How harm reduction is winning the war against drug overdoses

Following decades of advocacy efforts led by people who use drugs, the first sanctioned overdose prevention centers in the United States were opened in New York City at the end of 2021. Drawing on the exper­tise and ministry of people with experiences of substance use and overdose, OPCs provide sanctuary for people who use drugs, including social connection, access to compassionate social services and other health care, safer use supplies, and monitoring by people trained to respond to an overdose event or other medical emergency. The new sites, which are housed in existing syringe service programs in Manhattan’s East Harlem and Washington Heights neighborhoods, saved over 115 lives in their first six weeks of operation.

There was significant public opposition to these sites, even though accidental drug overdose now kills more Americans annually than gun violence and automobile accidents combined. The national response to the overdose crisis has been largely shaped by the criminalization and dehumanization of people who use drugs. In the enduring spirit of Nixon’s “all-out offensive” against “public enemy number one,” the war on people who use drugs has decimated families, incarcerated millions of people (most of whom are Black or Brown), enabled the spread of infectious diseases such as hepatitis C and HIV, and failed to prevent problematic substance use or make evidence-based treatment for substance use disorder more widely accessible.

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Maia Szalavitz makes the case that there is a better way, one that has been proven to save lives and that is positively transforming social narratives and policies on drugs and the people who use them. It is called harm reduction, and it finds its roots in the creativity and wisdom of people with lived experience of substance use.

The harm reduction model is a set of practices for minimizing drug-related harm, a person-centered philosophy for addressing substance use across the spectrum, and a movement for social justice which recognizes the multitude of social determinants that impact a person’s relationship with substance use and their vulnerability to drug-related harm.

Szalavitz details the development of harm reduction as it has been created and led by people who use drugs and others living at the margins and as it grew from a grassroots public health effort to a global social justice movement. Rooted in her experience with injection drug use and recovery, she weaves an intimate account of her conversion to this new way of thinking about drugs and the people who use them, alongside the evolution of harm reduction in policy and practice as it took shape in the lives of its early practitioners and then began to express itself in the lives of people who use drugs in communities across the country.

Szalavitz centers humanity and human connection in her narration of the growth of this movement for healing and justice. Beginning with the height of the AIDS crisis and ending with the current overdose crisis, she charts the rise of an expansive way of understanding and responding to substance use and addiction.

The harm reduction model replaces judgment with empathy and punishment with love. It recognizes the conditions of substance use as indivisible from the social conditions people are subject to. It puts the power of defining recovery in the hands of people who use drugs. Harm reduction insists that we move beyond the old ways, beyond unjust laws and moralizing about drug use. It asks us to proclaim that people who use drugs are deserving of respect and dignity—and that their lives have inherent value.

Szalavitz anchors her narrative of the harm reduction movement in protests against the political indifference to the loss of human life as the AIDS epidemic took hold. By the end of the 1980s, injection drug use was fueling the HIV epidemic in New York City. Due to limited access to sterile syringes, people who used drugs were forced to share injection equipment, and as a direct result HIV spread rapidly. This wound was deeply felt both by people who use drugs and by their loved ones.

Community members, people who use drugs, and health professionals began to form collectives, such as the AIDS Coalition to Unleash Power and the Association for Drug Abuse Prevention and Treatment. They began taking safer use supplies to places where people were using drugs, such as shooting galleries and garbage-strewn lots on the city’s Lower East Side. In addition to illegally distributing syringes, they distributed bleach and safer use education, including instructions on how to clean used syringes. They took help and healing to the people, meeting them where they were at—a core tenet of harm reduction philosophy.

Undoing Drugs portrays the course of harm reduction as it grew from a fringe effort to the mainstream in the United States. The book recounts multiple drug panics (amphetamine, heroin, crack cocaine, prescription opioids), the development of antiretrovirals to treat HIV, the legalization of syringe access in an increasing number of communities, and the expansion of community-level naloxone distribution. In the context of increasing overdose fatalities across the country, Szalavitz reflects on the current state and future of harm reduction with a quote from Anthony Fauci. Looking back on his experience with the HIV crisis, Fauci said: “I’m flashing in my mind . . . [to] how difficult it is for society to accept harm reduction . . . and then when you accept it, you realize, why didn’t I do this before?”

With more than 841,000 lives lost to drug overdose in the United States since 1999, Undoing Drugs makes it undeniably clear that the time for a more robust uptake of harm reduction, led by people who use drugs, is upon us. The human toll of the war on people who use drugs would be even graver if not for the lifesaving and life-giving ministries of people who use drugs, and their persistence, resilience, and love in action despite innumerable odds. Szalavitz concludes with these words: “Through harm reduction, we can undo the ideology that underpins damaging policies and make way for a future that is healthier, happier, and more humane for everyone.”

A version of this article appears in the print edition under the title “Embracing harm reduction.”