controlled conditions, participants were able to regulate their substance use—and many were long-time drug users.
The theory is that substance use, even in the face of harmful consequences, can be a rational way of coping with stressors common in a society that produces pockets of isolation, extreme poverty, and an ever widening gap between rich and poor. Dr. David Nutt of Imperial College, London says, in response to Hart’s work, “Addiction always has a social element, and this is magnified in societies with little in the way of work or other ways to find fulfillment.”
Dr. Stanton Peele, the addiction theorist and Influence columnist, also places structural social issues at the center of addiction. This lines up with Bruce Alexander’s well-known “Rat Park” study. I’m no scientist or doctor, but there’s a clear connection between human suffering and addiction. The War on Drugs compounds those issues, with criminalization and incarceration pushing people with substance use disorders further toward the margins of society, in turn increasing their suffering and vulnerability.
Some people can use drugs long-term with few harmful consequences. They don’t fit the popular caricatures (few of us do). For a time, I was one of these people. I used heroin and held down a highly demanding software engineering job for close to three years.
It made sense to me. After a childhood marked by abuse, isolation and untreated mental illness, heroin was the best medicine I could find. There were times I would stop; then I would rationalize going back to it because heroin made mebetter at my job, especially after I lost that software gig and started working as a server/bartender (this was a rational choice to me, which helped me earn better tips—I counted).
Eventually, the costs of spending large sums every week on heroin, trying to hide my use from family and friends, an escalating series of legal problems (I had to steal to support my use, even though I was working), the near-unbreakable cycle of jail, probation and prison, and the lost opportunities for employment and education that followed left my life a wreck. Overall, my heroin use became definitely harmful and seemed inescapable.
Costs and Benefits of Drug Use
It wasn’t something I considered much at the time, but most of the harms I just listed weren’t a result of heroin itself, but of its prohibition. (This isn’t to say that all problems are associated with the legal status of a substance; many people develop problems with legal drugs like nicotine and alcohol.)
Meanwhile, another important realization during my most difficult times was that there were benefits to my heroin use—even in the face of high costs like strained relationships and incarceration. This helped me reframe the way I thought about using drugs and ultimately positioned me to make healthier choices.
The cost-benefit analysis (CBA) is a tool I learned in SMART Recovery. It’s deceptively simple, just requiring a sheet of paper, but it can help people overcome ambivalence to change, gauge where harms originate, or analyze their overall health and wellness at in any stage in the change process.
The CBA is easy to use and it’s an excellent way to take inventory of what you can do to move toward a healthier lifestyle—even if your end goal isn’t complete abstinence. The CBA can be applied not only to substance use, but a range of short and long-term problem behaviors including gambling, sex addiction, eating disorders and, for some people, mental health issues. It’s a tool I still use today when I’m struggling with ambivalence.
Here are a couple of examples from my experience as an illustration:
Costs of Continuing:
- Expensive: Have to steal to afford drugs much of the time
- Limited access to syringes, can lead to disease transmission, scarring, vein damage
- Unknown dosages can lead to overdose, mixing with other substances can increase that risk, even if I know the dose
- Street drugs are often cut with potentially harmful adulterants or fillers
- Using can impair judgement and make certain activities (driving, work) potentially dangerous. I once drove completely over a stop sign and didn’t look back
- Judgement by and isolation from family members and loved ones that I value
Benefits of Continuing:
- Blunts emotional pain, reduces stress, controls anxiety
- Keeps my brain feeling “normal”, like medicine, I don’t have access to health care
- Eliminates back pain I’ve lived with since my early 20s
- Helps me sleep, stabilizes my mood, reduces effects of bipolar mania and depression
- Enjoy the routine and ritual of using
- Feel like I have friends who understand me
- Using makes me more social and helps me perform better at my job (I was a server/bartender and anxiety impacted my work)
Benefits of Stopping:
- Rebuild relationships that have been strained by drug use
- Will help my legal situation, don’t have to worry about failing drug screens at probation
- Psychiatrists are more likely to treat someone who isn’t actively using heroin
- Don’t have to worry about how I’m going to avoid withdrawal every morning
- Reduce the risk of overdosing from an unknown dose of street drugs
Costs of Stopping:
- Withdrawal if I stop using “cold turkey”
- Might impact my social life, most of my friends use. I was a loner before I started using
- There’s no guarantee I won’t relapse, which is risky if I choose to abstain for a period and return to using, esp. if I have to use alone
- What are my options? Can I afford detox? Outpatient rehab? Medication-assisted treatment?
Each box is filled with costs and benefits I never would have imagined prior to this exercise. And I could keep going. For example, I never previously thought about the costs of stopping or benefits of continuing to use because I was conditioned to think that abstinence was always the only choice.
It’s not—and this is significant. For many people, abstinence itself can be harmful, especially forced abstinence, or kicking drugs like opioids or benzodiazepines (above all, forced withdrawal in jail).
Until 1973 the DSM, a manual used to diagnose psychological disorders, listed homosexuality as a mental illness. The most recent edition, DSM-5, lists gender dysphoria (a cleaned up version of the DSM-IV “gender identity disorder”) as a condition, suggesting that trans people are mentally ill.
At the same time, behaviors that cost millions of lives per year, like using tobacco and drinking alcohol, are considered normal—within limits. Still, the CDC lists tobacco use as the leading preventable cause of death in the US and estimatesthat 88,000 Americans die from alcohol-related causes each year. Legality or social norms are poor indicators of harmful effects from substance use.
A Health Continuum
In the end I decided medication-assisted treatment (MAT) was right for me. If I were to draw a personal wellness continuum, I think that option would lie near the “healthiest” point. That’s not the case for everyone: MAT isn’t an option for some people (it’s limited mostly to opioid use disorders), and some people don’t want to stop.
For illegal drugs like heroin or methamphetamine, reducing use or changing routes of administration (e.g., from injecting to snorting) can carry health benefits, but just using these drugs is a felony in most states. This doesn’t mean they’re impossible to use moderately. In fact, many people who are exposed to harm reduction services decrease their substance use or eventually enter more formal treatment.* And there are programs, like HAMS and Moderation Management, to help problem drinkers reduce their drinking (similar principles can be applied to drug use).
Being caught with illegal drugs by the police just one time, however, can have serious, life-altering consequences. In addition, many rehabs simultaneously teach that relapse is an expected part of recovery, but have zero-tolerance policies when clients end up using. Just one slip could have you living on the street, and at a much greater risk of overdose.
Traditional recovery narratives frame abstinence as the least harmful option, but that’s not true for some people. Many street drugs mimic the effects of pharmaceutical medications. People without access to those medications might be better off self-medicating. That’s a decision they have to make. Maybe a CBA can help them determine where those choices line up on the personal wellness continuum.
Substance Use and Social Conditions
While individuals wrestle with their own decisions, there are some hopes for broad and meaningful changes. Grassroots drug user unions and harm reduction organizations press for health-oriented solutions which place the voices of active drug users at the center of the conversation. These organizations, sometimes led by openly active drug users, promote policies which empower directly-impacted people to decide what’s best for their health.
Influence contributor Ellie Navidson recently chronicled a story about substance users in a Chicago homeless campwhere people look out for each other in different ways. For example, a man who smoke cannabis stands guard with naloxone on hand in case one of his colleagues should overdose. There’s a sense of community, something we all desire, in that.
Organizations like the Urban Survivors Union and People’s Harm Reduction Alliance, among many others, are pioneeringsyringe decriminalization, supervised injecting facilities (SIFs), and heroin (or hydromorphone) assisted treatment. These ideas, which weren’t open for discussion a few years ago, have recently gained support from some surprising places. Svante Myrick, mayor of Ithaca, NY, is hoping to establish an SIF in his city. Canada’s government recently voted to allow prescription heroin as a treatment for addiction.
Policymakers hoping for that “drug-free America” will never find it. If they’re sincere in their efforts to improve public health, rather than exploit drug policy as a form of social control, they should prioritize treatment over punishment and increase access to proven health strategies.
If you use drugs, legal or illegal, do the benefits outweigh the costs? Can you improve your health while still meeting whatever needs those substances fill?
Only you can answer that—with the help (hopefully) of useful tools, such as the CBA; evidence-based programs and professionals, if you need them; and supportive people in your life.
In a world with so much suffering, social marginalization, structural violence, and an ever-widening gap between rich and poor, substance use and self-medication are sometimes the most effective means of coping. A policy shift toward human rights—prioritizing humanity over ideology and assistance over punishment—would be the most effective possible harm reduction tool.
Until that happens, we each have to do the best we can.