Harm Reduction’s Road From Fringe to Federal Drug Policy

Note: This transcript has been created with a combination of machine ears and human eyes. There may be small differences between this document and the audio version, which is one of many reasons we encourage you to listen to the episode!

Dan Gorenstein: The overdose crisis in the U.S. is as bad as it has ever been.

News clip: The CDC says 100,000 people died of drug overdoses over the past year. 
News clip: That’s the highest yearly death toll from drugs ever recorded in the U.S. Let that sink in.

DG: In the last two decades, more than 1 million people have died from drug overdoses.

Now to save lives, the Biden Administration is pushing a once-taboo strategy.

It’s called harm reduction. 

The goal is to keep drug users safe even as they continue using drugs, and it’s having a moment.

Today, how harm reduction went from fringe to federal policy and what kind of impact we can expect it to have on our overdose epidemic.

From the studio at the Leonard Davis Institute at the University of Pennsylvania, I’m Dan Gorenstein and this is Tradeoffs.

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DG: 50 years ago, President Richard Nixon declared war on drugs.

President Richard Nixon: America’s public enemy number one in the United States is drug abuse. 

DG: It was a national strategy to stop the buying and selling of illegal drugs. 

The president’s message was clear — people should not use drugs and people who did should be punished. 

This thinking dominated federal policy for decades.

Here’s what then-Sen. Joe Biden said in 1989.

Biden: We have to hold every drug user accountable because if there were no drug users, there’d be no appetite for drugs and there’d be no market for them.

DG: Now, here’s what President Biden said about addiction in 2021.

Biden: To those still struggling, I want you to know that I see you, and we’re going to beat this thing together.  

DG: The rhetoric has clearly softened, so we asked producer Ryan Levi to dig into what’s driving these changes and whether it’s translating into different policies. 

Ryan, thanks for being here.

Ryan Levi: Happy to do it. 

DG: For a long time, presidents have framed drug use as a crime. 

But over the last decade or so, it seems like that attitude has given way to emphasizing treatment.

RL: That’s right. 

But as more and more people die, a growing number of experts and advocates say we’ve got to figure out how to keep people who use drugs alive.

That’s the “harm reduction” approach — this idea that instead of punishing people or even getting them into treatment, we should first keep them safe when they use drugs. 

DG: And when did this idea, Ryan, pop up in the U.S.?

RL: The movement really took off around the time of that clip you played from Senator Biden, around the late 80s. 

Archival news clip: It’s the collision of the two great epidemics in America today: AIDS and drugs. 

RL: HIV and AIDS were spreading fast among people who used drugs.

Archival news clip: Right now some 250,000 drug addicts nationwide are infected with the AIDS virus. And more than half the people carrying the virus eventually come down with AIDS and die.

Ricky Bluthenthal: It was a scary time.

RL: Ricky Bluthenthal was a young researcher in those days working with injection drug users in Oakland.   

RB: The data we had suggested that probably 1 in 10 injection people who inject drugs had HIV in the country. And in cities like New York, Miami and San Juan, Puerto Rico, that number was closer to half.

RL: Ricky’s spent his career studying drug use, and he’s now an associate dean and professor at the University of Southern California. 

30 years ago, his job was to convince drug users to get tested for HIV — tests he knew had a good chance of coming back positive.

RB: We were handing out death sentences.

RL: Remember, Dan, treatments were just starting to come out, so there weren’t many options.

And many people viewed drug users as criminals, so there was very little compassion out there.

And that just didn’t sit right with Ricky.

RB: I wasn’t willing to exist in a world where I knew this was happening and not do something to try and prevent it.

RL: So Ricky helped start a needle exchange where people could get fresh syringes, making it less likely they’d share infected needles.

This was one of the earliest examples of harm reduction in the U.S., Dan, and it was also illegal.

RB: I think we got arrested probably 10 to 15 times for operating the program, but we just wouldn’t stop.

DG: Wait, he got arrested for running a needle exchange?

RL: That’s right.

In the late ‘70s, the Carter administration convinced most states to make handing out needles for drug use a crime.

That meant when needle exchanges like Ricky’s started popping up in the ‘80s and early ‘90s, they were breaking the law.

And even in states where these exchanges were legal, Congress wanted to limit their spread and preemptively banned federal funding for them in 1988.

DG: Let me get this straight — you’ve got all these drug users getting AIDS.

And you’ve got folks like Ricky trying to protect them by giving them clean needles.

And policymakers’ response is to say: We won’t help you. We might even arrest you.

RL: Pretty much. That was where they were at at that point.

That stance finally began to soften under President Obama.

President Barack Obama: When we talk about opioid abuse as the public health problem that it is, more people will seek the help that they need.

RL: That’s when, for the first time, Congress allowed state and local governments to use federal money for needle exchanges.

The Obama administration also saw harm reduction as a way to fight what was then a growing overdose crisis. So they made federal dollars available to buy and distribute naloxone too, which is a medication that can reverse an opioid overdose.

DG: Can you break this down?

How, Ryan, did we go from a place where harm reduction was outlawed in many places to the Obama administration starting to fund this stuff?

RL: It’s a good question, one I was curious about too, Dan. 

So I called Maia Szalavitz.

She’s a journalist and a former drug user herself who just published the first history of harm reduction, a book called Undoing Drugs. 

She told me that one of the biggest factors in this shift was race.

Maia Szalavitz: ​​Once people we cared about, AKA white people started being seen as victims of overdose and people who inject drugs, suddenly harm reduction was really acceptable.

RL: She said in the ‘80s and ‘90s, drug use was seen as a “Black” problem.

And the response was this war on drugs approach that put a lot of people of color behind bars. 

But while researching her book, Maia discovered that the opioid crisis in the 2000s changed the face of drug use for a lot of people.

MS: Empowered white, middle and upper class parents began losing kids to overdose or just having them be addicted. And they were horrified by this whole just arrest them over and over and over. So the parents were just like, “This doesn’t work.”

RL: Maia and other experts I talked with said there were obviously other factors too — growing evidence behind harm reduction, pressure from advocates.

But this fact that more well-off white people — including we should say policymakers themselves — saw this as a problem in their own communities, this made harm reduction much more acceptable to them.

And now that we’re seeing this crisis get worse and worse in recent years, the Biden administration is pushing that acceptance to the next level.

DG: Very good.

Ryan, when we come back, harm reduction’s moment in the spotlight and the ongoing debate over what should happen next.

BREAK

DG: Welcome back.

Before the break, Tradeoffs producer Ryan Levi told us that under President Obama the federal government began to embrace harm reduction — ways to make it easier to use illegal drugs in safe ways.

For decades, mainstream America frowned on these policies as being too permissive.

But in just the last 7 years, the number of needle exchanges has tripled to more than 400.

Naloxone — the drug used to reverse opioid overdoses — is available at libraries, schools, and handed out to drug users on the street. 

Ryan, you’re saying that the Biden administration is now going even further in their support of this strategy.

RL: That’s right, Dan.

And we can actually pinpoint the moment when this happened.

Kevin Lindamood: Good morning and welcome to Health Care for the Homeless…

RL: It was the end of October 2021 — a sunny, 70 degree day in Baltimore — and a bunch of reporters had gathered at this health clinic to listen to Biden’s Health Secretary Xavier Becerra do something no one in his job had done before. 

Sec. Xavier Becerra: Today we are talking about something very important because we are in a crisis…

RL: Becerra stood at a makeshift podium. He’s wearing a grey suit, grey tie, reading off note cards.

He said that decades of stigmatizing and punishing drug users was over.

That he was there in Baltimore to announce a new strategy.

Becerra: A strategy that’s different, that changes course and that gives people the help they need.

RL: Then with, I swear, with all of the excitement of a DMV worker checking your paperwork, Dan, Xavier Becerra made history. 

Becerra: Our strategy consists of four priorities: primary prevention, harm reduction, evidence-based treatment and recovery support. 

RL: Harm reduction was now a core pillar of U.S. drug policy.

And in his speech, the secretary punched the point home.

Becerra: Evidence-based harm reduction strategies save lives.

DG: Alright, so what is the Biden Administration going to do, Ryan, that’s different?

RL: The administration is continuing to support needle exchanges and naloxone, both of which we saw under Obama and Trump.

What’s new is state and local governments are now allowed to use federal money to buy fentanyl test strips. These let people check to see if their drugs are laced with fentanyl, which is that very potent synthetic opioid fueling our latest overdose increase.

And, Dan, the other big thing here is that HHS has made $30 million in grants available to states, local governments, nonprofits — just for harm reduction. 

DG: What’s the big deal about $30 million, Ryan? In the context of the overall budget, obviously that’s really modest. 

RL: Obviously, you’re right. Especially when you think about the federal government spends $40 billion on treatment, prevention and drug enforcement, so $30 million is tiny in comparison.

But it’s the first time the federal government has said, “Hey, needle exchanges, hey, small community naloxone group, we want to give you money specifically.”

The way I think of it is it’s the difference between you can get this money for harm reduction vs. you have to do harm reduction to get this money. 

DG: So really what’s important about this is that it’s a signal, and the signal is the Biden administration is opening its mind and starting to reach into their wallets.

RL: That’s a good way of putting it.  

And the administration is really being pretty explicit.

Whenever we see officials from the administration talking about the overdose crisis, they say they want to see more harm reduction.

In December, they even hosted a two-day summit on this.

And there is one more specific policy, Dan, where this administration may be about to do something we have truly never seen before.

News clip: It’s a first here in the United States, a major city has officially sanctioned supervised drug injection sites.

RL: Just after Thanksgiving last year, New York City opened the country’s first locally sanctioned supervised injection or supervised consumption sites.

News clip: Users bring their own drugs to shoot up while supervised by trained staff with clean needles, medication to reverse an overdose, or the option to get clean.

RL: These have been around in Europe, Canada and Australia for decades, but they’ve never been a thing in the U.S., because under what’s known as the “crack house statute,” U.S. law prohibits anyone from running a facility for people to use illegal drugs.

DG: I remember there was a site here in Philly that was gonna open, but the Trump administration cracked down and it never happened. 

RL: Right they actually sued the organization that was going to start that to stop them from opening, and the Biden Justice Department has to decide in the next couple of months if they’re going to keep blocking that Philly site.

But right now, the administration is letting the New York sites run.

And to be clear, those sites are not eligible for any federal funding.

And if the administration ends up endorsing or even just ignoring them, experts I talked to said there are as many as a half dozen cities and states waiting in the wings ready to open their own.

News clip: Rhode Island has become the first state in the country to authorize so-called safe injection sites
News clip: The conversation over safe drug consumption sites in Seattle has been renewed.
News clip: This building in San Francisco’s Tenderloin might be boarded up and covered in graffiti now, but the mayor would like the city to buy it so it could possibly be used as a supervised drug use site.

RL: For harm reduction advocates, Dan, these sites really embody the movement’s basic philosophy.

People are going to use drugs, that’s a given, so we have to keep them safe.

The alternative, they say, is unethical.

Kimberly Sue: The alternative is people are going to use in a McDonald’s bathroom or they’re going to use in a parking lot or an alley alone, or they’re going to use in a hotel room alone and die.

RL: Kim Sue is an assistant professor of medicine and addiction specialist at Yale, and she’s also the medical director of the National Harm Reduction Coalition.

Kim said she thinks we may be at a tipping point.

The spiking death rate and the administration’s openness to new ideas has pushed harm reduction more into the mainstream than she’s ever seen.

But with just New York’s consumption sites on line and the modest boost in federal funding that we’re seeing right now, she’s keeping her expectations in check.

KS: It’s not a panacea. I wouldn’t be surprised if we don’t see a decrease in overdose deaths for a while, and I’m trying to be measured about it.

DG: Ryan, as the administration goes down this path, how will we know if it’s working?

What does harm reduction success look like?

RL: It depends a little on who you ask.

I asked Keith Humphreys who studies addiction at Stanford and was a drug policy advisor in the Obama administration, and he told me there are two camps.

Both of them support harm reduction as a way to keep drug users safe and alive. 

And for one camp, that’s enough.

Keith Humphreys: If 50,000 people use the needle exchange and they don’t get HIV, and they don’t ever go to treatment, that’s OK. That’s not the point. It’s to keep them alive today. 

RL: But the other camp wants more.

KH: It’s good to do, say needle exchange and stop somebody from getting AIDS, but ultimately we’d love to see them not be using drugs at all.

RL: For this camp, harm reduction is a gateway to treatment and hopefully not doing drugs anymore at all.

Connecting people to treatment is one of the biggest selling points of harm reduction, Dan. You hear it all the time. 

One of the big phrases is, “Dead people don’t recover.”

To be clear, folks in that first camp — the “just keep people alive” camp — they like it, they love it when harm reduction leads to treatment. They just don’t see it as necessary for it to be a success. 

DG: So even among the folks who agree, who all love harm reduction, there’s this dispute over what the end goal should be. 

Ryan, what kind of harm reduction evidence is out there on these two measures of success — saving lives and connecting people to treatment?

RL: There’s pretty strong evidence out there, Dan.

Needle exchanges significantly cut the likelihood of someone getting HIV, Hepatitis C.

The drug naloxone, which can reverse opioid overdoses, has overturned hundreds of thousands of them.

With supervised consumption sites, we know less.

I thought Beau Kilmer, who directs the Drug Policy Research Center at RAND, captured this really well.

Beau Kilmer: At the end of the day, I’m sure that a supervised consumption site, it’s going to save some lives and it’s going to reduce infections, but I can’t tell you how much.

DG: And what about whether harm reduction leads to actual treatment?

RL: We know people get referred to treatment from consumption sites. It’s unclear how big a difference the sites make for this.

We have better evidence on this for needle exchanges.

Several studies show people who use needle exchanges are more likely to enter treatment.

In fact, one study shows they’re five times more likely to do it. 

DG: I guess the evidence suggests regardless of the camp you’re in, there’s a harm reduction policy that meets your measure of success.

But for policymakers to really understand the impact of this, we also have to think about access.

Who actually gets the services?

RL: This is a really important point, Dan.

Because we’re seeing overdose rates increase the most among Black Americans.

And there’s evidence that people of color actually have less access to naloxone and needle exchanges.

But interestingly, the Biden administration sees its push for harm reduction as a part of a broader effort to address disparities like this.

DG: OK. And what about rural parts of the country, places that are often more conservative?

RL: We have seen more conservative states like Idaho and Kentucky, for instance, legalize needle exchanges and embrace naloxone in recent years.

But it’s true, most of those 400+ needle exchanges are in cities.

And experts I talked with said something like a supervised consumption site works best when they’re in the neighborhood, walking distance, which makes them a tougher fit for less urban areas.

DG: So before policymakers really move forward with this, they’ve got to understand a couple of things: what success looks like, who they’re helping, and also, importantly, consider downsides.

I know, Ryan, the big concern historically is that harm reduction just enables drug use.

Is that thinking going away at all?

RL: It’s still out there.

We’ve heard it in places considering consumption sites.

News clip: Isn’t this just taxpayers paying for enabling the lifestyle of addicts instead of getting them the treatment they need so they’re no longer addicts?

RL: And we know that in parts of West Virginia and Indiana some needle exchanges shut down last year after elected officials pushed back on them.

News clip: I have a hard time handing a needle to somebody that I know they’re going to hurt theirself with.

RL: There’s no evidence needle exchanges or supervised consumption sites encourage or increase drug use.

There’s also little evidence behind the other big concern we hear, Dan, which is that crime will spike in the neighborhoods around these facilities. 

Despite all that, these two arguments almost always come up when communities talk about harm reduction.  

DG: Listening to you, it makes it pretty clear that even though the rhetoric is changing at the federal level, and there’s action from the Biden administration that is unprecedented, there’s still a lot of resistance to this to all this. 

RL: That’s right, it’s definitely not smooth sailing, but based on my reporting, it’s pretty clear there’s a lot less resistance than there used to be, a lot less resistance honestly.

Policymakers are considering things that used to be unthinkable.

It seems like they’re acknowledging that this tough love approach of the last 50 years just hasn’t worked that well.

The problem has gotten worse and because of that more people are ready to try something different.

DG: Ryan Levi, thanks so much for this story. This is great.

RL: Thank you, Dan.

DG: I’m Dan Gorenstein, and this is Tradeoffs.