Harm Reduction's Road From Fringe to Federal Drug Policy

January 27, 2022

Photo by Todd Hoffman licensed under CC BY 2.0

The overdose crisis in the U.S. is as deadly as it’s ever been. In response, the Biden administration is embracing a controversial strategy known as harm reduction, which seeks to keep drug users safe even as they continue using. We explore how harm reduction has become more mainstream and what kind of impact we can expect it to have on the overdose crisis.

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The Problem: America's Growing Overdose Epidemic

U.S. deaths from drug overdoses from July 2020 to June 2021¹
0 %
share of recent overdose deaths due to opioids¹

1 million+

U.S. deaths from drug overdoses since 1999²

¹ Provisional Overdose Death Counts (National Center for Health Statistics, CDC, Accessed 1/26/2022)
² More than a million Americans have died from overdoses during the opioid epidemic (Brian Mann, NPR, 12/30/2021)

More people died from drug overdoses in the U.S. during the first year of the pandemic than in any single year on record. Experts say the spike has been driven primarily by the pandemic and a more potent drug supply, particularly the synthetic opioid fentanyl. Overdose rates have jumped the most among Black Americans

While the vast majority of recent overdoses were caused by opioids, there have also been increases in overdoses from methamphetamine and cocaine in recent years, as well people using multiple substances at the same time.

The Basics: Harm Reduction

When it comes to drug use, harm reduction is a philosophy that focuses on keeping people who use drugs safe and alive even if they continue to use. It first gained traction in the U.S. in the 1980s in response to the HIV/AIDS crisis, which infected as many as half of all injection drug users in some cities.

The earliest harm reduction interventions — like telling drug users to bleach their needles and offering them fresh syringes at needle exchanges — were generally rejected by Democrats and Republicans who viewed them as enabling drug use. Needle exchanges were illegal in many states, and the federal government preemptively banned federal funding for programs that promoted needle cleaning or needle exchanges in 1988.

The Shift: Harm Reduction Starts To Go Mainstream

Federal policies started to shift during the Obama administration. In 2009, Congress reversed the ban on federal funding for needle exchanges. (It was reimposed in 2011 and ended again in 2015.) The Obama administration also saw harm reduction as a way to fight the burgeoning overdose epidemic, so it made federal dollars available to state and local governments to buy and distribute naloxone, a medication that can reverse an opioid overdose.

State and local lawmakers also began to soften their resistance, leading several states to make naloxone easier to distribute and legalize needle exchanges (which are more commonly known today as syringe service programs).

Experts point to several factors for this increased acceptance of harm reduction: 

  • The worsening overdose crisis
  • Overdoses becoming more associated with white middle and upper class Americans as opposed to people of color
  • A growing evidence base, specifically around syringe service programs
  • Continued advocacy from harm reduction activists

The Biden administration is continuing previous administrations’ support for syringe service programs and naloxone, while also pushing federal acceptance to new frontiers. The administration is the first to:

Include harm reduction as a core pillar of its overdose prevention strategy

Set aside federal grants ($30 million) for states, local governments and nonprofits to use specifically for harm reduction

Allow state and local governments to use federal dollars for fentanyl test strips

Not actively oppose supervised consumption sites, where drug users can use illegal drugs under supervision and receive additional services (see more below).

The country’s first sanctioned supervised consumption sites opened in New York City in November 2021. (At least one unsanctioned site has been operating for years in the U.S. and been evaluated by researchers.) These sites have operated in other countries for decades, but a federal law prohibiting facilities from allowing illegal drug use has prevented their opening in the U.S. until recently. The Biden administration has let the New York sites operate while not yet taking a public stance on the legality of the sites.

Despite increased federal support, harm reduction remains controversial. In 2021, Scott County, Indiana, shut down a popular needle exchange that was credited with ending a massive HIV outbreak and increasing support for harm reduction among conservative policymakers. Also last year, West Virginia passed legislation making it more difficult to open and operate needle exchanges, even though the state is experiencing one of the country’s worst spikes in drug use-related HIV cases.

The Evidence: What We Know About Harm Reduction

In general, harm reduction strategies have been shown to save lives and connect people to treatment without increasing drug use or crime. But the evidence varies from strategy to strategy.

Needle Exchange/Syringe Service Programs

Researchers have amassed a large body of evidence on needle exchanges in their 30 years of operation in the U.S. 

That research shows needle exchanges significantly reduce the risk of people who use drugs contracting HIV, Hepatitis C and other blood-borne diseases, and increase their likelihood of getting into treatment.

It also shows needle exchanges do not increase drug use or crime.


Naloxone has reversed hundreds of thousands of overdoses and has been shown to be most effective when distributed to drug users themselves as opposed to just police and first responders.

The evidence is unclear on naloxone’s impact on treatment, drug use and crime.

Fentanyl Test Strips

Fentanyl test strips are relatively new, so there is very limited research on them so far. Early small studies suggest these strips can dissuade people from using drugs that test positive.

However because fentanyl is so prevalent in much of the country’s opioid supply, some experts question how useful they are for opioid users. They say test strips could be potentially lifesaving for people using other drugs like cocaine or methamphetamines who are not expecting fentanyl and have not built up a tolerance for it.

Supervised Consumption Sites

Extensive research has been conducted on these sites abroad, and it has generally shown them to save lives, connect people to treatment, be cost-effective and not increase drug use or crime.

However, a recent literature review by RAND found only a handful of studies that compared communities with sites to those without, making it hard to draw definitive conclusions about the scope of their impact. 

Beau Kilmer, the director of the RAND Drug Policy Research Center, said the evidence is strongest on the fact that consumption sites do not increase crime.

What's Next? The Future of Harm Reduction

Many experts interviewed for this story do not believe the existing increases in funding and support for harm reduction services will lead to a significant or immediate decrease in overdose deaths.

Advocates hope the Biden administration will expand its support of harm reduction strategies by setting aside additional funding, removing naloxone’s prescription-only status, rejecting a proposal to increase criminal penalties for fentanyl and endorsing supervised consumption sites.

The Justice Department has until March to decide whether to continue a Trump-era lawsuit blocking a supervised consumption site in Philadelphia. If the administration endorses or declines to take action against the sites in New York, several other cities and states could open their own, including Rhode Island, California, Massachusetts, Denver and Burlington, Vermont.

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Episode Resources

Episode Credits


Ricky Bluthenthal, PhD, Professor of Population and Public Health Sciences, Associate Dean for Social Justice; Keck School of Medicine, University of Southern California

Keith Humphreys, PhD, Esther Ting Memorial Professor of Psychiatry and Behavioral Services, Stanford University

Beau Kilmer, PhD, Director of the RAND Drug Policy Research Center

Kimberly Sue, MD, PhD, Assistant Professor of Medicine, Yale School of Medicine; Medical Director, National Harm Reduction Coalition

Maia Szalavitz, Journalist and Author, Undoing Drugs: The Untold Story of Harm Reduction and the Future of Addiction

The Tradeoffs theme song was composed by Ty Citerman, with additional music this episode by Blue Dot Sessions.

This episode was reported by Ryan Levi and mixed by Andrew Parrella.

Additional thanks to:

Mia Antezzo, Leo Beletsky, Magdalena Cerda, Peter Davidson, Corey Davis, Don Des Jarlais, Amanda Latimore, Jodi Manz, Marlene Martin, Ryan McNeil, Eliza Mette, David Murray, Kellen Russoniello, Charlie Severance-Medaris, Bryce Pardo, Leslie Suen, Eliza Wheeler, the Tradeoffs Advisory Board and our stellar staff!