Driving cars. Having sex. And in the times of COVID-19, shaking hands.
All these activities bear risk, yet they are fundamental to our everyday experiences.
Few swear them off entirely and instead use practical strategies to minimize preventable harm by wearing seat belts, using barrier forms of contraception, and bumping elbows.
Such is the case with consuming psychoactive substances, which are just as much a part of modern life as the above.
Harm reduction is a concept centered around both reducing some of the harms that come with drug use and respecting the right of individuals to make informed choices about their own bodies.
But harm reduction is not simply a so-called “common sense” approach. It’s a theory and practice developed by and for people who use drugs in the face of government policies designed to incarcerate them and withhold lifesaving resources.
It aims to support people who use drugs in making positive changes in their lives at their own pace and on their own terms.
In practice, that has meant, among other things, liberating and providing criminalized resources, from sterile syringes to pharmaceutical-grade heroin, to people who need them most.
There’s no single set of principles around harm reduction, but these are the core tenets embraced by many organizations working in this space.
‘Any positive change’
The point of this phrase is pretty simple: You decide exactly what needs to change in your life and when it happens.
Maybe it’s consuming one bag of heroin per day instead of three. Or maybe it’s stopping consuming heroin altogether, which is the traditional change required by 12-step programs.
Harm reduction differs from those programs not because it doesn’t honor the choice to abstinence, but because it doesn’t see it as the only option for people to improve their lives.
The phrase is attributed to John Szyler, an early Chicago-based harm reductionist.
Meet people where they are
Harm reduction doesn’t put conditions on who deserves health and safety. Instead, it seeks to provide judgment-free support for people at all points of the substance use spectrum.
For example, someone doesn’t need to be working toward full abstinence or commit to specific goals to receive services.
‘Nothing about us without us’
The movement advancing harm reduction has long emphasized the importance of people who use drugs being meaningfully engaged and empowered to intervene in policy decisions affecting their lives.
Unions for people using drugs have been a vehicle for consumers to demand representation and involvement, from the Dutch Junkiebond founded in 1981 and VANDU (Vancouver Area Network of Drug Users) in 1998 to the Urban Survivors Union in the United States since 2009.
Drug use is here to stay
This is evident in the United States’ “War on Drugs.” Despite trillions of dollars being poured into this effort, the drug supply has only grown, not decreased.
Harm reduction emphasizes that drug use is a normal and expected part of human existence, and efforts should be directed toward minimizing harms instead of the near impossible task of eradicating drug use.
Peoples’ relationships to drugs are numerous and complex
Simply consuming a drug, even on the daily, does not mean you’re addicted to it.
Many factors help define what drugs mean for you in your life. Why, how often, and in which contexts are you consuming? How are your priorities in life changing as a result of your consumption? Would you be open to making changes if something bad happened as a result of your consumption?
Substance use experts recognize a spectrum of relationships to drugs, but they differ on the exact name of each relationship.
They vary as follows:
1. Managed use
There tends to be an implication that you’re not using every day and not experiencing negative health consequences. It’s similar to what Patt Denning and Jeannie Little, two founders of harm reduction psychotherapy, have called “experimental,” “occasional,” or “regular use” in their self-help guide, “Over the Influence.”
Managed use could fit with what others describe as “experimentation” or “social use.”
2. Problematic use
Problematic use occurs when you experience negative effects as a result of not abiding by your expectations of consumption.
You may be partying harder on the weekend than you once said you would, and you’re now calling out sick every Monday. Or you borrowed your friend’s used syringe because you’re worried about entering withdrawal.
Denning and Little have called this “heavy” use. Others have traditionally called this “substance abuse,” a term that tends to no longer be best practice, because it suggests people who use drugs are violent.
“Problematic use” or “substance misuse” are more accurate alternatives.
3. Chaotic use
When your consumption is no longer bound by self-regulation and the negative effects on your life outweigh the original benefits you found from consuming drugs, it’s considered chaotic use.
Denning and Little also use the phrase, “chaotic.” It’s similar to what the National Institute on Drug Abuse recognizes as the definition of addiction: You continue to compulsively consume drugs despite its negative consequences.
Your mindset and environment are important for keeping you safe
The phrase “set and setting” was first used in the early 1960s to talk about people’s varied experiences with psychedelic drugs. In the 1980s, psychiatrist Norman Zinberg revisited the phrase in the context of other drugs, including alcohol and cocaine.
Zinberg presented it as a framework for considering the many factors that contribute to your relationship with drugs:
- “Set” refers to your personal attributes, like personality and other psychological characteristics.
- “Setting” is your environment, including your housing status, police presence, and the people around you.
At the time, Zinberg’s ideas around set and setting disrupted the tendency for experts to focus solely on the individual when it came to questions of addiction, rather than considering all contributing factors.
Harm reduction took shape in response to the Euro-American AIDS crisis of the 1980s and 1990s, though some of its ideas and practices predated its exact formation.
In the book “Undoing Drugs: The Untold Story of Harm Reduction and the Future of Addiction,” author Maia Szalavitz identifies Liverpool, England, as the home of harm reduction.
It started with a syringe exchange and a clinic that prescribed pharmaceutical-grade heroin and and methadone, including in injectable and smokable formulations, to people who’d otherwise purchase them on the street.
The former was modeled after the world’s first-known syringe exchange in the Netherlands, which occurred in response to hepatitis B transmission in 1984. The latter was an extension of an early 20th-century British policy of so-called “maintenance” prescribing.
By bringing together the two practices, British activists “packaged and sold the concept [of harm reduction] to the rest of the world,” Szalavitz writes.
The concepts and practices soon spread to North America, where activists, like those from ACT UP, engaged in high-profile direct action and advocacy for the legalization of syringe exchanges — conducting underground distribution in the meantime — as HIV spread through communities of people who injected drugs.
Throughout its history, harm reduction has been a political and social movement driven by and put into practice by people directly impacted by the War on Drugs and frontline healthcare workers, while also being informed by academic public health experts.
Often called “syringe exchange,” the distribution of equipment needed for injecting drugs is one of the defining practices of harm reduction.
But don’t let the name fool you: It goes beyond just providing syringes and needles.
Sterile water pouches, small cups for mixing drugs, cotton for filtering the solution, tourniquets for finding veins, skin cleaning pads, and wound care are all vital items included alongside the rig that ends up in your arm.
Kits to reduce the risks of smoking crack or methamphetamine or sniffing powdered substances are also often provided.
While half of syringe exchange is ensuring consumers have the materials they need to be safe, the other half, and just as importantly, is offering safer-use education, disease testing, counseling, and referrals to treatment.
As the overdose crisis continues to soar to ever higher death tolls, harm reductionists, and even government agencies, are scaling up training on and distribution of naloxone.
Naloxone is an overdose-reversal medication liberated by Chicago harm reductionist Dan Bigg from the confines of hospitals and placed in the hands of some of the world’s
Supervised consumption sites
These sites, which provide a safe, clean space for consuming drugs, got their start in 1986 in Switzerland as a result of unhoused people who inject drugs claiming space for themselves in the face of police harassment and exclusion from private businesses.
Supervised consumption sites have since become one of the top harm reduction strategies for countering the overdose crisis. If someone starts to show signs of experiencing an overdose, people trained to use naloxone can quickly intervene and save a life.
Throughout various periods of the 20th century, particularly in Western Europe, physicians prescribed pharmaceutical-grade, low-cost heroin or cocaine.
Amid the overdose crisis and the COVID-19 pandemic, “safe supply,” as activists have dubbed it, has emerged as a key intervention that could save lives in the face of increasing drug contamination and respect people’s choice of what they put in their body.
As with most social movements, harm reduction has its critics. Here’s a look at some common arguments.
‘It will increase drug use and crime’
Opponents of programs like syringe exchanges or supervised consumption sites have long said that these practices promote drug use and increase crime rates in their surrounding area.
But there’s no evidence that such programs result in more people using drugs. And
‘It keeps people from getting help’
Others argue that these services prevent people from entering treatment for substance use disorders.
In reality, harm reduction programs are a key tool for initiating substance use disorder treatment.
New participants of syringe exchanges are five times more likely than those who’ve never utilized such services to enter treatment. People who frequent supervised consumption sites are more likely to seek help than those who don’t go as often.
‘Syringe exchanges just make a mess, driving up syringe litter in its neighborhood’
There’s a common misconception that syringe access programs leave a trail of used syringes.
But syringe service programs actually decrease syringe litter, according to a
‘If you use harm reduction services, you need addiction treatment’
Again, people who use drugs have diverse relationships with their consumption patterns, and many of them don’t fall into the category of problematic or chaotic use.
For example, in 2019, of the 5.5 million people the U.S. government estimated to have used cocaine that year, only about 18 percent had cocaine use disorders.
Even if someone attending, say, a syringe exchange does have a substance use disorder, that doesn’t mean treatment is the best fit for them at that exact moment in their life.
Harm reduction isn’t just about minimizing risks. It’s also about respecting the agency of the person in question and providing them with the resources they need to get where they’re trying to go.
Harm reduction is an activist-driven movement to provide people who use drugs with the materials, education, and resources to make choices about their bodies and lives on their own terms and at their own pace.
Sessi Kuwabara Blanchard is an independent drug journalist and transgender critic. She was formerly a staff writer at Filter, one of the only online journalistic publications dedicated to covering harm reduction. Follow her on Twitter.