The Disability in Addiction

A Safe Injection Site in Vancouver (Credit: Elana Gordon/WHYY)

One way of making sense of our thoughts about addiction is by considering our attitudes towards programs and institutions that propose to mitigate the harms of addiction.

Consider safe injection sites (also known as ‘supervised injection sites’). These sites provide unused needles to intravenous drug users, and thereby allow people addicted to heroin and other intravenously-injected drugs to use their drug of choice while substantially reducing their risk of contracting infectious diseases such as HIV and Hepatitis C.

There is a long-standing debate about the creation of safe injection sites.

On the one hand are the advocates of harm reduction. Heroin addiction is a harmful condition, destroying families and careers, and drastically shortening lifespans. Safe injection sites reduce this harm, if only a little: they take away the additional harm of contracting an infectious diseases. They thereby make the life of someone addicted to heroin somewhat better than it would otherwise be.

On the other hand are the advocates of use prevention. They agree that heroin addiction is a harmful condition. And they point out, not without reason, that making heroin use less costly, as these sites do, makes people who are addicted to heroin more likely to continue using heroin, which in turn makes them worse off. They thereby make the life of someone addicted to heroin somewhat worse than it would otherwise be.

This is a long-standing debate. But the very terms of this debate are, in fact, misguided. We should not be thinking of safe injection sites in terms of harm or prevention. Instead, we should be thinking of them in terms of accommodation.

Think about the ramps that are placed alongside stairways on buildings for individuals in wheelchairs and others who are unable to easily walk upstairs. What precisely is the justification for building these ramps?

It would be odd if one argued that the point of these ramps is that it reduces the harms associated with using a wheelchair. In a way this is true: the built environment in many places imposes considerable harms on persons who use wheelchairs, and the introduction of wheelchair ramps lessens these harms to such degree.

But it feels like a mistake to think of wheelchair ramps in terms of harms and their reduction in the first place. And it would be perverse to argue against wheelchair ramps as some people argue against safe injection sites, whatever it might even mean to do so.

The argument for wheelchair ramps is simply that persons who require wheelchairs have a disability, and that a just society should accommodate disabilities, unless it is prohibitively expensive to do so. We do not calculate the benefit of wheelchair ramps to their users and weigh it against the cost of their construction and their associated inconveniences.

We simply observe that we can afford to construct wheelchair ramps, and that it is the just thing to do for persons who need such ramps, and we do so.
I want to suggest that this is how we think about safe injection sites as well. Safe injection sites should not be thought of as reducing the harm associated with addiction. Rather, they should be thought of as accommodating persons with a disability — namely, the disability of drug addiction.

In something like the same way that wheelchair ramps make life more manageable for someone who uses a wheelchair, so do safe injection sites make life more manageable from someone with a drug addiction.

Accordingly, it is a mistake to focus on the calculation — as the contemporary debates do — of whether the benefits of safe injection sites outweigh their harms. Once we see safe injection sites as an accommodation for a disability, it is reasonable to think that they should be provided unless doing so is prohibitively expensive or imposes excessive burdens.

Recognizing addiction as a disability, and safe injection sites as an accommodation for that disability, makes the case in favor of safe injection sites simpler and more compelling than most contemporary debates take it to be.

Some people find it strange to think of drug or alcohol addiction as a disability. But in fact this follows naturally from our understanding of what a disability is.

A disability arises from a complex interaction between a health condition and environmental factors. That is an apt description of addiction. An addiction is a health condition, typically a physical dependence on alcohol or a drug, that is exacerbated by environmental factors, including widespread and often institutionalized discrimination.

This understanding of addiction is, in fact, black-letter law in the United States. The Americans with Disabilities Act (ADA) requires that persons with disabilities be provided with reasonable accommodation.

The ADA is not limited in its scope to physical disabilities, such as those requiring the use of its wheelchair. Its scope is broader than that. It acknowledges that individuals with an addiction to alcohol and, under certain conditions, an addiction to other drugs, have a disability that cannot be discriminated against and must be provided with reasonable accommodation.

I do not want to argue that there is a legal argument for safe injection sites, and in fact the current legal situation around safe injection sites is complicated and unsettled. Rather, laws like the ADA give support for the idea that addiction is a disability. And once we see this, we can see that there is a moral case for safe injection sites, one which turns on the idea of respecting the needs of disabled persons.

Crucially, this argument does not turn on a cost-benefit analysis of safe injection sites — though their benefits are considerable. Rather, it turns on the idea that disabled persons have a right to accommodation, a right which is not absolute but which is, at least in most cases, of considerable weight.

Once the accommodationist case for safe injection sites is recognized, other kinds of accommodation come into view. Medication-assisted treatment for opiate addiction, the provision of medical leave for addiction treatment (which does in fact come under the scope of the ADA), and perhaps even the decriminalization of drug possession and use — all of these can be seen as accommodations for disabilities.

The alternative to a judgmental and punitive treatment of addiction is not necessarily a medical and rehabilitative one — rather, it is an approach that simply accommodates the needs of persons with addiction, just as any other disability should be accommodated.

I am a therapist and philosopher, based in Cambridge, Mass.