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Harm reduction is an approach to engaging with substance use behaviors by meeting substance users where they are. Harm reduction is designed to improve the physical, mental, and behavioral health of substance users, in addition to reducing the risk of overdose and increasing infection disease control. Critically, harm reduction is also based in the respect for the rights of people who use drugs.
An average harm reduction program consists of:
- Safe needle exchanges
- Distribution of naloxone as overdose prevention (a medicine that counteracts the effects of opioids and significantly reduces risk of overdose)
- Public access to fentanyl test strips (which allow drug users to test their drugs for the presence of fentanyl, an opioid with significantly more potency and lethality than standard forms such as heroin and Oxycodone)
A final key aspect of harm reduction engagement is providing low-threshold options for accessing substance use disorder (SUD) treatment and other health care services.
History of Harm Reduction
Harm reduction began as a grassroots movement by public health advocates in the 1990s. At that time, public policy and law enforcement around drug use was growing stricter. Communities with disproportionate rates of substance abuse were affected most acutely by these policies, with little support for addressing the mental and public health issues that were driving substance use.
People in these communities-especially poor people, people of color, and residents of urban areas-recognized the need for a different approach to skyrocketing rates of overdoses, drug use, and incarceration for drug-related offenses. They began to develop harm reduction approaches that addressed drug-related usage and negative consequences not as a bottom-up problem, but rather an opportunity for community-driven solutions.
One of the first efforts of the harm reduction movement was to establish needle exchanges (which were illegal at the time). As of 2022-three decades since the beginning of the harm reduction movement-significant progress has been made because of the work of activists, community groups, and local governments. Today, the federal government recognizes the need to increase harm reduction efforts across the country in the fight to end the opioid epidemic.
Principles of harm reduction
Essential to harm reduction is respect for people who use drugs and are unable to stop, as outlined in the guidelines put forth by the National Harm Reduction Coalition. The notion that people struggling with substance use disorders deserve to live with dignity is foundational to harm reduction.
The key principles of harm reduction include:
- Harm reduction accepts that drug use is part of our world and works to minimize its negative consequences rather than ignoring or condemning them.
- Harm reduction understands drug use as a complex continuum of behavior ranging from severe use to total abstinence.
- Harm reduction acknowledges that some ways of using drugs are safer than others.
- Harm reduction assumes that individual and community wellbeing is the goal, not necessarily stopping all drug use.
- Harm reduction means that services are provided to people who use drugs in a nonjudgmental, non-coercive manner in the communities where they live.
- Harm reduction ensures that anyone who is a drug user or has a history of drug use retain a voice in creating the harm reduction programs and policies that serve them.
- Harm reduction recognizes that poverty, class, racism, social isolation, past trauma, gender-based discrimination, and other social inequalities affect people’s vulnerability to drug use, and their ability to deal with that use.
- Harm reduction does not attempt to minimize or ignore the very real harm that can come with illicit drug use.
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How harm reduction works in practice
Harm reduction efforts help prevent death, injury, disease, overdose, and substance misuse. Specific harm reduction methods include:
- Connecting people to overdose education, counseling, and treatment for infectious diseases and substance use disorders.
- Distributing Narcan spray (naloxone) to people at risk of overdose, such as those in homeless shelters or people leaving prison.
- Creating clean needle exchanges to decrease risk of spreading infectious diseases, including HIV, viral hepatitis, and bacterial and fungal infections.
- Reducing overdose deaths through provision of fentanyl test strips, which allow people to test their drugs for fentanyl to avoid accidental overdose.
- Helping homeless drug users find supportive housing that isn’t contingent on sobriety. Many supportive housing organizations link new residents to drug treatment and other health and social services.
- Facilitating links to further drug treatment following ER visits.
- Reducing stigma associated with substance use and co-occurring disorders through PSAs and other public education campaigns.
- Promoting a philosophy of hope and healing by employing people with lived recovery experience in the harm reduction field.
Public hesitancy about harm reduction
Despite becoming more mainstream, the harm reduction movement is still considered somewhat-controversial. There is a long held negative perception of substance use disorder (SUD) and those struggling with it, leading some to believe that harm reduction in fact encourages substance use. Related, many people think that complete abstinence is the only goal worth pursuing in the fight against drug and alcohol addiction-sometimes to the detriment of incremental measures like harm reduction. A brief look at both factors:
Many people still believe addiction is a sign of weak character and morals, or a lack of willpower. It is neither. Rather, SUD is a mental health issue just like depression, anxiety disorder, PTSD, and many others. And like those other mental illnesses, SUD is caused and exacerbated by a combination of physical, hereditary, and environmental factors.
At the same time, the stigma around substance use has decreased significantly over the past two decades. This has led to an increase in acceptance for harm reduction efforts, especially as evidence has mounted against large pharmaceutical companies that played a large role in creating and spreading the opioid epidemic. People are more “worthy” of receiving help with their drug use if they’re not seen to be lacking in willpower or criminally minded.
Bottom line: People who need harm reduction efforts aren’t bad people. They’re simply drug and alcohol users whose brains in many cases have been taken over by powerful, addictive substances, and they need help with that. For many, the harm reduction help they receive is the first step in their long-term recovery.
This term means you take no illicit drugs or alcohol. Abstinence is often considered the traditional and more socially acceptable goal for someone who is addicted to drugs or alcohol.
But for many, achieving abstinence can be a very difficult step, and relapse is common. Which is why harm reduction advocates believe it is so important to reduce harm, reduce risk of death and disease, and to provide health and social services to people who use but who haven’t been able to stop (as opposed to relying on abstinence as the primary way to fight addiction).
Harm reduction advocates are not necessarily anti-abstinence though. Many see drug and alcohol use as a continuum that stretches from full-on addiction to total abstinence. Advocates believe that everyone along that continuum ought to have access to harm reduction efforts.
What harm reduction is not
From its beginnings in the ‘90s, harm reduction has met resistance from many sectors in society, including abstinence-only advocates.
People often claim that harm reduction “promotes drug use” or “rewards” drug users. They may view harm reduction as a slippery slope toward a radical policy that will backfire. They may even believe that substance users are criminals who don’t deserve resources that could be better used elsewhere.
In response to those claims, advocates believe the following about harm reduction:
It is not in opposition to abstinence
Abstinence is one of the strategies of harm reduction. Substance use behaviors are on a continuum from severe, dangerous use to total abstinence, and the goal of harm reduction is to move behaviors away from the dangerous end of the continuum.
It does not promote drug use
A Canadian study found that the opposite is true. “It can no longer be argued in a compelling fashion” say the study authors, “that harm reduction exacerbates drug use and undermines treatment efforts.”
It is not in opposition to standard drug treatment
Rather, it often leads to it. Example: In one study, people who recently started using a syringe service program were five times more likely to enter treatment as those who didn’t use the program.
It is not being “soft” on crime or drugs
Ridding the world of substance use is nearly impossible. In this way, harm reduction is a series of practices that address this reality. In fact, according to a 2018 Brookings Institute study, harm reduction efforts do not increase criminal activity.
The future of harm reduction
Because of recent top-down support from the highest levels of the federal government, combined with continued efforts from grassroots organizations around the country, harm reduction is gaining momentum in the U.S.
Many see harm reduction as simply another weapon in the fight against addiction and the overdose epidemic. It’s not the perfect stand-alone solution (abstinence-based treatment and other measures are needed as well) but harm reduction is a critical tool in the fight to end the current opioid and overdose epidemic across the U.S.
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