Our Theory of Change for the Future of Harm Reduction
And, while I’m certainly not a public health expert, the promise of harm reduction has always been an area about which I’ve felt particularly passionate. I consider it the portion of R Street’s work that’s likely to have considerable impact on the greatest number of lives and accordingly, as R Street’s president, I’ve written this to outline our current thinking about where we hope to go with the expansion.
Our overall strategy stems from a simple insight that is well supported by decades of research and experience: abstinence-only approaches do not work across large populations for any type of common-but-dangerous behavior. For example, abstinence-only sex education in schools has been a dismal failure that merely exacerbates many of the problems it aims to prevent; a multi-decade “war on drugs” has been deeply problematic; efforts that ask smokers to “quit or die” have left more than 30 million Americans still smoking combustible cigarettes, despite well-known harms. Even the widely and justifiably admired Alcoholics Anonymous program is moderately effective over one year, but produces almost no long-term recoveries from Alcohol Use Disorder. Some individuals certainly benefit from abstinence-only approaches, but they will never solve major problems altogether. This is why we think that harm reduction strategies are a better way and should be part of almost every public health strategy.
Quite simply, harm reduction asks people who might engage in a potentially harmful behavior to find less harmful alternatives, if they cannot or will not abstain altogether. And this actually makes good common sense: After all, people begin to engage in potentially harmful behaviors because of real or perceived utility. And if those behaviors have what they perceive as even a temporary benefit, the usefulness of that behavior is reinforced to the individual engaging in it. It is precisely for this reason that simply telling them they should stop doesn’t work.
And even among those who may want to quit, often they find that just stopping is simply too difficult and unrealistic. Harm reduction therefore involves a variety of methodologies that range from syringe access programs for people who inject drugs to encouraging the use of e-cigarettes for current smokers. In this way, it offers a middle ground between the otherwise extreme “quit or die” and “you only live once” mentalities. In most cases, harm reduction is not a good first resort: injecting street drugs with an unused syringe in a controlled setting is still not safe nor is it something that society should promote. But it’s far better than having thousands of people who use drugs die in the streets.
We also know it works. In fact, nearly all common harm reduction approaches are effective and have attracted some political support. To take just a few examples, comprehensive sex education is both effective and universally popular among voters; harm reduction approaches to opioid use have resulted in a national strategy that leans away from criminal sanctions as a means to fight the epidemic; e-cigarettes have produced a genuine grassroots movement and, according to a Cochrane review, they are a highly effective way to reduce smoking. Yet, for all this success, we still see a major problem: while nearly everyone involved in public health policy embraces harm reduction sometimes, hardly anyone is consistent. People pick “good guys” and “bad guys” in the debate and ignore massive evidence that harm reduction works across the board.
As such, whatever its successes—which are real—the national approach remains fragmented and weak in many ways. The federal government, some states and many school systems still waste money on abstinence-only sex-ed (now sometimes rebranded); sixty five percent of those in correctional facilities suffer from substance-use disorders that could have benefited from a harm reduction approach; and rather than promoting safer alternatives to smoking, some places have even sought to ban them—even as they continue to allow the sale of far more dangerous combustibles. The list could go on. The point is that, while proven in the research, harm reduction underperforms politically and, as a result, millions of Americans die and suffer needlessly, while billions of dollars get spent poorly. We want to change this and, to do so, we plan to launch a more integrated, evidence-based strategy.
Such an approach is simple: it brings together social workers, thinkers, citizen advocates, community practitioners, scientists and medical professionals from various harm reduction communities. We want them to find synergies between their work that will help influence policy. Our goal is to help apply the best science to solve a wide variety of problems—many of which often intersect. We therefore envision a world where clinics for people who use opioids could also help those who smoke to switch to something safer if they can’t quit. Or, one where high school health classes include not only more comprehensive sex education but accurate information about the relative risks of all sorts of behaviors that are demonstrated to damage health and well-being. We believe we can make the fastest change by taking a more holistic, comprehensive approach—and this can best be done by encouraging existing groups to collaborate.
To do this, we’re working to bring together a team of respected experts with public policy experience in many different facets of harm reduction. The individuals on our staff will produce research both separately and jointly, and will collaborate with all sorts of stakeholders. Some of the work we do may simply advance effective harm reduction approaches we’ve long supported: we’re continuing our ongoing efforts to promote birth control availability (which we approach mostly as a regulatory issue), syringe access programs and tobacco harm reduction.
But, much of our new work will do more. Once we bring various types of experts together, they’ll inform each other, build joint political alliances and push for meaningful change in the public health space. Together, this venture will likely involve nearly every type of work that R Street does: white papers, articles for the popular press, academic journal articles, coalition building, educational outreach to policymakers, public events, private convenings and more. It’s not going to produce results overnight but we very much believe it’s the best political path to policy success.
If we’re right, the dividends to society could be massive: not only would a powerful new movement emerge, but we could produce very real changes that improve real people’s everyday lives. More and better comprehensive sex education could continue the promising downward trends in teen pregnancies and STDs; opioid harm reduction could reduce a persistent and unnecessary crisis; and tobacco approaches could relegate combustible cigarettes to museum exhibits. It’s one of the most ambitious efforts R Street has ever launched but we know we’re up to it. We like a challenge and we know we can make a difference in policy that will save lives. The opportunity awaits.