Harm reduction is not a new concept in the medical field, dating back to ancient Greece and the oath of the great physician, Hippocrates, to first do no harm to the patient. However, when applied to substance use disorder, harm reduction has generated controversy as to how far clinicians, lawmakers, and the public should go to assist clients who take drugs and who are unable or unwilling to pursue complete abstinence.

Harm reduction, according to the Substance Abuse and Mental Health Services Administration (SAMHSA), consists of strategies to reduce the risks associated with chemical dependencies. Partners actively collaborate with clients experiencing addiction, rather than attempting to control their behavior. In the past, advocates of drug rehabilitation programs and drug resistance efforts had taken a definitive stance against any approach other than complete abstinence from drugs or alcohol. A study from the Johns Hopkins University’s Bloomberg School of Public Health had determined that people generally regarded drug use as a moral failing among “weak” clients, rather than as a medical issue. Armed with this perspective, the public tends to stigmatize people with substance use disorder as undeserving of social services or empathy.

Unfortunately for clients and their loved ones, this adversarial view has only made the problem worse. SAMHSA has pointed out that the federal government’s traditional hands-off approach to assisting clients with chemical dependencies, mixed with public scorn, has led to higher addiction rates. With nowhere to turn, many clients experience overdose or medical emergencies, sink deeper into co-occurring mental and behavioral health disorders, or simply die of addiction-related accidents, injuries, or illnesses. The National Institute on Drug Abuse has reported that, in 2021 alone, over 106,000 people died from drug-related overdoses. That number increased in 2022, with figures close to 120,000, as per the CDC.

What is Harm Reduction?

Given the crisis, federal, state, and local officials have come up with approaches to work with clients. People take drugs for many reasons, and harm reduction acknowledges the complex origins of substance use disorders. Simply cutting clients off “cold turkey” from drugs can do more harm than good. Rather, harm reduction strategies include drug use prevention, reducing the harmful effects of taking drugs, building up clients’ confidence and offering them support, and bringing clients back together with their local communities.

These approaches form six main pillars to help clients recover in the manner and to the extent of their choosing. They help clients become part of their communities again. Each harm reduction program should feature elements from these six pillars to maximize its effectiveness.

The 6 Pillars of Harm Reduction

Leadership

The first pillar of harm reduction is to place clients with substance abuse disorder in leadership positions in addiction education, prevention, intervention, and recovery programs. No one knows substance abuse more than those who have experienced it. They understand the struggles and outlooks of others fighting their addictions, and are on their side. Clients who have controlled their addictions act as role models for those entering treatment or seeking to manage their recovery.

Clients in leadership positions also encourage the public to see those with substance use disorders not as addicts, but as people. Leaders break the stereotype that individuals with substance use disorders are hopeless and have nothing to contribute to society.

Personhood

The second pillar extends the concept of personhood to all clients seeking rehabilitation. Rather than scorn clients and judge them for their addictions, harm reduction advocates believe in treating all people with dignity and respect. They recognize that most clients have outside problems that feed into their drug use, and that each person’s addiction is complex. By restoring clients’ dignity, advocates can make them feel welcomed and empowered to beat their chemical dependencies.

Community

The third pillar connects the harm reduction site to its local community. No site exists in a vacuum, and harm reduction sites reflect the values and culture of the surrounding neighborhood. Like any storefront or business, each harm reduction site should actively participate in their community’s growth and wellbeing. This means not hiding. Now, clients may feel wary about being seen at a harm reduction site, but one way to overcome the stigmas surrounding substance abuse is to interact with neighbors. By showing that you care about your community, the community will start to care about you.

Inclusion

The fourth pillar ensures that harm reduction leaves no one behind. Engaging with local communities means looking out for those members who might have slipped through the cracks, like ethnic minorities, LGBTQ+ members, seniors, the poor, and other vulnerable groups. Clients know what it feels like to be ignored, shunned, and whispered about, and harm reduction workers go out of their way to make sure everyone has a voice in the program. That way, clients look out for each other, and with numbers come strength in peer support.

Self-Determination

The fifth pillar recognizes that strength doesn’t have to be a show of bravado or force. Not every client can commit to a program, and clinicians understand that many clients relapse throughout their recovery. As such, harm reduction emphasizes self-determination. Clients find their internal strength to seek recovery on their own, and in their own time.

Self-determination extends to privacy rights as well. This connects with the second pillar and its premise of respecting clients as individuals with dignity. This means that clients have the right to not disclose personal information if they wish. Clinicians, doctors, and drug researchers don’t cross boundaries when it comes to collecting data.

Positive Change

Finally, the sixth pillar focuses on creating positive change. Drugs are a complicated and emotional topic. Wellness also has many different meanings, but the most important definition is how the client envisions their improvement. Clients, family members, and clinicians should never lose focus that harm reduction exists to make clients’ lives better and more healthy, even if that means controlling drug use disorder without complete abstinence.

Do Harm Reduction Programs Work?

The 6 Pillars form a solid foundation for building harm reduction programs, but not everyone agrees on the benefits of such programs.

Cons of Harm Reduction Programs

Some critics contend that harm reduction programs, by their very nature, do not serve society’s interests because they prolong harm for the clients. Rather than deter people from using drugs entirely, harm reduction programs can seem to make clients feel good about their drug use, which can encourage them to keep using drugs. One article published in the National Library of Medicine notes that harm reduction centers give priority to the client’s views, rather than the doctor’s, even though the doctor is the expert. This approach places the client in charge of their own program, which can lead to bad outcomes if the client insists on using drugs, does not want to stop, or does not listen to the advice of their physician.

Another drawback with harm reduction centers, according to critics, is that they can make substance use seem normal. Older programs, like the War on Drugs, were dedicated to eradicating any and all forms of controlled substances forever. However, more recent efforts to decriminalize drugs, such as marijuana, have sparked concerns that the public might have a growing tolerance–and even acceptance–for illicit substances. Rather than reach abstinence, some clients might simply want to control their intake to avoid an overdose. For critics, harm reduction can also risk reducing public morals to accommodate everyday drug use.

Finally, some critics have argued that harm reduction facilitates substance abuse. Ironically, this is the same point that harm reduction advocates have used to promote their sites. Critics allege that harm has multiple meanings. Clients’ views about reducing harm may not be the same as a loved one’s. By giving clients priority to choose how much treatment they need to meet a level that fits their definition of reduced harm, harm reduction can ignore the continued harm that impacts family members, friends, and coworkers.

Pros of Harm Reduction Programs

The potential downside of harm reduction centers have worried critics, but proponents have argued that the evidence does not bear out their concerns. The National Institute on Drug Abuse has published studies showing that harm reduction services have lowered the number of overdoses in various communities while seeing a rise among clients who commit to treatment programs. These numbers indicate fewer individuals who need emergency services and fatalities.

Equally as important, harm reduction centers counter the stereotypes surrounding drug users. While critics expressed concern that the removal of stigmas can normalize drug use, harm reduction activists believe that relieving some of these negative views can strengthen clients’ resilience. Showing empathy, proponents believe, is intrinsically the right thing to do to bring communities together and make them stronger.

Types of Harm Reduction Programs

Harm reduction sites share similar goals, but they vary in terms of size, formats, and services. Depending on their clients’ needs, and what state and federal laws allow, harm reduction sites can offer some or all of the following programs.

Syringe Exchange

Syringe exchange programs allow clients to swap their dirty/used hypodermic needles and syringes for sterile ones. The clinic safely disposes of all dirty needles, which prevents accidental injuries if left in public. Syringe exchange programs also help prevent the spread of blood-borne diseases, such as HIV and hepatitis C, as clients do not share used needles. However, not all states have made syringe exchange lawful, and not all harm reduction sites have this feature.

Safe Injection Sites

Safe injection sites are designated locations where licensed clinicians supervise clients with substance use disorder. The clinician may administer the drug or monitor the client self-administering. Supervision helps prevent overdose, and clinicians can assist the client in cleaning up wounds and disposing of used syringes and personal hygiene materials. Clinicians may also offer counseling or other treatment services. Like syringe exchange programs, safe injection sites may not be available in all states, and services at each safe injection site may differ.

HIV and Hepatitis Prevention

HIV and Hepatitis education and prevention are a main feature at many harm reduction sites. HIV and hepatitis can spread through contact with shared hypodermic needles and other blood-borne injections. Harm reduction centers may feature syringe exchange programs and safe disposal of all used syringes. Additional services may include primary care to close open wounds, literature, and education resources for clients at-risk from HIV. Specialized harm reduction sites may also offer vaccinations against hepatitis A and B, antiretroviral therapy for HIV and hepatitis C, and referrals to outside treatment centers. These programs may be available at a sliding scale fee.

Overdose Prevention

Overdose prevention is available in many harm reduction sites. Like safe injection sites, licensed clinicians may monitor clients who bring their own drugs. Supervision can ensure that clients do not overdose. Clients who overdose can receive primary care and emergency services. Services may also include literature and training to clients to help prevent overdoses outside the center, and clients’ loved ones may also take training courses to treat individuals who lose control of their substance use disorder.

Naloxone Distribution

Naloxone distribution is legal in all 50 states, although each state has a different way of distributing this medication. Naloxone, popularly known by its brand name, Narcan, helps clients who overdose by reversing the effects of opioids and restoring normal breathing patterns as clients regain consciousness. Two forms of naloxone are available, and at-risk clients and/or their loved ones generally do not need prescriptions to receive naloxone or medical training to use it. Depending on state laws, naloxone may have no cost or a reduced sliding scale based on ability to pay and insurance.

Drug Checking Kits and Test Strips

Drug checking kits and test strips are a main feature of harm reduction. Drug tests can help clients know which drugs are in their system, and clients can use test strips to check the potency level of ingredients in a batch of unknown substances. Clients can receive drug testing kits and strips from designated harm reduction centers or can purchase test kits at local pharmacies. Drug testing kits vary, depending on which drugs the client wants to test for and the testing procedure. Clinicians can administer a test strip at a harm reduction site, or the client can self-test at home. Clients can also send their tests to an outside lab to ensure accuracy and to test for elusive designer drugs.

Whatever methods of harm reduction clients choose, they should keep in mind that these services do not cure any addiction. However, for clients who have relapsed or are considering treatment for the first time, harm reduction programs can improve their overall wellness and make their substance use disorder more manageable.