If We Care About Overdose Deaths, We Must Go All-In on Harm Reduction
“Almost nobody is taking America’s drug crisis seriously,” Charles Fain Lehman wrote in a recent article for National Affairs. With hundreds of Americans dying of preventable deaths from overdoses every day while Congress drags its feet on the most uncontroversial legislation, this assessment is heartbreakingly accurate. So is Lehman’s recognition that, given the volatility of the current illicit drug market, we need better population-level efforts to prevent experimentation and first-time use. His error, however, lies in claiming that harm reduction is a poor fit for the current crisis, lacking the capacity to make any real dent in overdoses. Harm reduction is not a panacea, and it must be applied in concert with other tactics to reduce deaths and improve well-being. But its current limits are not because the approach itself is lacking; rather, they are the result of insufficient funding and policy environments that continue to get in the way.
Enforcement-First Can’t Solve a Lab-Produced Drug Crisis
Life as a person who used drugs in the United States was not easy a decade ago, and it certainly came with both inherent and policy-related risks to one’s social, economic, mental and physical well-being. But it didn’t have the same extreme unknowns people face today. Adulterants have always been an issue and people who use illicit drugs have never had much control over the quality or purity of their supply. However, in the past, people could generally count on stimulants being adulterated primarily with other stimulants, not opioids. And heroin was generally heroin, not something 50 times stronger, like fentanyl.
To understand why harm reduction is more important than it’s ever been, we must first understand how the war on drugs contributed to the growing instability and potency of the illicit drug supply, as well as the limitations of an enforcement-dominated approach to stopping the overdose crisis. As my colleague Jillian Snider wrote in the Fall issue of National Affairs:
“What became known as the ‘war on drugs’ was marked by several failures, however: It did not significantly curb crime, it neglected to address the root causes of drug addiction, and it resulted in overcrowded prisons filled with individuals who would have been better served by substance-abuse treatment.”
There was a time when law enforcement-based tactics aimed at stopping drug use by cutting off the drug supply may have actually slowed the sale and consumption of certain substances (though never without causing considerable harms of their own). But, as Lehman acknowledges, today’s market is increasingly dominated by synthetic drugs, which are much more potent and represent a better “value proposition” over the plant-derived substances of past decades.
Compared to cocaine or heroin, potent synthetic substances such as methamphetamine and fentanyl are inexpensive to produce and easier to hide from law enforcement. Following a bust, new labs pop up quickly and cheaply replace old ones. And, increasingly, new substances come onto the scene. Indeed, research shows that this process has rendered the war on drugs little more than a tragic game of whack-a-mole and “an expensive assault on personal freedom,” as two retired law enforcement officers noted. It incentivizes those who work in the illicit drug trade to get more and more innovative, making or sourcing drugs that are more potent and thus more dangerous. These fluctuations are especially problematic when clouded in the opacity of the illicit market. Indeed, a recent study in Indianapolis revealed that drug seizures preceded spikes in overdose deaths, suggesting that the busts disrupt both the supply chain and individuals’ efforts to reduce risks by purchasing from trusted sellers.
Nonetheless, since the launch of the war on drugs in 1971, the United States has spent more than $1 trillion enforcing the policy. In 2021 alone, the federal government’s “drug control” budget topped $40 billion. Going into 2024, that number is likely to be much higher, and an estimated 43.5 percent of it is once again earmarked for law enforcement and interdiction efforts. If we keep trying to arrest our way out of a public health crisis, we will no doubt see one of the biggest government interventions ever known. What’s more, if 50 years of history tell us anything, it won’t stop people from using and likely dying.
And yet lawmakers keep doubling down. Maybe that’s what Lehman meant when he said it seems like nobody cares. After all, the government’s failure to do something different is costing us lives, and it is hurting our communities.
We Need to Go All-In on Harm Reduction
Lehman suggests that we need to lean into stopping drug use in the first place. On this, he’s right. After all, only 7 percent of that federal drug control budget mentioned above goes toward prevention. We need to embrace evidence-based efforts (as opposed to the ineffective scare tactics so many of us grew up with) aimed at helping young people understand that today’s drug market is far riskier than what their parents or even older siblings may have navigated during their own experimental phases. But reducing the risk that people will develop a substance use disorder also means ensuring they are better able to meet their basic needs, from housing to mental health care.
Unfortunately, however, prevention alone—even the best strategy the world has ever seen—is not going to stop the surge of human loss that we are collectively facing right now. It won’t help the chronic pain patient who turns to the illicit market when their prescription painkillers are cut off by fear-based government overreach. It won’t help the long-time rural heroin user who struggles to access medications for opioid use disorder because the nearest programs or prescribers are an hour away. And it won’t help the teens who, despite all the talks from concerned adults, still buy counterfeit pills on the informal market for a variety of reasons, from experimentation and fun to coping with anxiety or depression.
Research tells us that harm reduction can make a real dent in those deaths. Lehman frames the approach as one that may help the individual but that has little impact at the population level. In this regard, he is wrong. Harm reduction can reduce overdose deaths at the population level, but only if we go all-in.
The Biden administration’s unprecedented 2021 allocation of $30 million on harm reduction is a start. If saving lives isn’t enough, harm reduction interventions tend to be cost-effective enough to convince even the most fiscally oriented cynic. For example, one study estimated the one-year return on investment for syringe services programs (SSPs) (the most common harm reduction program in the United States) to be $62.4 million in Baltimore and $243.4 million in Philadelphia. What’s more, the more comprehensive the services offered, and the more tailored to their local communities, the more cost-effective these programs tend to be. That could mean going beyond handing out clean injection supplies to also providing overdose prevention education and opioid antidote medication, referring participants to evidence-based treatment or offering mobile services to reach further into communities.
Despite such upstream cost-savings, funding harm reduction is not a priority in the United States. A recent study found that the median annual budgets of harm reduction organizations were 46 percent or more below the Centers for Disease Control and Prevention’s minimum recommendation. And for all its good intent, the Biden administration’s landmark funding was less than 0.075 percent of that year’s federal drug control budget.
But lack of money is not the only problem. Harm reduction cannot work when policy, red tape and overregulation continue to prevent community-based organizations from doing their work. Research suggests that drug checking leads people to use more safely and take steps to reduce their risk of overdosing. Yet, as of August 2023, nearly half of U.S. states still prohibit some forms of drug checking, from distributing xylazine test strips to conducting community-based, point-of-service testing with Fourier transform infrared analysis. Such restrictions prevent organizations from adapting swiftly to the rapidly changing drug market.
We also have more than 30 years of evidence demonstrating the many benefits of SSPs. They reduce infectious disease transmission, provide overdose prevention education and reversal medication, and facilitate substance use disorder treatment initiation and long-term recovery. Nonetheless, several states still don’t even permit the programs to operate, and others place such stringent regulations on the programs that they’re unable to implement best practices or tailor their outreach to community needs. This leaves just a handful of activists willing to work in legal gray areas. There is no question that these dedicated individuals care deeply. And there is no question that their work greatly impacts the people they are able to serve. For instance, South Carolina’s Challenges, Inc. is not technically illegal, but it’s not authorized either. They have traced their naloxone distribution program to more than 500 overdose reversals. Imagine what the state’s grassroots organizations could do if they didn’t have to scramble to convince potential landlords or funders that their operations do in fact have the right to save lives.
In New York, OnPoint—the nation’s only legally sanctioned overdose prevention centers—show what can happen when a community recognizes that people who use drugs are part of that community, rather than a separate problem to be dealt with. The centers have saved more than 1,000 lives since opening their doors in 2021, and they have not led to an increase in neighborhood crime.
Finally, even when governments pass smart harm reduction policies, they may need to do a better job of educating all those who are affected. Good Samaritan laws that provide immunity to individuals who call 911 or administer naloxone to someone who is overdosing can reduce people’s reluctance to lend a helping hand and prevent many overdose deaths. But their efficacy is often hampered by limited awareness among law enforcement officers and the public. Over-the-counter status and standing orders that allow people to purchase naloxone at the pharmacy without getting a prescription from a provider could be a huge benefit, especially to people in areas lacking harm reduction organizations. However, stores must stock the medication—some research suggests that many don’t—and employees (including pharmacists) need to treat the people seeking it with respect, not fear or disdain. On the bright side, studies suggest this may be improving.
There Is No Magical Solution
It can indeed feel as if too few people care about the more than 100,000 lives lost to a drug overdose in the United States each year. Certainly, those with the power to change things are not doing enough. Our investment in the war on drugs keeps growing, despite decades of evidence that it does not work. And we are reluctant to reallocate that investment to alternative solutions like harm reduction.
But perhaps our problem is less about apathy and more about the endless quest for a singular solution. If we are going to give the millions of Americans currently at risk the tools to avoid or survive an overdose, we must expand our acceptance of harm reduction. We must integrate these tools fully into a system that grows its support for educational prevention based in reality, not fear tactics, and prioritizes evidence-based treatment.
Rather than giving up on harm reduction because it doesn’t single-handedly stop illicit drug use, let’s focus our efforts on saving lives today that may be gone tomorrow.