For harm reduction to work, we need a full defense

With the recent release of the National Drug Control Strategy, the Biden administration has codified its support of harm reduction to reduce the number of overdose deaths attributed to substance use. In 2021, the nation experienced over 100,000 overdoses and preliminary data suggests that number will be higher by year’s end.

The grimmer reality is that we have lost one million lives since the opioid epidemic began over a decade ago. Although support of opioid harm reduction is a step in the right direction, in the absence of a full defense of all forms of harm reduction, the Biden administration is poised to provide more confusion than clarity.

Harm reduction is a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use. The most common tools against the overdose crisis include distributing clean equipment through syringe services programs (SSPs); expanding access to the overdose reversal drug naloxone (commonly known as Narcan); providing test strips to identify the presence of fentanyl and related substances in a drug supply; and offering medications such as methadone and buprenorphine to prevent withdrawals and reduce cravings for individuals in recovery. 

Most of these strategies are supported by decades of evidence. For example, the Centers for Disease Control and Prevention (CDC) recognizes that SSPs reduce transmission of HIV and hepatitis C by as much as 50 percent. Expanding access to naloxone through enhanced pharmacy access and innovative community-relevant approaches such as vending machines, hospital “take-home” and first responder “leave-behind” programs, saves thousands of lives. The medication successfully reverses overdose 75 to 100 percent of the time with no serious side effects and zero potential for abuse.

Even fentanyl test strips (FTS) have a role to play. While FTS cannot tell people who use drugs how much fentanyl is in their supply, they can confirm its presence. This information can help people make potentially life-saving behavior changes. Because FTS only indicate the presence, not the amount, of fentanyl or its analogs, they can be of limited relevance when the supply is saturated with fentanyl. However, they remain very helpful in opaque and shifting markets, and for individuals who are opioid-naive, such as people who exclusively use stimulants. 

The Biden administration’s strategy does a commendable job recognizing and supporting the above tools, calling for better integration, training and funding for them. Completely absent, however, is any mention of supervised injection sites, also known as overdose prevention centers (OPC). OPCs are places where people can consume drugs they acquire elsewhere under medical supervision, though facilities and employees do not provide or handle the drugs that clients use. 

The first U.S.-based OPCs opened in November 2021 in New York City, and reversed 150 overdoses in the first three months. In 2019, Safehouse, a nonprofit organization, attempted to open an OPC in Philadelphia, but U.S. prosecutors sued to block the effort, citing violation of the “crack house statute” in the federal Controlled Substances Act, designed to outlaw any site that operates with drug use as its purpose. The Biden administration has kept mum on its position on OPCs, likely given the controversy surrounding their operation.

Smoking is yet another behavior where harm reduction strategies can be employed but the Biden administration is also inconsistent in their support of reduced-risk tobacco products. The Food and Drug Administration has approved low-nicotine cigarettes to be marketed and sold in the United States while simultaneously denying applications for a variety of e-cigarettes which have been consistently proven less harmful than combustible cigarettes.

For the Biden administration to take advantage of the population health benefits of harm reduction — most importantly to save lives — it needs a full defense of all its forms. In order to save more lives, the moment calls for courage, not compromise. It also calls for some consistency.

Mazen Saleh, MSc, is the policy director of Integrated Harm Reduction at the R Street Institute where he oversees a team of harm reduction scholars. Stacey McKenna, PhD, is a medical anthropologist and senior fellow of Integrated Harm Reduction policy at the R Street Institute.