In 2022, the Office of National Drug Control Policy (ONDCP) published a new, revised, five-point National Drug Control Strategy. The White House created the plan in response to the opioid overdose crisis. The opioid crisis is a public health emergency that has claimed over a million lives in the U.S. since 1999. Just last year, over 110,000 people died of drug overdose, with close to 75 percent of those deaths attributed to opioids.
Rates of overdose continue to increase, despite coordinated nationwide efforts over the past several years to halt the increase. Local, state, and federal authorities began addressing the opioid crisis as long ago as 2014. Various initiatives, programs, and approaches showed varying degrees of success. These programs represent our best efforts to mitigate the damage caused by the opioid crisis to individuals, families, and communities across the country.
But they haven’t been good enough – because rates of fatal overdose continue to increase. That’s why we needed a new national strategy. To learn more about that five-point strategy, please navigate to the blog section of our website and read this article:
The first priority in the five-point strategy is to enhance and fund nationwide harm reduction efforts. The funding will come from the Helping to End Addiction Long Term Initiative (HEAL) Initiative. The HEAL Initiative allocates 36 million dollars over the next five years to support harm reduction services. To learn about the HEAL initiative and the various programs in effect as we speak, please read this article:
That article offers basic information about harm reduction and its benefits. This article goes further. It offers an updated summary of the three primary goals of harm reduction and an in-depth discussion of the principles of harm reduction.
Harm Reduction: Three Goals
Here’s a comprehensive definition of harm reduction, as published by the non-profit harm reduction advocacy 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 underlying concept behind harm reduction is in the name. Harm reduction advocates seek to reduce the widespread pain and suffering related to drug use. Here are the three goals of harm reduction, as defined by the experts at HRI:
The Three Goals of Harm Reduction
1. Save Lives
The first goal is to prevent drug-related deaths. Alongside that goal, harm reduction services are designed to help people who use drugs create positive change in their lives. Approaches are supportive instead of coercive. They seek to promote any positive change in the life of a person who uses drugs, whether large or small.
2. Reduce Unintended Harms Associated With Drug Laws and Policies
Harm reduction recognizes that the warlike/bellicose attitude toward drug users and drug use advocated during the 1980s did not work. In many cases, it was counterproductive and caused harm. Negative components of this approach include:
- Criminalization of people who use drugs
- Excessive/abusive policing of people who use drugs
- Denial of care/lifesaving support services
- Restrictions on sale of safe supplies
- Forced testing
- Incarceration or detention as opposed to treatment and rehabilitation
- Discrimination related to drug use, economic status, race, or gender
3. Creating Treatment Options/Alternatives
For people who use drugs, increasing access to evidence-based treatment is essential. However, not all people who use drugs want to seek treatment. Many do want to reduce the harms drug use causes in their lives, though. Therefore, one concept of harm reduction is not requiring abstinence to participate in support programs. The idea is that abstinence should be considered a personal choice. It should be neither a barrier to support nor a prerequisite for seeking support in mitigating the harms associated with drug use.
Those are the three fundamental goals of harm reduction. Next, we’ll examine the four principles of harm reduction.
Harm Reduction: Four Principles
These four principles are an update to the eight principles of harm reduction we discuss in the article we link to above, National Harm Reduction Research Effort Could Reduce Overdose Deaths, revised for 2023:
The Four Principles of Harm Reduction
1. Follow the Evidence
All harm reduction policies and practices are evidence-based. Decades of peer-reviewed research shows harm reduction interventions are safe, effective, practical, and cost effective. Harm reduction services are inexpensive and simple to implement. For their relatively low expense, harm reduction efforts have a disproportionately positive impact on individuals, families, and communities, in comparison to traditional approaches to reducing drug use and associated harms.
2. Respect First
In past years, approaches to curbing drug use and reducing drug-associated harm often dehumanized and devalued not only people who use drugs, but also the communities where drug use is common. Harm reduction prioritizes treating people who use drugs – and their families and communities – with dignity and respect. The idea is that people who use drugs have the same basic human rights we all have, which include:
- The right to life
- Access to affordable, effective health care
- Access to social services
- The right to privacy
- The right to freedom from unnecessary detention/incarceration
- Freedom from discrimination, prejudice, and degrading/dehumanizing treatment
These rights are common to all people. Harm reduction advocates see no reason to deprive any human of fundamental rights because they use drugs.
3. Social Justice and Collaboration
With regards to social justice, harm reduction advocates seek to ensure that no entity denies anyone access to healthcare or social services as a result of:
- Drug use
- Racial/ethnic identity
- Gender identity
- Sexual orientation
- Economic circumstances
In addition, harm reduction advocates support the inclusion of people who use drugs in the “design, implementation, and evaluation” of programs and policies that have direct impact on their lives and communities.
4. Reduce Stigma
Reducing stigma happens on two levels: public and private. It involves changing the way we think and talk about people who use drugs on a person-to-person level. It involves how we talk about and think about public policies that impact people who use drugs. Harm reduction reduces barriers by meeting people where they are and offering services in a way they can accept them, and stresses using respectful, person-first language based on medical knowledge rather than social tradition. For instance, instead of junkie or heroin addict we say a person with opioid use disorder or a person with heroin use disorder. This makes a difference, and reduces barriers to support and care.
Those are the four principles that inform all harm reduction programs worldwide. Next, we’ll examine how we can apply these principles in order to help as many people as possible.
Harm Reduction in Action: Eight Policy and Program Approaches
We outline the conceptual framework for harm reduction above. The application of those ideas appears in public policies and publicly and privately funded programs to reduce harm for people who use drugs, and improve the lives of their families, and the communities where they live.
Here are the eight most common harm reduction programs currently active in the world today:
1. Education Programs
Education programs are exactly what they sound like, and more. At the most basic level, they’re programs designed to teach people the facts about drugs, drug use, and treatment for substance use disorder. Harm reduction education programs go further, and include classes or workshops on how to access social services, vocational support, relationship support, and a continuing education/basic education support.
2. Overdose Prevention and Reversal Programs
After education and prevention programs, which can stop drug use before it starts, the most effective way to prevent overdose fatalities/reverse an overdose is through targeted naloxone distribution programs. Naloxone – brand name Narcan – is a drug that carries no risk of abuse and can reverse and overdose and prevent fatality. Distributing Narcan to people who use drugs or people who know people who use drugs can save lives by getting the same medication paramedics use into the hands of people who are on the scene of an overdose when it happens. In fact, in a major step forward for harm reduction and overdose prevention, the Food and Drug Administration recently approved Narcan for over-the-counter sale without a prescription. Evidence shows access to over-the-counter naloxone can help reduce rates of fatal overdose.
3. Opioid Agonist Therapy (Medication-Assisted Treatment, or MAT) Programs
Opioid agonist therapy is a subset of medication-assisted treatment (MAT). This approach uses medications for opioid use disorder (MOUD) to reduce cravings, mitigate withdrawal symptoms, and help a person with opioid use disorder (OUD) transition from chronic drug use to recovery. Both the U.S. Substance Abuse and Mental Health Service Administration (SAMHSA) and the World Health Organization (WHO) consider MAT with MOUD as the most effective available treatment for people with opioid use disorder. Current MOUDs approved for use in the U.S. include methadone, buprenorphine, and Naltrexone. Of these three medications, methadone and buprenorphine are opioid agonists, while naltrexone is an opioid antagonist.
4. Needle & Syringe Programs
These programs are also known as syringe service programs or needle exchange programs. These programs work for three primary reasons:
- They prevent the transmission of infectious disease – hepatitis C, HIV, and others – by providing clean and sterile needles for people who otherwise might reuse needles, or share a needle despite carrying an infectious disease.
- They provide a safe, non-judgmental environment for people who inject drugs to discuss drug use in an open and honest way. These conversation build support and trust, and often result in a person who injects drugs deciding to seek treatment and support.
- The staff who manage needle service programs can connect people interested in seeking support with access to substance use treatment, naloxone, or other social services.
Needle and syringe programs face stiff opposition in the U.S., but evidence shows they reduce harm associated with opioid use, which is why they’re an integral component of our national strategy to reduce rates of opioid use and opioid overdose.
5. Drug Consumption Rooms
Like needle/syringe programs, drug consumption rooms face significant opposition in the U.S. Resistance is strong, despite the fact these programs are supported by both the American Society of Addiction Medicine (ASAM) and the American Medical Association (AMA). Also called supervised injection facilities, a drug consumption room is a safe, clean place where a person who injects drugs can inject drugs with clean supplies under the supervision of staff prepared to offer emergency support, or connect individuals directly to substance use treatment programs. Evidence shows drug consumption rooms reduce the spread of infectious disease, reduce crime associated with drug use, and prevent overdose.
Here’s how the AMA describes the current state of research on drug consumption rooms:
“The data speaks for itself—supervised consumption sites effectively treat health emergencies and help prevent certain drug-related harm or death.”
The authors of a study published in July 2022 on the impact of drug consumption rooms in Denmark and France concluded:
“DCRs may be a suitable tool for fighting the dramatic opioid overdose crisis in North America.”
There are currently two official DCRs in the United States, both located in New York City. Data from one center shows 150 overdose reversals in over 9,500 visits during the first three months of operation.
6. Drug Checking
This is a service that allows people to submit a sample of a drug – illegal or prescription – to have it tested for the presence of dangerous additives or chemicals used by drug distributors to cut or expand the volume of the substance. Drug checking is an important part of the harm reduction effort in the U.S. due to the increased presence of fentanyl and xylazine in the illicit drug supply.
The housing component of harm reduction services involves programs to provide homeless people with substance use disorder or substance use problems with safe housing in a harm-reduction, recovery-oriented environment. Advocates stress the connection between chronic drug use and homelessness, and the fact that safe, stable housing is a protective factor against drug use and overdose. Some harm reduction housing services require abstinence, while others, like Housing First in Massachusetts, does not. Evidence shows that Housing First approaches are an effective way to reduce drug use. They can also improve health for people who use drugs who don’t have safe and stable housing.
8. Legal Services
Legal services related to harm reduction include both personal and public efforts to reduce the harm caused by drug use. On a personal level, volunteer lawyers and/or government sponsored legal aid programs can help people who use drugs navigate the criminal justice system. They can help patients access treatment and support, rather than experience punishment and incarceration. On a pubic level, legal services related to harm reduction involves challenging laws and policies that discriminate against people who use drugs. Lawyers can advocate for a transformation of drug-related laws from a wholly punitive approach to a holistic approach that includes treatment, support, and efforts to promote recovery. All of this takes the time and expertise of experienced, qualified legal experts.
Harm Reduction: A Summary
It’s important to understand that if traditional approaches – like the war on drugs, enhancing enforcement, and increasing punishment for drug offenses – were effective in reversing the dramatic increase in overdose deaths in the U.S., then there would be no need for a new national strategy, and we wouldn’t be considering – as a nation – adopting harm reduction strategies pioneered in Europe at the end of the 20th century.
However, traditional approaches have not been effective. Therefore, we need a new approach. The most reliable evidence, verified over the past three decades by respected experts in addiction medicine, indicates that harm reduction offers us the best chance of addressing and resolving the opioid overdose crisis. While some elements of harm reduction meet significant resistance and pushback from our citizens and leaders alike, every component of our harm reduction strategy is evidence-based and data-driven.
That’s why we’re implementing harm reduction strategies nationwide. Regardless of our opinions, the evidence shows these strategies are our best hope of bringing help and relief to the individuals, families, and communities negatively impacted by the opioid crisis.
At Pinnacle Treatment Centers, we honor the principles and practices of harm reduction every day. We begin with a foundation of respect and compassion for all our patients. Next, we apply our philosophy through the types of treatment we offer. Finally, we reduce harm with the ongoing aftercare support we provide for patients when they complete a treatment program.
We’re committed to reducing harm in any way we can. We hope our new national strategy, solidly grounded in evidence-based harm reduction principles, will turn the tide, and reverse the steady yearly increase in overdose deaths in the U.S.