Reduce Harm, Save Lives

In 1986, when I was still injecting cocaine and heroin, a friend’s girlfriend taught me to clean my needles with bleach if I couldn’t avoid sharing, dramatically reducing my risk of becoming infected with HIV. At the time, half of the people who shot drugs in New York city already carried the virus that causes AIDS, which was then nearly universally deadly. 

Though it hadn’t yet become widely known as “harm reduction,” the approach to drugs that focuses on reducing associated damage, rather than demanding abstinence, probably saved my life. At the time, I was addicted and wasn’t going to immediately stop injecting just because I learned about HIV risk. Most people don’t change overnight — and at that point of my life, I was in a state of complete despair, having had to drop out of Columbia because I was facing serious drug charges.

And even if I had tried stopping right away, most people attempting recovery relapse at least once. As it turned out, the man I was about to share needles with later tested positive for HIV. But thanks to his girlfriend, when I began my recovery in 1988 and returned to my previous career goal of becoming a journalist, I was not infected.

Soon, “harm reduction” became a drug policy movement that, during the current overdose crisis, went from the fringe to the mainstream. It got its name from some of its earliest proponents in Liverpool in the U.K. in the late 1980s, who started one of the first comprehensive programs and prevented HIV from becoming an epidemic in the city’s injection drug users. Their approach included the provision of clean needles, as well as prescribing heroin and cocaine to people who were not prepared to stop injecting, and expanding methadone treatment. That became a model for cities around the world.

Since then, an enormous amount of research has been conducted which shows that harm reduction is the best paradigm we have for managing problems associated with drugs and protecting life and health. The U.S. originally rejected the idea — banning federal funding of clean needle programs in 1988. But for the first time in 2022, President Joe Biden made it an official part of national drug policy.

Unfortunately, politics and widespread misunderstanding about the nature of both addiction and harm reduction has now produced a backlash, with critics claiming that it promotes public drug use and other disorder while “enabling addiction” and delaying recovery. 

In fact, research shows that harm reduction actually spurs recovery and does not create a conflict between preventing drug use, helping people who use drugs and helping those who want to stop.

This has been clear since syringe service programs began to be studied during the AIDS crisis. In the U.S., opponents claimed that people who inject drugs could not be taught to do so more safely — and that, even if providing needles did prevent disease, this would “send the wrong message” in the zero-tolerance war on drugs. If this meant more AIDS deaths among addicted people and their partners and children (most heterosexual and pediatric AIDS cases resulted from transmission from people who inject drugs), these deaths would serve as a deterrent to others.

But even before studies of syringe programs were widely published, it was clear that the laws criminalizing drug paraphernalia like needles did not deter use. In a 1991 decision clearing eight AIDS activists charged with breaking those laws, a New York judge noted pointedly that the states that had the toughest anti-needle laws had both the highest rates of HIV transmitted by syringes and the highest rates of IV drug use. In other words, criminalizing paraphernalia deterred safer practices, not drug use.

When studies of syringe service programs (SSPs) began to be published, none found increases in drug use or reductions in seeking help. In fact, one 2000 study found that those who began using syringe exchange programs were five times more likely than those who did not to seek treatment. As the CDC now sums up the data, “Nearly 30 years of research shows that comprehensive SSPs are safe, effective and cost-saving; do not increase illegal drug use or crime; and play an important role in reducing the transmission of viral hepatitis, HIV and other infections.”

And that theme — debunking the myth that harm reduction encourages addiction by preventing people from hitting bottom and getting better — runs through the overwhelming majority of studies on harm reduction programs, whether they hand out the opioid antidote naloxone, provide medically supervised drug consumption rooms, decriminalize drug possession or even prescribe heroin itself. None of those approaches are credibly linked with greater drug use by youth — but they are credibly linked with either greater likelihood or at least equivalent chances of recovery compared to law enforcement or “tough love” tactics.

Let’s start with heroin prescribing, which should be the most likely policy of all to lengthen addiction and delay recovery. After all, if you are getting all the heroin that you want, free or at a low cost, and it is pure and you have a safe place to use it, why would you ever quit? According to the ideology of 12-step programs based on Alcoholics Anonymous — which dominates American addiction treatment and policy discussions — people with addiction need to hit bottom and experience severe negative consequences in order to recover.

While many people frame their stories around the idea that they “hit bottom,” this can only be defined retrospectively, because if someone relapses after a significant period of abstinence — which is common — they now have a new bottom.  Also, many people’s bottoms are far from the time when they experience the most severe consequences — and many people’s turning points come when they are given new hope, not more pain.

In reality, research from Switzerland, which began experimenting with heroin prescribing in the 1980s after observing the practice in Liverpool, shows that the longer people stay on heroin prescriptions, the more likely they are to become abstinent or choose more traditional medication treatment. If dropping out of treatment that provides prescription heroin is less likely to lead to recovery, then providing safer drugs does not lengthen or worsen addiction, but simply preserves life.

The Swiss heroin program, which had expanded from pilot studies to a national initiative by the mid-2000s, was not associated with increased heroin use by youth. In fact, the number of new heroin users fell by 80% between 1991 and 2005 and the overdose rate was cut in half. The reduction in overdose death has been sustained, with drug use among youth remaining low. 

The Swiss also pioneered overdose prevention centers — known alternatively as “safe injection facilities” or “supervised consumption sites”— starting in 1986. Again, opponents feared that these would encourage drug use by youth, delay recovery and make neighborhoods less safe.

Again, the data show nothing of the sort, but, in many cases, an opposite correlation. There are now more than 200 overdose prevention centers in over a dozen countries. No one has ever died of an overdose at such a facility. A Spanish study found that frequent users of the centers in Catalonia were twice as likely to seek drug treatment compared to those who attended less often or didn’t use the sites. A review of the research found that they are often associated with reduced public drug use and with no increase in crime. And a brand new study of the two sites in New York City found no increase in surrounding crime after the programs opened, compared to similar neighborhoods without safe injection facilities.

Though critics have argued that distributing the opioid overdose antidote naloxone would increase teen drug use by making it seem less dangerous — and increase risk-taking by people who use drugs for the same reason — most studies do not support these ideas either.

Addiction is defined by the National Institute on Drug Abuse — the largest funder of addiction research in the world — as compulsive drug use that continues despite negative consequences. In other words, trying to stop addiction by making life worse for those who suffer from it is, by definition, not likely to succeed. This also means that the idea that people need to be made to “hit bottom” in order to get better is also wrong — and similarly, that being kind or providing support or even prescription drugs to those who are still using doesn’t “enable” continued addiction.

The data on harm reduction falsify the core of concepts like “enabling” and “hitting bottom” — and show us a better way to help people recover successfully. Being kind and nonjudgmental toward people with drug problems doesn’t steer them away from treatment. It encourages more healthy behavior because it shows them that they are valued. And being valued and respected helps people who are socially rejected and often full of self-hatred to begin to value themselves.

Research finds that there are numerous pathways to recovery. Most people — even those addicted to opioids, at least in the pre-fentanyl years before they became so much more deadly — recover, and they typically do so without formal treatment or even attending self-help groups. This natural recovery process is more likely when people are employed and have lower levels of mental illness and stress exposure. In other words, people in the middle or at the top are more likely to recover without help than those at the bottom. 

For those who do need help to get better, research finds that, for opioid addiction, the best approach is long-term use of the medications methadone or buprenorphine, which cut the death rate by half or more so long as people stay on the medications. Abstinence treatment that is kind, and that doesn’t focus on humiliating people by confronting them, also helps many — but it has not been shown to reduce death rates. 

Finally, while some people do appear to quit drugs when they reach a low point like being incarcerated, this is a minority. There’s no evidence that, for any identifiable group of people with addiction, harsh approaches are the only things that work. 

Arrest and “tough love” programs clearly cause significant harm — incarceration, for example, does not reduce the risk of future crime, and may increase it, while raising overdose death risk and spreading disease; tough love can worsen both mental illness and addictions.

Consequently, there’s no reason to continue them — let alone prioritize them. This doesn’t mean that people who commit actual crimes related to addiction shouldn’t be offered evidence-based treatment in the criminal prosecution system; simply that arresting people for drug possession is not an effective way to spur recovery.

Given these facts, it’s clear that harm reduction is both the best way to protect people who continue to use drugs and the best way to aid recovery. There is no trade-off here.

Harm reduction neither deters recovery nor worsens drug problems or public safety. It’s time we heeded the data, not the politics.