Compassion in Action: How Harm Reduction Saves Lives & Builds Healthier Communities

By trading punitive measures for compassion, the harm reduction approach preserves the dignity & autonomy of people who use drugs (PWUD) and weaves a stronger, healthier fabric for society.

Jul 27, 2023

Western culture has a long history of moralistic condemnation of intoxication with psychoactive drugs — including licit drugs like alcohol.

It wasn’t until the introduction of acquired immunodeficiency syndrome (AIDS) in the early 80s that leaders around the world became motivated to seek a different course of action.

As the disease spread through the country, people began realizing it was more important to educate people on healthy ways to consume their drugs than to talk down to them about it.

Pilot syringe exchange services first started in Amsterdam, then spread to parts of the UK before finally landing in New York City in 1989 after defeating stiff opposition.

One thread running through successful harm-reduction efforts is fixing problems that — as one study puts it — “impacted white communities in middle-class suburbs.”

Before the HIV/AIDS crisis was taking root, opioid crises had broken out in the 60s and 70s and were met with bitter media responses instead of calls to institute harm reduction measures.

As the first needle-exchange services were opening in New York, the so-called “crack epidemic” was taking over the nightly news. The government’s response was to increase the penalty for crack cocaine to 100x that of powder cocaine.

Powder cocaine — fueling unfathomable office days on Wall Street among white bankers in the 80s — didn’t get the same treatment.

The tragedy of HIV/AIDS affected people in power enough to take harm reduction measures, but this was the only motive for needle distribution. Additionally, as they were complaining about the worsening “crack epidemic,” states were restricting people from giving out clean smoke wear.

This happened despite the fact that crack cocaine — like fentanyl or most other illicit drugs — is far safer to smoke than it is to inject.

Why, then, only “reduce harm” through the most dangerous method of use instead of encouraging other routes of administration? Because it wasn’t about helping PWID, it was to serve the ends of politicians and people in power.

Today, a movement is brewing for the legalization of drugs and the implementation of a system that can help.

What Is Harm Reduction?

Harm reduction is a set of practical strategies and ideas aimed at reducing the negative consequences of substance use. After all, people have been using drugs for as long as there have been people; no prohibitive measure has ever been able to stop that.

Services stress saving lives, protecting health and safety, and promoting dignity over criminalization and stigma. Prohibition only destabilizes and worsens the supply of drugs while stigmatizing and endangering users.

For people who use drugs (PWUDs), the hardships of societal alienation, exclusion from meaningful employment, or deprivation of basic human rights due to past convictions feed addictive behavior. Even a functional user of stigmatized drugs may feel they have to use alone, isolated, and out of sight.

Programs often require participants to pass drug screening or take drugs that block their ability to get high to get in. What about those who aren’t ready to quit yet — I mean, don’t we always say you “have to hit rock bottom” and other platitudes?

Withholding help from them only exasperates health, economic, racial, and ethnic inequities while increasing the likelihood of encountering a harmful supply.

The Principles of Harm Reduction

The main principles of harm reduction revolve around the following:

Meeting people where they’re at instead of requiring them to come to you
Pragmatic approaches to drug use as opposed to criminal or emotional ones
Respecting the personal autonomy of PWUD
Encouraging a nonjudgemental approach to care for PWUD

Meeting People Where They’re At

Not every person who uses drugs is in the same place socially, culturally, or economically.

Many opioid-dependent individuals use the drug as a result of poor access to medication for pain. When healthcare professionals suspect a person is “abusing” opioids, they may cut them off even if their patients have a legitimate cause for them.

The point is: people use drugs — they always have, and they always will. Fighting to bring everyone into your form of the societal fold is a losing battle, and it’s much easier to meet them where they are and provide them with the tools they need.

Mobile naloxone, clean needle, and fentanyl test strip distribution are examples of meeting people where they are at.

Pragmatism

An emotional response to the spread of disease through sharing needles is to ban using drugs. Pragmatic responses, by contrast, focus on building harm reduction programs to address the practical problems of drug use.

We’ve never been able to stop drug use, but we might be able to reduce the spread of disease, overdose, and unhealthy pregnancies/STDs.

When we address the problems with practical solutions, we can ease some of the harm caused by drug dependency.

Respect for Personal Autonomy

Recovery is about being there for people when they decide to give up drugs; harm reduction is about being there regardless of their personal choices.

Humans can decide for themselves whether they want to use drugs, and we should make sure they can do so as safely as possible. Harm reduction measures work to educate PWUD on their drug of choice and its potential dangers.

It also allows for safer ways to use it and offers users a way to remove the drug from their life if they want to. And ONLY if, by the way.

If someone doesn’t want to give up drugs, that doesn’t mean they should die a preventable death. Education on safe use and practical measures for reducing harm instead of restricting the rights of PWUD empowers them to decide on their drug use for themselves.

Encouraging a Nonjudgmental Approach

The harm reduction philosophy doesn’t place moral judgment on PWUD. Instead, it focuses on empowering them to live a long, healthy life.

This principle emphasizes a compassion-based approach to reducing stigma and offers tools to safely consume drugs without requiring treatment.

Instead of the shame and embarrassment society places on drug use, harm reduction focuses on building trust and helping people.

Drug use is often the result of a complex mixture of social, economic, and cultural situations — not a moral failing. Almost every human on Earth uses drugs of some kind: be it coffee, heroin, cannabis, methamphetamine, or sugar; we all have a molecule we rely on from time to time.

These molecules aren’t even. In fact, they can’t be…they don’t have a mind with which to set that intention. Or, at least, we haven’t discovered sentience within fentanyl YET (though it’s surprising someone hasn’t tried reporting that we have yet, given the history of drugs in media).

We are the ones who place value on drugs and determine whether their use will be problematic or not. Fentanyl prescriptions are written every single day and many don’t have the capability to obtain one — health care is a privilege in this country, not a right — so they have to find it elsewhere.

Regardless of your opinions on a particular drug, you still shouldn’t extend those thoughts to the person using it as well.

I’ll never understand why someone might want to have an experience with Brugmansia, for example, but this doesn’t mean I think people who have braved the deliriant world it offers are any different than me. They simply use different drugs for different purposes.

Harm Reduction Strategies 101

Effective harm reduction requires a comprehensive, multi-faceted approach. There’s no one strategy that works on its own, but the combined effort of multiple different methods that work in synergy to address the complexities of substance use and mitigate its associated harms.

Here are some of the major strategies used for harm reduction today:

1. Education

Educating PWUD on safe practices and what to do in the event of an emergency empowers them to strengthen their community instead of asking them to leave it.

Governments often place heavy restrictions on harm reduction measures, but there are no restrictions on education.

Harm reduction activists should view their understanding of drugs as being a foundational aspect of their work. Keeping up to date with contamination trends and new drugs on the market to convey the information to the PWUD is one of the most crucial components of any harm reduction work.

2. Fentanyl/Xylazine Test Strips & Narcan Distribution

Fentanyl and Xylazine are the two most common contaminations to lead to a deadly result. The former is a potent opioid up to 50x stronger than heroin, and the latter is a non-opioid tranquilizer with powerful effects, worse withdrawal symptoms, and no current mechanism for overdose reversal.

Most illicit opiate consumers favor fentanyl over heroin today — largely due to an adjustment in the market where it was safer to get fentanyl than heroin that may have fentanyl in it. But people use a lot of different drugs and fentanyl (and, to a lesser extent, Xylazine) shows up in nearly everything

A 2022 qualitative study of 29 PWUD in Philadelphia between January and May 2021 analyzed their motivations and patterns for using fentanyl test strips. Both relied heavily on education, access, and quality of testing strips, concluding:

To support increased use of [fentanyl test strips], distribution campaigns should be widespread geographically and provide enough strips to ensure availability for PWUD to test more frequently.

Whenever a person accidentally consumes a drug contaminated with fentanyl, having Narcan — or its generic version, naloxone — on hand may be the difference between life and death. Naloxone is a powerful antidote for opioid overdose.

Unfortunately, this life-saving option doesn’t exist for an overdose of Xylazine. This makes it even more crucial to ensure people are testing their drugs before consuming them with every new purchase.

The PWUD are always the first ones to take care of the PWUD. Let’s empower them to help their community instead of requiring them to leave it.

3. Needle Exchange Programs & Providing Smokeware

Needle-exchange programs offer clean needles in exchange for dirty ones. Depending on the regulations in the state, PWUD may or may not be eligible to receive needles without providing a dirty one to discard first.

While the intention of this is to keep dirty needles off the street, it also forces PWUD to carry around dirty needles when they could just as easily place them in a strong plastic container and throw them out.

While many harm reduction measures can at least claim to be about the PWID, this one seems pretty obviously geared toward cleaning up litter.

Another limitation many states have is not allowing the distribution of glass pipes for smoking. Needles are one of the most dangerous ways people can use drugs, so it’s important to make pipes as widely available as possible.

4. Safe Injection Sites

Safe injection sites are locations where PWIDs receive medical observation while they use drugs. If a person is using a contaminated batch and experiences an overdose, trained staff can step in to help save them.

Currently, New York City has the only two state-sanctioned safe injection sites in the United States. In Canada, Alberta, British Columbia, and Ontario all have safe injection sites.

A 2005 Canadian study — two years after their first “safer” injection facility opened in Vancouver — found PWUDs who utilized the service were 70% less likely to share needles.

Two years later, the same publication found the fatal overdose rate within 500 meters of the site dropped 34% compared to just 9.3% in the rest of Vancouver.

The authors of the study conclude by urging the implementation of similar centers wherever “injection drug use is prevalent, particularly in areas with high densities of overdose.”

While the public may not care deeply about PWUD, as their values may not align, harm reduction is good for the community as well. Setting aside the fact that PWUDs should also be considered members of your community, harm reduction has a sweeping effect on all citizens.

Five years after the opening of a safe consumption center in Australia, researchers contacted residents and business owners in the area and discovered:

Consistent declines in seeing drug use in public
Consistent declines in seeing discarded needles in public
A slight decline in reports of people being offered drugs while staying mostly steady

5. MOUD (Medications for Opioid Use Disorder)

MOUD is one of the most effective ways to transition off dependence on opioids — it’s a form of replacement therapy that involves switching the powerful street drugs users are taking to non-injectable, longer-lasting alternatives.

Some of these drugs prevent users from being able to feel the effects of opiates at all, a safeguard against relapse and overdose. Most of these drugs are also long-lasting actions to prevent people from having to re-dose several times throughout the day.

The most common medications people use for this include:

Methadone — One of the first forms of MAT available, methadone is a long-lasting, semi-potent opioid that can quell cravings to taper off dependency. A single dose will last for 24–36 hours.
Buprenorphine — For less severe cases of opioid dependence, the partial against buprenorphine may be more effective. With a 36–48 hour half-life and a limit on the effects it can produce, it’s a great option for mild or moderate opiate withdrawal symptoms.
Naltrexone — As a long-acting antagonist for opioid receptors, naltrexone blocks all action from outside opioids for up to 48 hours at a time. This doesn’t produce any of the euphoric effects of opioids and users have to wait at least 7 days from their last time using an opioid to take it.
Suboxone — Three parts buprenorphine mixed with one part naloxone to prevent the subjective effects of the opioid. Unlike naltrexone, PWUDs only have to wait 12–24 hours from the last time using to take it.
Hydromorphone — Canada is unique in its offering of a “safer supply” option for opiate consumers. Hydromorphone is an opiate with roughly double the strength of heroin (making it still far less potent than fentanyl). Since the program is new, there’s little research surrounding it, along with quite a few kinks to work out but it’s exciting, nonetheless.

A 2022 case-control study involving over 30,000 Medicare beneficiaries found those who didn’t use buprenorphine were nearly 3 times more likely to experience an overdose.

This study came a few years after another peer-reviewed cohort study of more than 500 patients over 3 years. Here, researchers showed recipients of medication-assisted treatment (MAT) were about half as likely to contract hepatitis C than those using nonopioid agonist forms of treatment.

6. Safe Sex Education & Supplies

Educating people about safer sex and providing supplies is essential to preventing sexually transmitted infections. PWUD have sex just like the rest of us — sometimes in a transactional manner or otherwise not willing or enthusiastically.

Whether it’s for pleasure, money, or drugs, safe sex supplies can prevent the spread of disease and unwanted pregnancy. By no longer treating the PWUD as unwanted criminals, we can empower them to come forward in instances of harassment and sexual assault.

Community organizations, health clinics, and mobile screening services distribute safe sex supplies and offer testing for sexually transmitted diseases.

Depending on the state, they may also offer abortion care or assist with finding it.

Regardless of the motivations behind sexual intercourse, preventing a lifelong STD, unwanted pregnancy, or other problems is crucial. Having a baby on the streets is hell and so is the environment it will be born into.

The Ultimate Harm Reduction Strategy: Legalization & Regulation

Decriminalization is the go-to for most places looking to institute a more health-focused approach to drug use. While it’s always a great thing to stop considering PWUD as criminals, it stops short of addressing the actual concern — death from overdose.

Safe consumption sites, drug testing centers, fentanyl test strips, and more could all become easier to access and less necessary if we legalized and regulated the production of drugs.

Instead of drug users having to buy their substance of choice from a sketchy supplier, they could buy a product they know, trust, and understand.

As a group of researchers noted after reviewing Portuguese policy 20 years after they decriminalized personal possession of all drugs:

[I]n Portugal, as in other countries with a prohibitionist approach, there are ‘victims’ originated, not necessarily by drug use in itself, but by drug laws … some of them with effective prison sentences – which, again, can be seen as a harm to human rights. A non-paternalistic mid-term view, that broadens the scope of public health to include, for instance, the right to an informed choice and the right to risk-taking behavior … might offer a possibility

Key Figures & Organizations in Harm Reduction

Several organizations and individuals have played important roles in the harm reduction movement.

Here is a non-exhaustive list to get started:

The PWUD Themselves — The oft-forgotten hero of harm reduction is the PWUD. It’s not uncommon for a person to experience an overdose when living in a community with other PWUD but there is often someone nearby ready to help with naloxone. The government has never cared about PWUD, and it’s always been on them to look.
DanceSafe — Specializes in drug checking and harm reduction during music festivals, concerts, raves, and other party-type situations. DanceSafe has been on the scene since 1998 and is a phenomenal resource for drug users in party situations.
Dr. Alex Wodak — An early harm reduction advocate and Australian physician who established the first needle exchange program in Australia in 1986. He also helped establish the National Drug and Alcohol Research Centre and the Australian Society of HIV Medicine.
Dr. Ingrid van Beek — The founding medical director of Australia’s first medically supervised injecting center from 2000 until 2008. She was also the director of the Kirketon Road Centre, one of the world’s most integrated targeted primary health care services for at-risk young people, sex workers, and people who inject drugs, until early 2017.
DrugsData.org — Want to know what’s really in the batch of drugs you just bought? Drugsdata will test all drugs, including pharmaceuticals, through an anonymous mail-in service and publicly posts the results so you can search through them. This is a great way to test your drugs and see what else is going on in the drug market.
Dan Bigg — The so-called “godfather of harm reduction,” Biggs founded the Chicago Recovery Alliance, which was the first in the US to distribute naloxone. Tragically, after saving “tens of thousands of lives, perhaps hundreds of thousands,” Biggs died of an overdose in 2018, but his foundation lives on.
The North American Syringe Exchange Network (NASEN) — Find the nearest needle exchange in your area, along with a host of other harm reduction services near you.
Dr. Gabor Maté — A Canadian physician, author, and speaker who promotes harm-reduction approaches for addiction treatment. Maté focuses on the root causes of addiction, such as trauma and pain, and works with patients on mindfulness and compassion-based therapy.
Local Harm Reduction Organizations — Right now, somebody near you is putting boots on the ground in combatting the crisis of drug overdoses. No national organization will ever do the level of good people near you can do by simply passing out clean supplies to the PWUD.
Stephen Murray — Overdose survivor and former EMT, Murray is a dedicated advocate for the PWUD and moving towards evidence-based care. He frequently posts profound explanations straightforwardly.

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