When I was using heroin in New York City in 1986, half of all the people in the city who injected drugs were H.I.V.-positive. When a friend taught me to run bleach through my syringe at least twice and then rinse twice with water before injecting, she most likely saved my life.
There was no name for it at the time, but she was guided by an innovative philosophy now called “harm reduction.” She knew that simply telling me to quit drugs wouldn’t work, and back then, syringes were illegal without a prescription in New York, so I couldn’t buy clean ones. She also recognized that teaching me to lower my risk of contracting H.I.V. could help me survive and eventually recover from addiction, which, not long after, I did.
Rather than seeking an unattainable “drug-free world,” harm reductionists focus on reducing drug-related damage. People always have and always will take drugs, they argue. A better approach is to target harm, not highs.
The idea that policy should first reduce harm — not demand instant and complete cessation of risky behavior — has gained currency during the coronavirus pandemic. Epidemiologists realized, as they had with AIDS, that requiring total abstinence — in this case, from socializing — is unrealistic and that instead minimizing risk should be the focus.
Masking, testing and distancing offered a way out of lockdown, for some, before vaccines. Now harm reduction means masking only when risk is truly high, not requiring constant precautions from an exhausted public.
Trusting people to make better choices by providing accurate risk information is central to harm reduction. And when you look for it, harm reduction is everywhere: Seatbelts make cars much safer, though some people are still injured while wearing them; condoms greatly reduce but do not eliminate the risk of sexually transmitted infections.
In many ways, harm reduction seems like common sense. But its roots are radical. It was devised by some of the world’s most demonized individuals: people who inject drugs.
The idea has surprising power to upend conventional wisdom, especially in drug policy, where it was born. That’s because when doing less harm is the measure of success, harm that’s caused by prohibition and law enforcement counts against it, making conventional antidrug policies unsustainable.
Now that harm reduction is finally being embraced by the mainstream — this year, President Biden’s national drug policy emphasizes it for the first time — it’s important to remember its origins and the struggle it took to gain acceptance.
As H.I.V. spread in the late 1980s, drug users were forced to help ourselves. Politicians overwhelmingly opposed efforts such as clean-needle programs. Even among activists, the idea was fringe. But from our pain, users and ex-users forged a new way of thinking.
Harm reductionists created syringe exchanges, which are now so strongly supported by data that federal health officials promote them as essential to stopping the spread of H.I.V. They invented and organized the now ubiquitous campaigns to distribute the opioid overdose antidote naloxone, with at least tens of thousands of lives already saved. They developed “housing first” programs for drug users that don’t require abstinence — and which, when properly administered, can cut chronic homelessness by at least two-thirds.
The concept of harm reduction has helped at least 18 states legalize marijuana by emphasizing the fact that it is less dangerous than legal drugs such as alcohol and tobacco.
It also spurred demands for decriminalization of all drugs, because jail and a criminal record can make addiction worse, not better. Voters are listening: An Oregon initiative to decriminalize possession of small amounts of all drugs passed decisively in 2020, and one poll found 66 percent of Americans are in favor of such efforts.
The movement for harm reduction started small, as a collaboration between people who use drugs and health officials in Europe, where pragmatism about drugs was less politically risky. In Rotterdam, the Netherlands, in 1981, a self-described “junkie union” led by Nico Adriaans distributed clean needles to fight hepatitis B, with government support.
In Liverpool, England, in 1986, injectors and officials also came together to start needle exchanges and provide pharmaceutical heroin as a way to minimize risks from street drugs. To describe their philosophy, Russell Newcombe, a psychologist and drug user, labeled it “harm reduction” in 1987.
The approach was quickly adopted by Margaret Thatcher’s Conservative government. Consequently, Britain never saw the widespread H.I.V. infections among drug users that the United States did.
But in America, harm reduction ran smack into the drug war. From the start, needle exchange was vigorously opposed across the political spectrum. It was seen as “sending the wrong message” and condoning drug use. Today, the United States has both the world’s highest incarceration rate and its highest rate of addiction.
Harm reductionists countered with compassion. By 1990, the AIDS Coalition to Unleash Power, known as ACT UP, was on board, and members provoked arrest while trying to give out needles. Eight defendants (most from ACT UP) — including several people in recovery — won their case and New York later decriminalized the possession of needles.
By then advocates had discovered a welcome side effect of the harm reduction approach: Treating people with dignity itself empowers change. Those who feel respected are more likely to respect themselves. Humane treatment can spur self-care rather than self-destruction.
For decades, because of harm reduction’s clash with the policies of the drug war, the government tried to suppress it. Federal agencies advised research grantees to avoid the term; U.S. representatives at United Nations meetings refused to sign health and drug policy documents supporting it. In an illustration of how racism drives drug policy, harm reduction broke through only after opioid addiction began to be seen as a “white” problem and affected families wanted kinder treatment.
Perhaps drug warriors’ opposition to harm reduction makes a certain kind of sense. After all, if prohibition worked, people wouldn’t use illegal drugs, and no such alternative would be needed. Harm reduction can also reverse the polarity of policy arguments in a way that disadvantages prohibitionists. By refusing to accept “fighting drug use” as the most important goal, harm reductionists offer a more appealing objective: saving lives.
Research now shows that needle-exchange programs don’t “enable” or prolong addiction nor do they increase drug use. On the contrary, participants are five times as likely to start treatment than those who don’t use these programs. And in a pandemic, making room for safer socializing doesn’t encourage flouting of other rules; it makes people more likely to follow them.
Harm reduction is a gift from some of the most stigmatized people in the world. And it will continue to have influence beyond drugs: Epidemiologists promote harm reduction to combat Covid while minimizing pandemic fatigue; environmentalists use it to help cut climate-harming behaviors.
Harm reduction allows nations to set policies that are both humane and effective by putting risks in context and centering the perspectives of those who are most affected. By making it the cornerstone of drug policy — and all policies aimed at changing risky human behaviors — we can build a healthier, happier and more equitable world.
Maia Szalavitz is the author of, most recently, “Undoing Drugs: The Untold Story of Harm Reduction and the Future of Addiction.”
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