HArms reduction is having its moment in America. The doors to drug harm reduction have opened wide after years of being barred from federal funding. Vast opioid-related settlements, combined with the urgency to resolve the overdose crisis, have allowed harm reduction approaches to spread like wildfire.
But as renowned author William White believes, “The quickest way to kill anything in America is to make it a superficial fad that dies from distortion and overexposure.” » As an advocate for people with substance use disorders, I know it is essential that we protect harm reduction to avoid becoming a victim of fad culture.
Growing enthusiasm for harm reduction, both as a philosophy and in its practical applications like overdose prevention centers and needle exchanges, could lead to an expansion of these initiatives faster than our ability to adequately research them and integrate them sustainably.
In early 20th century America, a trend emerged and dissolved around America’s alcohol asylums, when facilities reported impressive recovery rates that did not reflect reality. Overestimating the capabilities of treatment facilities has led to widespread skepticism and growing pessimism about the entire drug treatment system, which ultimately propelled national policies towards criminalization of substance use.
Similarly, harm reduction programs can overstate their promises, to the extent that interventions lack the diversity of voices and range of research contexts that we see available for other evidence-based interventions against drug addiction. A systematic review carried out in 2022 concluded that the existing qualitative literature lacks “the perspectives of safe consumption site staff and other community members who might be able to provide additional insight into the factors influencing the implementation and sustainability of this promising public health intervention.”
Beyond just the voices included in the available literature, we also see a glaring lack of diversity in research contexts. The most recent 2021 systematic review on supervised injection centers, for example, included 22 peer-reviewed articles; however, 16 of the 22 articles were from the same institution and program in Vancouver, Canada.
Further compounding this problem and largely due to long-standing federal restrictions, there remains a dearth of peer-reviewed literature on this topic from the United States and its unique and complex health care system.
Better understanding through research will be crucial not only for the individuals these programs serve, but also for the diverse communities of which they are a part. Although the National Institutes of Health recently announced its inaugural funding to study overdose prevention centers in two states, there is strong interest in continuing to implement these models more widely. In the absence of more comprehensive and diverse research, we leave the door open to blind enthusiasm, typical of trendy movements, that propels funding and implementation with high hopes. If – or when – these high hopes do not match reality, it can jeopardize the credibility of the entire system.
While harm reduction initiatives have boomed in popularity, the central concepts of the approach have become diluted and distorted in ways that undermine the strength of the approach. One distortion that has taken hold involves the exaggeration of harm reduction as a panacea to the overdose epidemic, puzzling health departments and advocacy organizations across the country. As the OnPoint NYC overdose prevention center physically reversed itself more than 1,000 overdoses as of 2021, no one knows whether the program significantly increases individuals’ life expectancy after they leave, whether that’s an hour or a year later. Although interventions such as overdose prevention centers can intervene immediately, they are neither a cure nor a treatment for substance use disorders, the root cause of the current epidemic. The misconception that harm reduction programs are stand-alone solutions overlooks the critical role these programs could play in the broader continuum of addiction care.
In the court of public opinion, the “effectiveness” of these programs may ultimately depend on their ability to successfully direct individuals to additional treatment and recovery services. It’s easy for advocates to dismiss the judgment of public opinion, but it’s important here. Look at current decriminalization and harm reduction efforts in Portugal. The initiatives initially showed promise. However, as funding for wraparound support services declined, positive outcomes also declined, leading to a erosion of public support. Distortions around whether harm reduction is a stand-alone solution to the opioid epidemic or a cure for substance use disorders will ultimately erode support for the approach over time, as the promised results will not materialize.
Another particularly visible distortion concerns the concept of autonomy. The harm reduction movement is generating growing support for the idea that drug use is an individual’s birthright. This perspective deviates from a more conventional intention, who calls “benevolence and autonomy in the involvement of people who use drugs”. Autonomy in engagement is very different from autonomy of the individual, because we know that drug use has very real effects on families, the way individuals experience their communities, and even more broad when considering the heavy burden of drug use on the American health care system. system. Associating ideas of personal autonomy and the right to use drugs with harm reduction suddenly implies that “the harm my drug use causes to others is not my problem.” This position closely parallels similar, highly polarized areas of discourse around gun rights and vaccine refusal, highlighting a potential conflict between individual rights and societal well-being.
In the face of positive media attention or a sudden (although often superficial) shift in public opinion, there is a risk that harm reduction advocates will prematurely declare victory. The problem with fads, however, is that they are short-lived and widespread support is fleeting. The substance use challenges we face are anything but fleeting and require long-term, sustainable investments in harm reduction, treatment and recovery support services.
We need harm reduction in America. It is an approach that can save lives and serves as low barrier access point treatment and recovery services. When implemented thoughtfully, it is a compassionate and pragmatic approach that empowers people who use drugs, and their families and communities, to choose healthy, empowered lives of purpose. . But it must be implemented with the rigor, research and respect it deserves, otherwise we risk turning a life-saving approach into a fleeting sensation.
Alexandra Plante is a senior advisor on substance use disorders at the National Council on Mental Wellness. Alexandra is the recipient of a Fulbright Specialist Award in Substance Use Disorders, writes regularly for the Recovery Review, and volunteers her time with the Maine Recovery Advocacy Project.
