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If you’ve never heard of harm reduction in addiction treatment, the first thing to know is that while harm reduction is a relatively new concept in the United States, harm reduction itself is not new. Influenced by social justice and health equity movements in the U.S. in the 1960s, 1970s, and 1980s, harm reduction as we know it today is an approach to addressing and reducing drug addiction, overdose, and the myriad harms associated with drug addiction – particularly opioid addiction, called opioid use disorder (OUD) – that began in the early 2000s in Europe.
In 2001, Portugal was a decade into an opioid addiction and overdose crisis similar to the one we’ve faced in the U.S. for the past twenty years. However, they took a radical approach: rather than looking at addiction as a criminal problem, they followed the advice of psychologists and healthcare professionals and decided to view addiction and overdose as a public health issue.
That changed everything.
Rather than jail people arrested for using heroin or other opioids immediately, a person arrested for opioid/heroin possession/use went before a three-person panel including a lawyer, a social worker, and a healthcare/addiction professional. There, the panel offered options: consent to and participate in addiction education and treatment, stay out of trouble for six months – i.e. no drug-related arrests – and authorities would drop the charges.
When we say that changed everything, here’s what happened.
Harm Reduction: The Data Speak
- By 2017, the number of heroin users in Portugal dropped by 75%, from around 100,000 to around 25,000.
- Overdose fatalities decreased by 90%:
- 1999: 369
- 2016: 30
- IV-drug related HIV infection decreased by 98%:
- 2000: 901
- 2017: 18
- Drug-related incarcerations decreased by 70%
- 1999: 3,863
- 2017: 1,140
For context, between 1999 and 2016, overdose fatalities in the U.S. increased by 278 percent, from 16,849 to 63,632. But that’s not all:
The latest data from the Centers for Disease Control (CDC) shows over 109,000 people in the U.S. died of drug overdose between December 2022 and December 2023.
That’s why our paradigm has changed from the War on Drugs we declared in the 1980s to a new national policy, influenced by the success of harm reduction efforts in places like Portugal.
The Goals and Principles of Harm Reduction
First, let’s provide an updated, comprehensive definition of harm reduction, provided by the Here’s a non-profit harm reduction group Harm Reduction International (HRI):
“Harm reduction refers to policies, programs and practices that aim to minimize the negative health, social and legal impacts associated with drug use, drug policies and drug laws. Harm reduction is grounded in justice and human rights. It focuses on positive change and on working with people without judgement, coercion, discrimination, or requiring that people stop using drugs as a precondition of support.”
The unifying concept behind harm reduction is simple: shift from a punitive approach to a supportive approach, and implement policies and practices designed to reduce the negative consequences of drug addiction, which treatment professionals call substance use disorder (SUD).
Harm Reduction: Three Primary Goals
1. Save Lives
The first goal is to reduce and/or prevent fatalities associated with drug use. An important part of this goal is to use harm reduction services to help people who use drugs creates positive change in their lives, without making ultimatums, threats, or requiring immediate abstinence. Harm reduction programs always prioritize support and treatment over coercion and punishment.
2. Reverse Damage Caused by Old Policies
To move forward, we need to be honest with ourselves: The War on Drugs did not work. Negative outcomes of this national policy, adopted in the 1980s, include:
- Excess criminalization of drug use
- Disproportionate policing of people who use drugs
- Restricted access to care
- Restricted access to safe supplies
- Involuntary/forced/mandatory drug testing
- Incarceration and punishment as a first option, as opposed to treatment and rehabilitation
- Discrimination/vilification/stigmatization of people who use drugs
- Stigmatized seeking and engaging in addiction treatment
3. New Treatment Options and Treatment Approaches
Expanding access to evidence-based treatment is a core component of harm reduction. Not everyone who uses drugs is ready to engage in treatment, but most want to reduce the harm they experience as a result of drug use. That’s why one aspect of harm reduction is not making requiring abstinence a prerequisite for participating in harm reduction programs. Harm reduction advocates believe pursuing abstinence should be decided by the person using drugs, rather than establishing abstinence as a mandatory requirement for receiving harm reduction services.
Those goals are common to all aspects of harm reduction. Now we’ll look at the four principles of harm reduction, which inform all harm reduction programs.
The Core Principles of Harm Reduction in Addiction Treatment
These four principles are a condensed version of the eight principles of harm reduction in addiction treatment as outlined by the National Harm Reduction Coalition here. For clarity and ease of understanding, we combined and streamlined aspects their list in order to help people new to idea of harm reduction understand the most important components without presenting an overwhelming amount of information.
Harm Reduction: Four Core Principles
1. Evidence-Based Approaches Only
Harm reduction policies and practices are based on decades of peer-reviewed research. All available data shows harm reduction practices work. Not only are they effective, but they’re also practical and inexpensive to initiate and maintain.
2. People First
In all harm reduction programs, providers treat participants with respect and compassion. Each person who seeks support from harm reduction programs is entitled to the same treatment we all expect when we seek medical care. People with substance use disorder (SUD) have the same core human rights as all citizens:
- The right to a healthy and fulfilling life
- Unrestricted access to effective health care
- Unrestricted access to supportive social services
- The right to privacy
- Freedom from unnecessary punishment
- Freedom from stigma, prejudice, and dehumanizing treatment
While it’s surprising we need to remind people of these rights, the fact is we that we do. Over the past fifty years, people who use drugs, particularly opioids and heroin, have been stigmatized and treated as second-class citizens. They’ve often been deprived of both rights and respect, rather than offered the treatment and support necessary to rebuild their lives. This principle is simple: treat people who seek support for addiction the way we treat people who seek support for any other chronic illness: with dignity and respect.
3. Equality, Justice, Mutuality
Harm reduction advocates ensure that no public or private institution restricts access to healthcare or social services for any of the following reasons:
- Drug use
- Race/ethnicity
- National origin
- Gender or gender identification
- Sexual orientation
- Work/employment status
- Socioeconomic status
Harm reduction also requires the direction participation of people who use drugs in the creating policies and implementing programs that directly impact their lives. This principle is best understood by this motto:
“Nothing About Us Without Us”
4. Eliminate/Decrease Stigma
Reducing is essential in both public and private domains. As a culture, it’s essential for us to move beyond our War on Drugs mentality. We need to drop that bellicose attitude on an interpersonal level, meaning how we talk amongst ourselves and with people who use drugs about drug use and addiction treatment. We also need to eliminate the warlike/battle/fighting imagery in our public policy and programs. Yes, we will fight to help people, but we need to be careful, because people who use drugs are not enemies: they’re our friends and family members, not combatants in a war.
Harm reduction programs can reduce or eliminate stigma and barriers to care by meeting people where they are and offering support in a manner they’ll accept. Harm reduction in addiction treatment emphasizes using person-first, evidence-based language rather than defaulting to the stigmatizing language of the past. Rather than junkie, we say a person with opioid use disorder. Rather than a drunk/alcoholic, we say a person with alcohol use disorder.
This simple change can lead to a deep cultural change, but it will take time, and it will take all of us to remember how important language is: it can harm, and it can heal. The language of harm reduction is the language of healing.
Harm Reduction in Addiction Treatment: Our National Strategy
We’re honored to be among the primary providers of medication-assisted treatment (MAT) nationwide. MAT the gold standard treatment for opioid use disorder (OUD), and an integral component of a comprehensive harm reduction initiative.
In Harm Reduction in Addiction Treatment: Everything You Need to Know, Part Two, we’ll talk about the eight foundational policy and program initiatives associated with a funding initiative called HEAL: Helping to End Addiction Long-Term, initiated in 2022. The HEAL program received 36 million dollars to explore and implement harm reduction strategies across the U.S., in our first major commitment to harm reduction to address the ongoing opioid addiction and overdose crisis.
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