In 2013, there were 8,260 deaths from heroin overdose in America.1 Since then, heroin overdose death rates have continued to climb. It’s also estimated that nearly a million Americans over the age of 12 have used heroin in the last year with 586,000 of those individuals having a heroin problem. Opioids — a class of drug that includes prescription painkillers and heroin — account for about 61 percent of all drug overdose deaths, showing just how serious a problem opioids have become.
Finding a solution to America’s opioid problem has become a huge priority. Although there are thousands of addiction treatment centers available throughout the United States, there are still more people developing opioid addictions than there are opioid addicts getting sober. Consequently, some have suggested that we look outside the proverbial box for a solution to this problem. In particular, harm reduction is an unconventional approach to loosening the stronghold opioid addiction has on our society and can be used to great effect. However, due to its controversial nature, harm reduction strategies have been slow in making their way from Europe into North America.
If evidence shows that harm reduction can be beneficial, why is it so controversial?
There are many negative effects that result from having a substance abuse problem, including loss of overall health, loss of career, damage to relationships and so on. Many of these effects are the inevitable consequence of the long-term abuse of alcohol or drugs. For instance, it would be difficult to mitigate the damage that substance abuse does to one’s overall physical health while the alcohol or drug abuse continues. However, there are certain consequences of addiction — i.e., contracting a blood-borne illness by sharing syringes with other intravenous drug users — that are only possible rather than inevitable and can sometimes even be prevented altogether.
At its core, harm reduction is a rather simple concept that refers to the minimization of adverse effects resulting from some type of behavior. Alternately, one might say that harm reduction consists of strategies that prevent or reduce the likelihood of some of the negative consequences of addiction.2 More often than not, harm reduction strategies entail safer or managed use of mind-altering substances, being as concerned with the environment and conditions of the use as with the use itself.
The underlying tenets of harm reduction show just how different this perspective is from more traditional abstinence-based strategies. Among those tenets, it accepts that, for better or worse, alcoholism and drug addiction are part of the modern world. Rather than ignore or condemn the harmful effects of substance abuse disorders, harm reduction seeks to minimize the amount of harm that substance abuse disorders do. As well, harm reduction is based on the view of substance abuse as a continuum, ranging from less severe to more severe and from less dangerous to extremely dangerous. Therefore, it stands to reason that some methods of alcohol or drug use would be much more harmful than others.3 The implementation of harm reduction strategies requires a person to be non-judgmental and accepting.
Typically, harm reduction programs target intravenous users of opioids. For intravenous drug users, some of the biggest risks include contracting diseases by sharing injecting equipment with other users, bacterial infections that can result from frequent injection, injuries sustained from intravenous drug use and the potential for overdose. Most of these dangers can be mitigated substantially by supervised injection sites, which provide intravenous drug users with a safe, supervised environment in which to imbibe their drugs.
Supervised injection sites don’t provide the actual drugs. However, they do offer clean, unused syringes and can, upon request, offer assistance in the actual administration of the drug if the user is unable to do it himself or herself. Otherwise, staff members who supervise the drug users won’t intervene in the administration of the drug unless the individual needs medical attention or begins to overdose.
It’s estimated that there are currently about 100 supervised injection sites around the world. Many researchers have assessed the communal effects of supervised injection sites, often concluding that this form of harm reduction is effective in reducing rates of overdose deaths4 and preventing the spread of blood-borne illnesses5 in the area. Further, there have been studies that link supervised injection sites to decreases in crime,6 decreases in paraphernalia found in the street7 and increases in the number of individuals enrolling in recovery programs8 in the area of these supervised injection sites.
From the perspective of a drug user, a supervised injection site is a place where he or she can obtain all the clean syringes he or she could possibly need and a safe, private environment in which to administer his or her drugs. This means there’s much less transmission of diseases between drug users who are now in less danger than they would be using drugs on the streets. Meanwhile, using these sites means that trained staff members can intervene in many of the overdoses that would otherwise occur on the street.
But supervised injection sites aren’t the only form of harm reduction that’s shown promise. Needle exchange programs — sites that allow intravenous drug users to exchange their used syringes for clean, unused ones — have likewise reduced rates of disease transmission and are already available in the United States. However, the prospect of offering supervised injection sites is a conversation that’s only just beginning due to the amount of controversy that has surrounded harm reduction in the U.S.
Despite the evidence in favor of harm reduction, there are many who are vehemently opposed to the idea. In 2007, South Carolina Senator Jim DeMint was quoted as saying that supervised injection sites are “ridiculous” and that it’s like “ask[-ing] Americans to pay for drug addicts to inject themselves with heroin and cocaine.”9 Bertha Madras, an official from the Office of National Drug Control Policy, likened the possibility of opening a supervised injection site in San Francisco to giving up on the fight against against. It wasn’t until 2009 that the decades-long ban against federal funding for needle exchanges was finally dropped.10
Those who oppose harm reduction strategies like supervised injection, needle exchanges and maintenance programs tend to view harm reduction as encouraging addicts to continue their substance abuse. The priority of harm reduction is basically to mitigate injury, which many believe to be in opposition of the abstinence-focused rehabilitation programs found across the United States rather than an additional tool that can help the overall landscape.
What opponents of harm reduction fail to realize is that harm reduction is not about giving up. Rather, it’s about being pragmatic. For a number of the individuals who are struggling with addiction today, long-term sobriety may still be weeks, months or perhaps even years down the road. Even those who enroll in addiction treatment programs today have a journey ahead of them before they become comfortable and confident in sobriety. Since substance abuse is still a reality for many addicts, harm reduction can help protect them from many of the worst effects of addiction in the meantime. Until an addict can get sober, he or she could at least be more safe from blood-borne illnesses, overdose and other realities of drug use.
Currently, the most common forms of harm reduction in the United States are methadone maintenance programs, buprenorphine maintenance and needle exchanges. The only supervised injection facility in North America is actually in Canada, which has just the one site while officials prepare to open more.11 In many ways, supervised injection is one of the most progressive harm reduction strategies, but the severity of the nation’s heroin problem is progressive, too. As rates of opioid addiction continue to climb, it may be time to consider minimizing the deadly risks associated with heroin use as we continue searching for more effective rehabilitation methods.
Written by Dane O’Leary