March 1, 2023

The Honorable Andy Biggs
Judiciary Committee Subcommittee on Crime and Federal Government Surveillance
U.S. House of Representatives
Washington, D.C. 20515

The Honorable Sheila Jackson Lee
Ranking Member
Judiciary Committee Subcommittee on Crime and Federal Government Surveillance
U.S. House of Representatives
Washington, D.C. 20515

Chairman Biggs, Ranking Member Jackson Lee and members of the subcommittee:

Thank you for your decision to hold a hearing on March 1, 2023, titled “The Fentanyl Crisis in America: Inaction is No Longer an Option.” My name is Mazen Saleh, and I am the policy director of Integrated Harm Reduction at the R Street Institute. Last year, the overdose crisis in the United States took more than 110,000 lives, and since 2016, illicit fentanyl has been the primary driver of these deaths.[1] Although complete abstinence from non-prescribed substances would be preferable from a public health perspective, abstinence-only policies leave many people behind and as such do not work at the population level. Harm reduction, on the other hand, is a pragmatic approach that mitigates the risks associated with drug use by providing people who are unable, unwilling or simply not ready to quit with tools and resources to make safer, healthier choices.[2]

Due to the illicit nature of many recreational drugs in the United States, there are no safety or quality control mechanisms in place. The current drug supply is increasingly contaminated by fentanyl—which is 50 to 100 times as potent as morphine and has an extremely narrow margin between desired and dangerous effects—and related compounds. These drugs significantly increase risk for overdose, especially for individuals who consume them without knowing.[3] While addressing supply is undoubtedly important, we encourage this committee to explore strategies to address demand. The R Street Institute believes that the fentanyl crisis should be approached as a public health issue rather than solely a criminal one as history has shown that incarceration alone does not fix the problem. Leveraging opioid harm reduction tactics will keep people alive while providing space to address the root causes of illicit drug use and abuse, from disparate and insufficient access to mental health care to affordable housing and economic opportunity.

Harm reduction represents a diverse toolkit that can help address a variety of potential health and social consequences of drug use, including risk for infectious disease and overdose.[4] More than three decades of research indicate that many harm reduction interventions—and thus the policies that ensure equitable access to them—save lives and benefit communities.[5] While recent years have brought an increase in the number and variety of harm reduction-supportive policies in the United States, more can be done.[6]

One of the most relevant and talked-about harm reduction interventions in the fentanyl era is naloxone, a medication that reverses opioid overdoses. Studies indicate that policies and programs that increase naloxone access among people who use drugs and their friends and family have reduced overdose deaths by as much as 21 percent.[7] Although every state has passed some sort of legislation allowing laypeople to purchase the drug without a prescription, many of these laws still require consumers to present identification or jump through bureaucratic hoops.[8] As such, the vast majority of jurisdictions still fall short of sufficient naloxone access among the people most likely to witness and reverse an overdose.[9] The recent move by the U.S. Food and Drug Administration (FDA) to consider granting over-the-counter status to certain formulations of naloxone could help expand access further, especially if paired with strategies to keep out-of-pocket consumer costs low.[10]

Fentanyl test strips (FTS) and other drug checking equipment provide important information about the contents of a local drug supply and therefore serve as another important and potentially life-saving harm reduction tool.[11] Commercially available FTS are accurate, easy to use and detect fentanyl and as many as 24 of its most common analogs.[12] Furthermore, checking drugs often leads people to engage in safer drug consumption practices, such as using with another person instead of alone, starting with a small amount to “test” product potency or switching to smoking instead of injecting.[13]

Syringe service programs (SSPs) have been operating in the United States for more than three decades, making them one of the longest-running harm reduction interventions in the country.[14] In addition to safer injection equipment, SSPs often offer wrap-around services including HIV testing, counseling, links to housing assistance and overdose prevention education. In recent years, many SSPs have also become major distributors of naloxone and FTS. These programs, which are typically run out of community-based or public health organizations, have been shown to reduce the incidence of infectious diseases such as HIV and Hepatitis C (HCV) by as much as 50 percent.[15]

It is a common adage among advocates for harm reduction that a person cannot recover if they are not alive. Indeed, although treatment is not the primary objective of harm reduction, by providing a safe and trusted environment and meeting people where they are, these programs often serve as potential entry-points to recovery. People who use drugs who engage with SSPs are approximately five times more likely than those who do not interact with such programs to enter treatment and experience prolonged abstinence.[16]

To maximize the potential recovery-oriented benefits of a harm reduction ethos, we must also expand access to evidence-based treatment, especially medications for opioid use disorder. By allowing more providers to offer buprenorphine, which treats opioid use disorder, legislation like the recently passed MAT Act represents an important step. Another helpful action would be to permanently reduce barriers to methadone, an FDA-approved substitute for the treatment of heroin addiction. Permitting more take-home doses of this well-established medication during the COVID-19 pandemic showed that patients responded well to these measures.[17]

History teaches us that approaching the overdose crisis with an unbalanced emphasis on halting supply creates a number of unintended consequences, from driving a rise in the potency of substances to increasing overdose risk and disrupting access to treatment.[18] Recent policies that have temporarily classified an entire class of fentanyl related substances (FRS) as Schedule I have the added consequence of grouping inert and potentially therapeutic substances with those that are harmful. This hinders scientific progress in the development of novel, targeted overdose antidotes and medications for the treatment of fentanyl use disorder. Testing FRS for pharmacological effect before subjecting them to Schedule I status would ensure researchers have ready access to substances with no abuse potential but possible medical applications.[19]

In conclusion, we believe the most effective approach to addressing the fentanyl crisis is through a coupling of supply-side mechanisms—such as criminal justice enforcement for trafficking—with demand-reduction mechanisms such as opioid harm reduction strategies that keep people alive and maximize their ability to seek treatment. Chairman Biggs, Ranking Member Jackson Lee and members of the subcommittee, thank you again for holding this important hearing and for your consideration of my views. Should you have any questions or wish to have further discussion, please do not hesitate to contact me.


             Mazen Saleh, MSc
             Policy Director, Integrated Harm Reduction
             R Street Institute

Watch the hearing here. (Remarks begin at 3:33:53):

[1] Brian Mann, “2022 was a deadly (but hopeful) year in America’s opioid crisis,” National Public Radio, Dec. 31, 2022.; “Are fentanyl overdose deaths rising in the US?” USA Facts, Dec. 9, 2022.

[2] “Principles of Harm Reduction,” National Harm Reduction Coalition, last accessed Feb. 27, 2023.

[3] National Institute on Drug Abuse, “Fentanyl DrugFacts,” National Institutes of Health, June 2021.

[4] Ibid.

[5] “Harm Reduction,” National Institute on Drug Abuse, last accessed Feb. 27, 2023.

[6] Stacy Weiner, “As drug overdoses soar, more providers embrace harm reduction,” AAMCNEWS, Feb. 15, 2022.

[7] Tarlise Townsend et al., “Cost-effectiveness analysis of alternative naloxone distribution strategies: First responder and lay distribution in the United States,” International Journal of Drug Policy 75(January 2020).; Chandler McClellan et al., “Opioid-overdose laws association with opioid use and overdose mortality,” Addictive Behaviors 86 (November 2018), pp. 90-95.

[8] “State Naloxone Access Rules and Resources,” SAFE Project, last accessed Feb. 27, 2023.

[9] Michael A. Irvine et al., “Estimating naloxone need in the USA across fentanyl, heroin, and prescription opioid epidemics: a modelling study,” The Lancet 7:3 (March 2022), pp. E210-E218.

[10] Jan Hoffman, “Narcan Is Safe to Sell Over the Counter, Advisors to the F.D.A. Conclude,” The New York Times, Feb. 15, 2023.

[11] Traci C. Green et al., “An assessment of the limits of detection, sensitivity and specificity of three devices for public health-based drug checking of fentanyl in street-acquired samples,” International Journal of Drug Policy 77 (March 2020).

[12] Green et al., (2020); Marianne Skov-Skov Bergh et al., “Selectivity and sensitivity of urine fentanyl test strips to detect fentanyl analogues in illicit drugs,” International Journal of Drug Policy 90 (April 2021).

[13] Nicholas C. Peiper et al., “Fentanyl test strips as an opioid overdose prevention strategy: Findings from a syringe services program in the Southeastern United States,” International Journal of Drug Policy 63 (January 2019), pp. 122-128.

[14] Don C. Des Jarlais, “Harm reduction in the USA: the research perspective and an archive to David Purchase,” Harm Reduction Journal 14:51 (July 26, 2017).

[15] “Syringe Services Programs (SSPs) Fact Sheet,” Centers for Disease Control and Tradition, last accessed Feb. 27, 2023.,in%20HIV%20and%20HCV%20incidence.&text=When%20combined%20with%20medications%20that,reduced%20by%20over%20two%2Dthirds.

[16] “Syringe Services Programs (SSPs) FAQs,” Centers for Disease Control and Prevention, last accessed Feb. 27, 2023.

[17] Susan M. Walters et al., “Lessons from the First Wave of COVID-19 for Improved Medications for Opioid Use Disorder (MOUD) Treatment: Benefits of Easier Access, Extended Take. Homes, and New Delivery Modalities, Substance Use and Misuse 57:7 (April 21, 2022), pp. 1144-1153.; Kathlene Tracy et al., “The impact of COVID-19 on opioid treatment program (OTP) services: Where do we go from here?” Journal of Substance Abuse Treatment, 131, (April 9, 2021).

[18] Sarah Beller, “Infographic: The ‘Iron Law of Prohibition,’” Filter, Oct. 3, 2018.; Caleb J. Banta-Green et al., “Police Officers’ and Paramedics’ Experiences with Overdose and Their Knowledge and Opinions of Washington State’s Drug Overdose-Naloxone-Good Samaritan Law,” Journal of Urban Health 90 (July 31, 2013), pp. 1102-1111.;  Lauren Brinkley-Rubinstein et al., “Risk of fentanyl-involved overdose among those with past year incarceration: Findings from a recent outbreak in 2014 and 2015,” Drug and Alcohol Dependence 185 (April 1, 2018), pp. 189-191.; Jack Stone et al., “Modeling the role of incarceration in HCV transmission and prevention amongst people who inject drugs in rural Kentucky,” International Journal of Drug Policy 88 (February 2021).; Bryce Pardo and Peter Reuter, “Enforcement strategies for fentanyl and other synthetic opioids,” The Opioid Crisis in America: Domestic and International Dimensions, June 2020.

[19] Stacey McKenna, “When it comes to fentanyl-related substances, testing—not classwide scheduling—could save lives,” Real Solutions, Nov. 8, 2022.