In the United States, the drug overdose crisis is almost two and a half decades old. Also known as the opioid crisis, most experts place the beginning of this destructive public health emergency in the late 1990s. Since then, over a million people have died from drug overdose, with around three-quarters of those overdose deaths involving opioids.
The latest data from the Centers for Disease Control (CDC) shows that in 2021, close to 107,000 people died of drug overdose, with just over 80,000 of those deaths attributable to opioids. That’s a 450 percent increase since 1999. It’s also the reason public health officials use words like crisis and emergency to describe the situation.
To learn more about the opioid crisis in the U.S., please navigate to the blog section of our website and read these articles:
Those articles provide a solid overview of the opioid crisis and the steps we’ve taken, as a nation, to address and mitigate the harm caused by this phenomenon. One thing that’s apparent – and reflected in the information in the articles above – is a transformation in how we support people with opioid use disorder (OUD), which we used to call opioid addiction. We’ve evolved from a culture characterized by stigma and punitive approaches to substance use to a new culture of understanding and support characterized by the principles of harm reduction.
We now use all the available tools at our disposal to address the opioid crisis and support people with opioid use disorder and the people affected by opioid use disorder. That’s an important component of the harm reduction movement.
The HEAL Initiative: Paving the Way Forward
The transformation in our approach to supporting people with OUD and people at risk of fatal overdose did not happen overnight or by accident. It took the coordinated effort of harm reduction advocates, treatment providers, community organizers, and public policymakers to make this happen.
Most importantly, it took funding.
A new national research effort will ensure that this funding continues. It will ensure we double down on the harm reduction approach, which includes essential funding for various evidence-based treatment approaches. Treatment that works involves therapy, counseling, community support, and in some cases, medications for opioid use disorder (MOUD) in medication-assisted treatment programs (MAT).
In a December 2022 press release, Dr. Nora Volkow, Director of the National Institute on Drug Abuse (MIDA), reported that a new funding initiative – the Helping to End Addiction Long Term Initiative (HEAL) – will receive 36 million dollars over the next five years to explore and pursue harm reduction strategies in the U.S. Here’s how she describes this new funding development:
“Getting people into treatment for substance use disorders is critical, but first, people need to survive to have that choice. Harm reduction services acknowledge this reality by aiming to meet people where they are to improve health, prevent overdoses, save lives, and provide treatment options to individuals. Research to better understand how different harm reduction models may work in communities across the country is therefore crucial to address the overdose crisis strategically and effectively.”
Dr. Volkow offers a thumbnail description of harm reduction in that excerpt from her press release – but that just scratches the surface of what harm reduction is. Let’s take a deeper look, now, in order to learn more about harm reduction and gain a greater understanding of what kind of programs this new round of funding will support.
What is Harm Reduction?
We can trace the origin of the harm reduction movement to a handful of programs initiated in Europe in the 1980s, and to concepts associated with various social justice movements in the 1960s, 1970s, and 1980s in the United States.
Original European efforts included a syringe exchange program initiated in the Netherlands in 1984 designed to reduce the spread of hepatitis B, and a needle exchange and clinic in Liverpool, England, that prescribe methadone and pharmaceutical grade heroin that users would otherwise have purchased illegally.
The social movements in the U.S. that impacted the harm reduction movement include:
- Free breakfast, lunch, and health clinics for kids initiated by the Black Panthers in New York City
- A well-known acupuncture clinic for heroin users in the South Bronx, NYC launched by community organizers
- The women’s equal rights and reproductive rights movement in the 1970s
- The movement to bring awareness to the AIDS crisis in the mid-1980s
When combined, needle exchange programs, medications for opioid use disorder (MOUD) such as methadone, and a consciousness of social justice and health equity coalesced to create a template for the harm reduction movement we recognize now. The harm reduction movement is prevalent worldwide, from Europe to North and South America to Africa to Asia. It’s instrumental in reducing the negative effects of drug use overall, and opioid addiction/opioid use disorder (OUD) in particular.
While there is no one definition of harm reduction – since it’s a concept and approach to mitigating the negative effects of drug use – it’s possible to define harm reduction by elucidating the overall philosophy behind the harm reduction movement. Here’s a good explanation of the concept of harm reduction provided by the non-profit harm reduction advocacy group The National Harm Reduction Coalition (NHRC):
“Harm reduction is a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use. Harm Reduction is also a movement for social justice built on a belief in, and respect for, the rights of people who use drugs.”
That’s the big picture: the origin of harm reduction and it’s guiding concepts. Now let’s take a look at what harm reduction looks like in action.
Harm Reduction: How it Works to Reduce Opioid Addiction and Overdose
The NHRC identifies eight foundational principles of harm reduction, which form the theoretical framework for guiding harm reduction programs, harm reduction advocates, and all harm reduction efforts in practical application.
The Eight Principles of Harm Reduction
Principle One: Acceptance
Harm reduction advocates accept that both legal and illegal drug use is part of our world and choose to work to minimize its harmful effects rather than ignore, condemn, or criminalize them.
Principle Two: Understanding
Harm reduction advocates understand drug use is a complex, multi-faceted phenomenon that involves a wide range of behaviors, from severe use to total abstinence. Harm reduction advocates acknowledge that some ways of using drugs are clearly safer – for the individual and the community – than others.
Principle Three: Modern Concept of Recovery
Harm reduction advocates understand that the contemporary concept of recovery recognizes that quality of individual and community life and well-being — not necessarily cessation of all drug use or total abstinence — as the criteria for successful interventions and policies.
Principle Four: Equal Resources Delivered Equitably
Harm reduction advocates call for the non-judgmental, non-coercive provision of services and resources to people who use drugs and the communities in which they live in order to assist them in reducing harm associated with drug use.
Principle Five: Nothing About Us Without Us
Harm reduction programs must ensure that people who use drugs and those with a history of drug use routinely have a real voice in the creation of programs and policies designed to serve them. This concept – and the phrase nothing about us without us – is derived directly from the disability rights and equity movement that occurred in the U.S. in the 1970s.
Principle Six: Meet People Where They Are
Harm reduction programs must affirm and recognize people who use drugs are the primary agents of reducing the harms of their drug use. Harm reduction advocates seek to empower people who use drugs to share information and support each other in strategies which meet their actual conditions of use.
Principle Seven: The Social Determinants of Health
Harm reduction programs and advocates recognize that the realities of poverty, class, racism, social isolation, past trauma, sex-based discrimination, and other social inequalities affect vulnerability to and capacity for effectively dealing with drug-related harm.
Principle Eight: Realistic Appraisal
Harm reduction advocates and program workers will not attempt to minimize the significant human tragedy, harm, and danger associated with illicit drug use.
Helping End Addiction Long-Term (HEAL) Initiative: Nine Major Harm Reduction Research Programs
1. Johns Hopkins University
Research at Johns Hopkins will examine:
- The effect of mobile harm reduction programs on overdose among females who use opioids or other drugs
- Program will focus on women in Baltimore, Maryland
- Mobile vans will offer participants harm reduction supplies including:
- Fentanyl test strips
- Program staff will provide treatment service such as:
- Brief trauma-informed counseling
- Referrals for treatment and support
- Program staff will provide additional support such as:
- Medical care
- Social services
- Program staff will help connect people in need with necessities, including food and clothing
The research team will examine the outcome of these harm reduction services on women in Baltimore who use illicit drugs and report their findings to the public.
2. New York University School of Medicine
Researchers at NYU School of Medicine will investigate:
- The impact of a mobile harm reduction programs on Black and Latino/Latina participants in:
- New Haven, Connecticut
- The Bronx, New York
- Community coordinators will identify the needs of study participants, including:
- Hood assistance
- Mental health treatment
- The coordinator will connect participants to appropriate social services
The research team will examine the outcome of these harm reduction services on Black and Latino/Latina participants who use illicit drugs and publish their results when the research period is complete.
3. Oregon Health and Science University
Researchers in Portland will evaluate two interventions:
- Contingency management, which is evidence-based behavioral intervention for the treatment of a variety of substance use disorders
- The identification of personal harm reduction goals with the support of a peer with lived experience
These studies, in contrast to the two above, will focus on community-based organizations in rural areas. Their goal is to increase the availability and effectiveness of harm reduction services for people with methamphetamine use disorder, which is a driver of the current wave of drug overdose deaths. The research team will examine outcomes and publish their results at the end of the study.
4. Research Triangle Institute (RTI)
Scientists from the RTI in North Carolina will assess the impact of a harm reduction program in San Francisco. The research team will examine the following program elements:
- Does it reduce harm?
- Who uses the program?
- How many people use the program?
- What’s the demographic breakdown?
- How effectively and efficiently is the program managed?
- Maintenance of services:
- Can the program sustain and maintain its services?
The goal of this effort is to help all relevant stakeholders gain a greater understanding the scope of harm among people with opioid use disorder or people who use drugs other than opioids. The research team will publish their findings at the end of the study period.
In addition, the RTI will create a harm reduction research network. The network will provide support to the nine research efforts in the harm reduction research network.
5. University of Chicago
The research team at the University of Chicago will:
- Examine the use of harm reduction programs statewide
- Investigate how to initiate and manage remote harm reduction strategies in rural Illinois communities, including secondary distribution approaches
- Secondary distribution includes:
- People who obtain non-medication harm reduction supplies from harm reduction programs and subsequently provide them to people who use drugs but cannot access harm reduction services
The University of Chicago research team will publish their findings at the end of the study period.
6. University of Nevada-Reno
The Nevada research team will:
- Test new methods to identify and support overdose responders
- Overdose responders are people who use drugs who help peers when those peers overdose
- The goal of this research is to:
- Identify barriers to naloxone use
- Increase naloxone distribution and use among people vulnerable to overdose
The University of Nevada-Reno research team will publish their findings at the end of the study period.
7. University of Pittsburgh
Researchers at the University of Pittsburgh will:
- Develop and test an intervention designed to create behavioral change and reducing risk among black people who use drugs and visit the hospital emergency room for drug-related reasons
- This intervention is unique for two reasons:
- People with lived experience of drug use will deliver the intervention
- Researchers will combine two harm reduction strategies: take home naloxone and fentanyl test strips.
The University of Pittsburgh research team will publish their findings at the end of the study period.
8. University of Wisconsin-Madison
Researchers at the University of Wisconsin-Madison will:
- Develop and test four internet- and smartphone-based harm reduction tools
- These tools will increase access to harm reduction programs for people who rarely have access to public health services, including harm reduction services
- Researchers will recruit participants in urban and rural Wisconsin
The University of Wisconsin-Madison research team will publish their findings at the end of the study period.
9. Weill Medical College of Cornell University
Researchers at Cornell in New York will launch a research effort to determine:
- Where to provide harm reduction supplies, if delivered by mail
- How to provide harm reduction supplies, if delivered by mail
To achieve this goal, researchers will examine:
- Barriers to delivery of harm reduction supplies via mail
- Factors that predict use harm reduction services delivered by mail
- Factors that predict sustained engagement with harm reduction services delivered by mail
- Preferences of study participants who use harm reduction services delivered by mail
The Weill Medical College research team will publish their findings at the end of the study period.
Those are the nine programs that will receive the bulk of the 36 million dollars allocated to enhance our understanding and implementation of harm reduction programs around the United States. Let’s take a moment to discuss the implications of this commitment.
How Supporting Harm Reduction Helps Individuals, Families, and Communities
The opioid crisis is in the process of teaching us that drug addiction, overdose, and the harm associated with the disordered use of substances – a.k.a. addiction – is not simply a problem that one individual experiences. It’s a problem that affects everyone. The long-term consequences of substance use impacts the individual who uses substances, but also their family, their peers, and their community.
That’s why harm reduction is crucial. It takes a holistic, all-of-the-above approach to healing. Think of it this way. The integrated model for addiction treatment focuses on all the things in a person’s life that may impact their substance use. That includes social factors, financial factors, family factors, work factors – everything. When treatment addresses everything with an all-of-the-above approach, outcomes improve.
Harm reduction is analogous.
When we take an all-of-the-above approach to reducing harm on a national level – meaning we implement programs in all the areas we describe above, according to harm reduction principles – what we do is akin to applying an integrated treatment plan to the entire country. With a comprehensive approach, we not only address the individual experience of addiction, but address the social determinants of health that may contribute to substance use and create barriers to substance use treatment.
That’s an important step forward. It’s a step we think will have a significant, positive impact on the opioid crisis in the years to come.