Harm reduction is having its moment in America. The doors of drug-related harm reduction have swung wide open after years of federal funding bans. Extensive opioid settlement payouts combined with an urgency to address the overdose crisis have allowed for harm reduction approaches to catch on like wildfire.
But as renowned addiction author William White muses, “The fastest way to kill anything in America is to turn it into a superficial fad that dies from distortion and over-exposure.” As an advocate for people with substance use disorder, I know it is critical that we protect harm reduction from falling victim to faddist culture.
The growing enthusiasm for harm reduction, both as a philosophy and in its practical applications like overdose prevention centers and needle exchanges, may lead to these initiatives expanding more rapidly than our capacity to adequately research and sustainably integrate them.
In early 20th century America, a trend-driven movement arose and dissolved around American alcohol asylums, when facilities reported impressive recovery rates that did not reflect reality. The overstatement of the abilities of treatment facilities resulted in widespread skepticism and a growing pessimism about the entire addiction treatment system, which ultimately propelled national policies towards the criminalization of substance use.
Harm reduction programs may similarly be overstating their promises, as interventions lack the diversity of voices and range of research settings we see available for other evidence-based interventions for addiction. A systematic review conducted in 2022 concluded that existing qualitative literature lacks “the perspectives of safe consumption site staff and other community members who might be able to provide additional insight into factors influencing the implementation and sustainability of this promising public health intervention.”
Beyond simply the voices included within the available literature, we also see a severe lack of diversity in research settings. The most recent 2021 systematic review on supervised injection facilities, for example, included 22 peer-reviewed articles; however, 16 out of the 22 articles came from the same facility and program in Vancouver, Canada.
To further compound this issue and due in large part to long-standing federal restrictions, there remains a dearth of peer-reviewed literature on this topic from the U.S. and its unique, complex health care system.
Greater understanding through research will be crucial not just for the individuals these programs serve, but also for the diverse communities they are a part of. Although the National Institutes of Health recently announced its inaugural funding for studying overdose prevention centers in two states, there’s a keen interest in continuing to proceed with wider implementation of these models. In this absence of more comprehensive and diverse research, we leave the door open to blind enthusiasm, typical of faddist movements, that propels funding and implementation forward with high hopes. If — or when — these high hopes misalign with reality, it can jeopardize the credibility of the entire system.
As harm reduction initiatives experience a meteoric rise in appeal, central concepts to the approach have become diluted and distorted in ways that detract from the soundness of the approach. One distortion taking hold has been around the exaggeration of harm reduction as a panacea to the overdose epidemic, intriguing health departments and advocacy organizations across the nation. While overdose prevention center OnPoint NYC has physically reversed more than 1,000 overdoses since 2021, no one knows whether the program meaningfully increases the life expectancy of individuals after they leave, whether it’s an hour or a year later. While interventions like overdose prevention centers can immediately intervene, they remain neither a cure nor treatment for substance use disorder, the root cause of the ongoing epidemic. The misconception that harm reduction programs are standalone solutions overlooks the critical role that these programs could play within the broader continuum of addiction care.
In the court of public opinion, the “effectiveness” of these programs may ultimately hinge on their ability to successfully refer individuals to additional treatment and recovery services. It’s easy for advocates to dismiss the court of public opinion, but it matters here. Look at Portugal’s current decriminalization and harm reduction efforts. The initiatives initially showed promise. However, as funding for wraparound support services dwindled, so too did the positive outcomes, leading to an erosion in public support. Distortions around harm reduction being a self-contained solution for the opioid epidemic or cure for substance use disorder will ultimately erode support for the approach over time as promised outcomes fail to materialize.
Another particularly noticeable distortion taking hold is around the concept of autonomy. Attaching to the harm reduction movement has been a growing support for the idea that it is the innate right of the individual to use drugs. This perspective deviates from a more agreed upon intent, which calls for “kindness and autonomy in the engagement of people who use drugs.” Autonomy in engagement is very different from the autonomy of the individual, as we know that drug use has very real effects on families, how individuals experience their communities, and even broader implications if we examine the heavy burden of drug use on the U.S. health care system. Attaching ideas of personal autonomy and the right to use drugs to harm reduction suddenly implies that “the harm my drug use does to others is not my problem.” This stance closely parallels similar, very polarized areas of discourse around gun rights and vaccine refusal, highlighting a potential clash between individual rights and societal well-being.
In the face of positive media attention or a sudden (though often superficial) shift in public opinion, there is a risk that harm reduction advocates may prematurely claim victory. The problem with fads, however, is that they are short-lived, and the widespread support is fleeting. The substance use challenges we face are anything but fleeting and require sustainable, long-term investments in harm reduction, treatment and recovery support services in tandem.
We need harm reduction in America. It is an approach that can save lives and serves as a low-barrier access point to treatment and recovery services. When implemented thoughtfully, it is a compassionate and pragmatic approach that empowers people who use drugs, along with their families and communities, to choose a life of health, self-direction, and purpose. But it needs to be implemented with the rigor, research, and respect it deserves, lest we risk turning a life-saving approach into a short-lived sensation.
Alexandra Plante is a senior advisor of substance use disorder at the National Council for Mental Wellbeing. Alexandra is a recipient of a Fulbright specialist award in substance use disorder, writes regularly for the Recovery Review, and volunteers her time with the Maine Recovery Advocacy Project.