A Pragmatic Approach to Harm Reduction
Earlier this year, police raided Idaho’s needle and syringe exchange pilot program for distributing drug paraphernalia. In response, the state legislature pushed to repeal the program while simultaneously pursuing decriminalizing test strips that can detect fentanyl. One news outlet called this move “mixed messaging.” But what they consider “mixed messaging” is really just the nuanced understanding America needs when it comes to the set of controversial policies and practices known as “harm reduction.” America’s drug crisis is complex and high stakes, and responses to it demand nuanced consideration by lawmakers. In this case, Idaho’s lawmakers got it right.
Today’s drug crisis differs from yesterday’s. As of 2022, death by overdose was only slightly less common than those by homicide, suicide, and vehicular death combined. The expanded prescription of opioids, widespread creation of illegally synthesized drugs, and increased drug trafficking across the border all contributed to the exponential growth in deaths by overdose since the 1990s—a number that grew from 21,705 deaths in 2001 to 111,219 reported deaths in 2021. Though most of these deaths are still associated with the most prolific drug users, the danger used to come from the drawn-out effects of addiction and long-term drug use. Now, the drugs themselves are so much more dangerous that the danger comes more from the increased risk that any given use could be someone’s last.
Harm reduction policies aim to reduce specific harmful effects of drugs, especially infectious diseases and overdoses, rather than to stop drug use outright. It is a philosophy that focuses on practical, mitigative strategies that range broadly from programs that educate users about strategies to minimize certain injuries or diseases to sites where people can use drugs under supervision. Not all policies are equally effective, especially when the primary risk of harm is death, and the research supporting each policy varies considerably.
Despite a similar unifying principle, each policy idea under the umbrella of harm reduction has unique benefits and drawbacks. Fentanyl test strips are inexpensive at about $1 per strip and highly accurate. Importantly, they are also generally seen as successful at changing behaviors, such as users decreasing their dosage or abstaining from use when drugs test positive for fentanyl. There is less scientific consensus about needle and syringe exchange programs like the one formerly active in Idaho. While there is some limited evidence that through repeated interactions, there may be an increased likelihood of treatment, these programs may not be as effective as they purport to be at reducing the transmission of diseases. One study even found a short-term increase in publicly discarded syringes associated with the opening of new exchange programs. Over the long term, the team observed a gradual decrease in syringes collected, but these findings coincided with an increased law enforcement activity so it is difficult to determine causality.
Even if we could perfectly measure and precisely weigh these policies’ costs and benefits, something more important to consider remains. We must question the government’s proper role in determining which of these services to prohibit, encourage, and permit. Distributing naloxone (commonly known as Narcan) to save lives is different than distributing needles, syringes, or pipes; one is a medical response to an immediate need for service, while some may reasonably see the other as enabling. Drug education programs funded by the state are different than supervised injection sites funded by the state; one is preventative, and the other is permissive. There are fundamental, philosophical distinctions in how the government intervenes in this crisis that require our thoughtful deliberation rather than our haphazard judgment based on political alignment.
Picking and choosing from the harm reduction catalog is not a sign of inconsistent decision-making—it’s prudent. For policymakers afraid to touch harm reduction and those frustrated with its lack of progress, the answer is to step away from an all-or-nothing approach. Even those who advocate for going “all in” on harm reduction make a point to say that “there is no magical solution.” The problem is not simple, so our solutions cannot and will not be simple either.
We need to identify local public health priorities, deliberate on proposed solutions, investigate their implications, and determine our own philosophical lines in the sand. Practical and theoretical wisdom must guide our application of harm reduction, not totalizing language. Until we treat harm reduction with the sophistication it requires, the drug crisis will be doomed to be handled with stale approaches and hasty undertakings.