As fentanyl propelled overdose deaths to ever more alarming numbers several years ago, public health officials throughout the United States stepped up a blunt, pragmatic response. Desperate to save lives, they tried making drug use safer.
To prevent life-threatening infections, more states authorized needle exchanges, where drug users could get sterile syringes as well as alcohol wipes, rubber ties and cookers. Dipsticks that test drugs for fentanyl were distributed to college campuses and music festivals. Millions of overdose reversal nasal sprays went to homeless encampments, schools, libraries and businesses. And in 2021, for the first time, the federal government dedicated funds to many of the tactics, collectively known as harm reduction.
The strategy helped. By mid-2023, overdose deaths began dropping. Last year, there were an estimated 80,391 drug overdose deaths in the United States, down from 110,037 in 2023, according to provisional data from the Centers for Disease Control and Prevention.
Now, across the country, states and communities are turning away from harm reduction strategies.
Last month, President Trump, vowing to end “crime and disorder on America’s streets,” issued a far-flung executive order that included a blast at harm reduction programs which, he said, “only facilitate illegal drug use and its attendant harm.”
But his words, implicitly linking harm reduction to unsafe streets, echoed a sentiment that had already been building in many places, including some of the country’s most liberal cities.
San Francisco’s new mayor, Daniel Lurie, a Democrat who campaigned on a pledge to tackle addiction and street chaos, announced this spring that the city would step away from harm reduction as its drug policy and instead embrace “recovery first,” aspiring to get more people into treatment and long-term recovery. He banned city-funded distribution of safe-use smoking supplies such as pipes and foil in public places like parks. A year earlier, San Francisco voters had signaled their restiveness with pervasive drug use by approving a measure stipulating that some recipients of public assistance who repeatedly refused drug treatment could lose cash benefits.
Philadelphia stopped funding syringe services programs, which the C.D.C. has called “proven and effective” in protecting the public and first-responders as well as drug users. The city put restrictions on mobile medical teams that distribute overdose reversal kits and provide wound care for people who inject drugs, and stepped up police sweeps in Kensington, a neighborhood long known for its open-air drug markets and a focal point of the city’s harm reduction efforts.
Santa Ana, Calif., shut down its syringe exchanges; Pueblo, Colo., tried to do the same but a judge blocked enforcement of the ordinance.
Republican-dominated states have also been retreating from the approaches. In 2021, West Virginia legislators said that needle exchange programs had to limit distribution to one sterile syringe for each used one turned in and could only serve clients with state IDs. Last year, Nebraska lawmakers voted against permitting local governments to establish exchanges.
“Harm reduction” is a decades-old concept, grounded in the reality that many people cannot or will not stop using drugs. Since the 1980s, when AIDS activists began distributing sterile syringes to drug users to slow the spread of diseases, the expression has moved to the mainstream of addiction medicine and public health.
Over time, it has become shorthand for a wide range of approaches. Some are broadly popular and will certainly continue. In April, the White House’s office of drug control policy released priorities reaffirming support for drug test strips and naloxone, the overdose reversal medication that has become an essential item in first-aid kits in homes, restaurants and school nurse offices.
But critics contend that making drug use safer, with distribution of supplies and pamphlets directing how to use them, normalizes drug use and undercuts people’s motivation to quit and seek abstinence.
“The more you’re sort of funding and feeding the addiction, you’re going to get more addiction,” Art Kleinschmidt, now the head of the federal agency that oversees grants for substance abuse, said on a podcast last year. Such programs, he said, “definitely are breeding dependency.”
Others argue for nuance.
“Harm reduction is neither the singular solution to the overdose crisis nor a primary cause of public drug use and disorder,” said Dr. Aaron Fox, president of the New York Society of Addiction Medicine. “It’s one component of a spectrum of services necessary to prevent overdose deaths and improve the health of people who use drugs. But if communities want long-term solutions to homelessness, they need to work on expanding access to housing.”
Harm reduction supporters reject the notion that protecting people from the worst consequences of drugs encourages use.
“I don’t think the availability of sterile supplies really makes a difference about whether someone is going to start or continue using drugs,” said Chelsea L. Shover, an epidemiologist at the University of California, Los Angeles, who oversees Drug Checking Los Angeles, which tests the contents of drugs for individuals and public health agencies. “But I do think it will make a difference in terms of whether that person is going to be alive in a week or a month or a year, during which time they might get into recovery, whatever that may mean for them.”
Some addiction experts fear that a retreat from harm reduction will reverse the falloff in deaths from injection-related diseases.
“Hepatitis C and H.I.V. numbers will go up, and more people are going to die,” said Dr. Kelly Ramsey, a harm reduction consultant who practices addiction medicine at a South Bronx clinic.
While overdose deaths have fallen, it is unclear whether drug use itself has also slowed. In neighborhoods across the country, from Portland, Maine, to Portland, Ore., many residents complain that the harm to them from drug use, including crime and syringe street litter, has not been reduced.
Mr. Trump particularly called out a type of harm reduction known as “safe consumption sites” — sometimes labeled “overdose prevention centers.” They are supervised locations where people can inject drugs without fatally overdosing, found in Europe, Canada and Mexico. Often drug users can test their supplies right away and staff members can quickly administer overdose reversal medication if needed.
There are only three in the United States, and they make for easy political targets. In addition to many Republicans, prominent Democratic governors, including Gavin Newsom of California, Kathy Hochul of New York and Josh Shapiro of Pennsylvania, oppose them. The Pennsylvania senate voted to ban them. One, in Rhode Island, is protected by state and local law. But the other two, in New York City, which provide treatment referrals and support services, operate in a legal gray zone and could face federal scrutiny.
Opponents of harm reduction offer few specifics about how to get more people to stop using drugs and into treatment. Mr. Trump’s order directs the health secretary and the attorney general to explore laws to civilly commit addicted people who cannot care for themselves into residential treatment “or other appropriate facilities.” But it is silent about how such programs would be paid for.
The administration has already made major cuts to the Substance Abuse and Mental Health Services Administration, the federal agency that awards grants for prevention, treatment and recovery. It has slashed the agency’s staff and the grants it gives for a wide variety of prevention, intervention and treatment services.
Cuts to Medicaid included in the sweeping domestic policy bill enacted this summer are also likely to affect many people’s access to treatment and states’ ability to cover it. Robert F. Kennedy Jr., the health secretary, who is in recovery from a substance use disorder, has focused on nutrition, chronic disease and vaccines during his first six months in office and has said little about plans to address the drug crisis.
The battle over whether harm reduction should remain a primary goal or be secondary to getting users into treatment and restoring order to public streets has been joined most intensively in San Francisco.
There, ample social services and ferociously expensive housing had contributed to a large population living on the streets, many struggling with mental illness and addiction. Then, by 2020, fentanyl and Covid had slammed into the city.
At public meetings this spring, angry residents brandished signs, some reading “Harm Reduction Saves Lives” and others “Drug Enablism Kills.”
Although the city has adhered to regulations for state-funded Housing First programs, which offer permanent housing for homeless people without requiring them to be drug-free, Mr. Lurie recently presided over the opening of the city’s first transitional sober living residence, with 54 units for adults committed to abstinence.
The drive to adjust the city’s drug policy to recovery first has been led by Matt Dorsey, a member of the San Francisco Board of Supervisors, who is in recovery from a substance use disorder.
In an interview, Mr. Dorsey said he supports aspects of harm reduction, including the distribution of safe supplies. But he sees the strategy as more of a floor than a ceiling. “We need to make clear that the objective of our drug policy is a healthy, self-directed life free of illicit drug use,” he said.
The difficult challenge, he said, was how to attend to the rights of pedestrians who daily confront drug use, while also trying to “help people addicted to life-threatening drugs.”
To pay for additional treatment and services, he said, city officials are working on ballot measures to redirect tax revenue.
“Part of what gives me confidence that we will ultimately find the funding,” Mr. Dorsey added, “is that the alternative is unthinkable.”
Jan Hoffman is a health reporter for The Times covering drug addiction and health law.
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