Putting More Humility in Harm Reduction

Many American cities are reeling under the weight of intersecting drug-use epidemics that include accelerating overdose deaths and myriad other challenges. Conspicuous increases in public drug use and accompanying disordered behaviors fuel public backlash in liberal bastions such as Seattle and Portland, and in more surprising places that include Wichita, Kansas.

This backlash sparks painful memories for us in public health. We remember how public anger and fears promoted the war on drugs’ massive overreaction. I came to public health during the HIV and crack epidemics, when America’s tenuous commitment to the humanity of people who use drugs, and to the humanity of our LGBTQ+ fellow citizens, fostered punitive policies and neglect that cost many lives. We remember how evidence-informed harm reduction interventions, most prominently syringe exchange, faced bitter opposition in many communities, and from political figures such as former Director of the Office of Drug Control Policy William Bennett, Senator Jesse Helms and Representative Charles Rangel, despite clear evidence that these interventions reduced HIV infection and did not increase drug use.

Those opponents of harm-reduction were dangerously wrong, as was Mayor Rudy Giuliani when, in 1999, he said, “Methadone means that you can be addicted for 15 or 20 years.” That misguided mentality — that medication treatments merely substitute one addiction for another — cost thousands of lives, worsening many harms endured by people who use drugs, their families and their communities.

It’s gratifying that Americans across political lines have come to embrace more humane and evidence-informed perspectives. In notable departures from drug-war rhetoric, Republican politicians including George W. Bush and Donald Trump supported bipartisan legislation to expand addiction treatment parity and to address the opioid epidemic. And though all the Republicans on the Senate Finance Committee voted against the Affordable Care Act (ACA), all supported components that expanded and protected addiction services. At the ACA’s passage, many of us in public health worried that newly insured drug users with criminal records would become the new Willie Hortons, stage extras in Republican efforts to repeal the law. Yet repeal advocates have generally avoided this path.

One shouldn’t overstate our progress. Our University of Chicago team surveyed American adults regarding their views of harm reduction and treatment interventions. Republicans, particularly those who hold conservative views on race, remain far more likely than others to oppose public funding of addiction treatment and other essential public health measures. 

So too, Black respondents continue to express striking ambivalence about harm reduction interventions. This is hardly surprising when one considers the brutal harms imposed by heroin and other drugs in predominantly Black neighborhoods. In the shadow of the Tuskegee syphilis study, it’s even less surprising that many distrust programs to provide clean needles to people who inject heroin, given the dearth of accompanying resources to address other drug-related harms.

It’s gratifying that a new generation of Black legislators are key supporters and ambassadors for evidence-informed harm reduction and treatment interventions. They are teaming up with a new generation of public health practitioners more in touch with local communities. Recent research indicates that well-implemented programs such as safe injection sites do not worsen crime or disorder in their immediate surroundings, and can accommodate the legitimate needs of neighboring communities. Such research helps to dispel harmful myths that lead many Americans to oppose essential harm reduction interventions.

Yet in pursuing these efforts and spreading these messages, we, in public health, sometimes lose our footing in addressing other discomfiting realities. 

One such reality is that HIV prevention offered favorable conditions for harm reduction that don’t always or completely carry over to other challenges. That virus is relatively difficult to spread in any single encounter between infected and uninfected persons. Sterile injection equipment, alongside evidence-based addiction treatment, can thus notably reduce the rate of new infections. In a harbinger of our current overdose challenge, these same interventions proved notably less effective in preventing hepatitis C — a far more infectious blood-borne disease.

It’s essential that public health scholars, practitioners and policymakers acknowledge that as lifesaving as harm reduction can be, interventions that effectively address one set of harms can prove far less effective when deployed against others. It’s no indictment of designated driver interventions — perhaps the greatest harm reduction measure ever invented — to note that they may not reduce alcohol-related dating violence on a college campus where victims and perpetrators rarely drive. It is likewise no fundamental indictment of syringe exchange to note that an intervention originally designed to slow the spread of a blood-borne pathogen must be modified to more effectively link participants with addiction treatment and to reduce overdose deaths. Outstanding public health practitioners recognize these challenges, proposing valuable responses that deserve greater attention and resources.

The overdose epidemic certainly challenges our harm reduction arsenal. Fentanyl has made street drugs vastly more lethal, as have new threats such as xylazine (also called tranq), a non-opioid that does not respond to naloxone. We face new challenges from methamphetamines and other stimulants, for which we possess weaker treatment options, and which carry other complicated risks.

Naloxone distribution, safer injecting spaces, fentanyl and xylazine test strips all can help our efforts to address the overdose challenge. Syringe exchanges can be strengthened. None of these interventions — no combination of them — will halt this epidemic. For the foreseeable future, under any feasible policy, tens of thousands of Americans will likely die of overdose every year.

Other challenges are less lethal, but they are scarcely less wrenching. People with serious substance use disorders do not generally perpetrate violent crimes. Disturbing numbers do, however, perpetrate survival crimes to meet basic needs or to get money to buy drugs. A November 25 story from the Brooklyn Daily Eagle, focusing on a quiet block overtaken by drug users, exemplifies the public anger that predictably arises from these experiences. Accompanying retail thefts also impose punishing financial harms on large and small local merchants. These harms are particularly punishing within low-income communities where substance use is especially prevalent and where merchants’ profit margins are especially thin.

Survival crimes also create unintended violence risks — as when shoplifters experience physical confrontations with store security staff. Years ago, someone tracked in one of my studies regularly shoplifted to meet basic needs. One day, an elderly merchant confronted her, trying to protect his stuff. She hurt him badly and incurred a serious felony charge. Effective interventions to address these problems likely include problem-solving courts and other measures to ensure that people who commit such crimes initiate and engage addiction treatment — and that they do not put others at risk.

Parents, partners, siblings and children endure real harms when a loved one struggles with addiction — particularly when addiction is accompanied by problematic behaviors that bring criminal justice involvement. Many loved ones are understandably drawn to abstinence-oriented interventions. 

Available research underscores the ineffectiveness of these interventions. Yet they hold out the promise of ameliorating problematic behaviors that sometimes appear unacknowledged or unaddressed by other interventions. An inclusive and sustainable harm reduction response should acknowledge these sources of pain and credibly engage these challenges. Measures to “support the supporters” are essential to this response.

We in the public health community rightly ask communities to embrace a list of evidence-informed interventions: addiction treatment on request, syringe exchange, housing-first interventions, naloxone distribution and novel treatments for methamphetamine disorders. We, in turn, might embrace a language of mutual responsibility, whereby the nation and local communities are responsible for supporting people who use drugs, while people who use drugs have reciprocal responsibilities to engage in treatment and harm reduction measures, and to avoid behaviors likely to harm themselves or others. And we should be more attentive to ways that our own experiences can promote our own absolutism and blind spots, with accompanying temptations to oversell worthy imperfect interventions.

We must particularly guard against political conformity. In 2022, economist Analise Packham published an analysis claiming that syringe exchanges worsened the overdose epidemic. She was savaged on social media and in the pages of public health journals. As I have written elsewhere, her analysis included genuine shortcomings, at times deploying gratuitously stigmatizing language. It was nonetheless a good-faith effort to investigate key challenges. Judged on the technical merits, her work compares favorably with many within the public health literature that were more enthusiastically received because they provided congenial findings. 

When public health researchers respond in this way, we undermine our public legitimacy. We lose opportunities for constructive engagement across academic disciplines and other boundaries.

At its best, harm reduction is a chastened and pragmatic vision. Practitioners work with affected individuals, families and communities to ameliorate drug-related harms. We act with the knowledge that while we can’t eliminate all harm, feasible, evidence-informed interventions can still help. The daunting challenges of this moment demand humility and communal self-reflection. They should not lead us to lose heart.