The current U.S. Secretary of Health and Human Services, Robert F. Kennedy Jr., has consistently captured public attention with his actions and rhetoric, but one aspect of his public health agenda that has received comparatively little scrutiny is his proposed reconceptualization of addiction treatment, undergirded by his support for and stated intent to emulate Patrignano. Patrignano is an addiction treatment program in Italy where people who use drugs (PWUD) participate in unpaid labor and service to the community, justified by the belief that hard work is good for the mind and soul and therefore an antidote to substance dependence. Many people have reported positive experiences, mentioning a strong sense of community, and there are high rates of self-reported recovery among individuals who remain for at least three years. However, one-fifth of Patrignano residents leave within a year, citing ignored mental health needs, overly strenuous working conditions, and a lack of evidence-based treatment. Concerns of abuse have been raised; some former residents report being locked in their rooms and having their freedom restricted even more so than incarcerated individuals, with one of the justifications being that residents must be broken to be fixed.
Despite Kennedy’s stated intentions, the discordance between his previous remarks and recent actions is alarming. During his congressional confirmation hearings, Kennedy emphasized adherence to science and prioritizing public health; however, he recently removed federal recommendations for seven childhood vaccines, a move broadly criticized by the scientific community. Who is to say that he will not conduct the same overhaul of the addiction treatment system?
These concerns are particularly salient given the addiction treatment system is already siloed and lacking regulatory oversight, which is epitomized by what is colloquially referred to as the Florida Shuffle. The Florida Shuffle describes a cycle between treatment and return to use, often with no demarcation. PWUD learn how to use drugs within a system ostensibly intended to keep them safe. This cycle is intentional and motivated by the “liquid gold rush,” which refers to the massive profits that self-proclaimed addiction treatment centers can incur by conducting urine drug testing regularly due to the absence of standardized oversight. A patient undergoing urine drug testing three times a week can generate $20,000 in billable claims per month, which has led to facilities competing for patients with incentives including iPhones, gift cards, and rent assistance. Just as PWUD are commodified for their urine and having their mental and physical health, in addition to their human dignity, ignored, could the implementation of Kennedy’s conception of Patrignano exacerbate these preexisting issues, with unpaid labor becoming more normalized in treatment settings?
With the enumerated issues, what can we do? We could wait for everything to go back to whatever “normal” is now in America. However, this is not a purely political issue, as proper comprehensive care for PWUD is a contemporary issue that has been largely dealt with insufficiently on a bipartisan level. One evidence-based approach that has been underutilized is harm reduction, a framework that acquiesces that, for better or worse, people are going to use drugs, and that minimizing harm and preserving human dignity supersede institutional paternalism. Harm reduction ranges across a spectrum from abstinence to continued substance use with the least possible harm. From this perspective, participation in residential programs like Patrignano may be appropriate for some, but it should never be the only option. A core aim of harm reduction is to save lives and protect the health of everyone in our communities, but perhaps even more importantly, its intent is to help others realize that PWUD deserve to be alive, happy, and healthy, not until they are in treatment, but simply because they are human. Two examples of harm reduction services include sterile syringe programs (SSPs) and safe injection sites (SIS). At SSPs, PWUD are provided supplies to reduce the incidence of overdose morbidity and mortality and the acquisition of skin and soft-tissue infections and common transmissible viruses, such as hepatitis and HIV, among others. SIS allow PWUD to bring pre-obtained substances and use them within a controlled clinical environment, with health care staff available to provide advice and overdose reversal services if necessary.
Patrignano represents one model of addiction treatment, and while some participants report benefits, its limitations and ethical concerns are well-documented. The central issue is not whether such a model should exist, but rather how Secretary Kennedy will implement its most problematic elements in a way that ignores human dignity and evidence-based medicine, in addition to exacerbating the already fragmented and predatory addiction treatment system. There is no singular solution, but expanding harm reduction utilization would go a long way in reducing stigma and respecting personhood, in addition to following evidence-based care.
Gary McMurtrie and Abhijay Mudigonda are medical students.
