A Fight to Do No Harm

SUPPORTERS SAY harm-reduction strategies are like air bags or seat belts: common-sense, low-cost ways to save the lives of drug abusers while also saving communities millions of dollars in medical costs per year.

Reducing the Harm of Opioid Addiction

With multiple studies confirming the effectiveness of such approaches and decades of success in Europe, they say, adopting them should be a no-brainer for cities and towns fighting the seemingly unbreakable grip of the U.S. opioid crisis.

Yet local and national politics – coupled with stigmatization and outdated notions of addiction – have dampened acceptance of practical ways to protect opioid users: issuing sterile hypodermic needles to curb infectious diseases, providing safe spaces for users to get high and prescribing other drugs, like methadone, to help them transition into recovery.

In Charleston, West Virginia, inside Appalachia's opioid-addiction hot zone, city leaders in March killed a needle-exchange program intended to protect residents from an infectious illness outbreak. Critics argued the program – among several shut down in recent years – was a magnet for outsiders who grabbed the clean syringes and tossed dirty ones in the streets.

Months later, California Gov. Jerry Brown, a Democrat and progressive hero, vetoed a bill that aimed to allow so-called safe consumption sites in the Golden State, rejecting the argument that it would curb drug addiction. Proponents point to data showing the medically supervised clinics can stem fatal overdoses, but opponents say they coddle drug users who don't want to get clean.

Meanwhile, as Philadelphia officials forge ahead with plans for a safe consumption site, the federal government has placed potential hosts on notice. In August, Deputy Attorney General Rod Rosenstein declared that such sites remain "illegal under federal law," and users "remain vulnerable to civil and criminal enforcement," whether or not there's a doctor present.

And although Congress moved to expand access to opioid treatment with safer, substitute drugs like methadone and buprenorphine – and the number of methadone clients has surged in recent years – only a fraction of hardcore drug users who want to quit are engaged in the treatment, and some states don't allow methadone to qualify for Medicaid reimbursement.

Regina LaBelle, an attorney and addiction specialist, says pushback against harm reduction is evidence of a persistent societal misconception, in which drug dependence is seen as a weakness and not an illness.

"We don't address addiction as if it's a chronic health condition," says LaBelle, program director of the Addiction and Public Policy Initiative at Georgetown University's O'Neill Institute for National and Global Health Law. "We don't have a health care system currently where we treat addiction as a disease" the way doctors treat diabetes or hypertension.

At the same time, she says, "I think there's denial in some communities: 'We can't possibly have a (drug) problem like this.'"

Once on the fringes of public health strategies, advocates say harm reduction became part of the public health toolbox during the fight against AIDS in the late 1980s, when advocates distributed condoms and preached about safe sex to at-risk populations. The drug addiction and recovery world came aboard after AIDS spread among intravenous drug users who shared contaminated hypodermic needles. Syringe exchange programs – where used needles are traded for fresh ones – helped keep blood-borne disease outbreaks in check.

According to advocacy group the Harm Reduction Coalition, the concept includes "a spectrum of strategies" that help medical professionals and addiction specialists meet drug users "where they're at." It also means accepting that "illegal and illicit drug use is part of our world" and will never be completely eliminated, and that mitigation of the dangers of drug use can save lives.

Methods vary, but the goal is to keep drug users as healthy as possible and, best-case scenario, guide them into treatment, according to the coalition. At worst, advocates say, the strategy helps users live to see another day, with another opportunity to leave drugs behind.

Since the 1990s, multiple medical reports and scientific studies have confirmed its effectiveness. A 2018 report from Harm Reduction International notes that dozens of countries, ranging from progressive Denmark to Estonia, a former Soviet republic, endorse harm reduction in plans to fight drug abuse.

In the U.S., the strategy has gained a firm foothold: A report by amfAR, the Foundation for AIDS Research, found that more than 203 clean-syringe programs were operating in 34 states in 2012, and a Pew Stateline report in October, citing Drug Enforcement Agency data, showed that the methadone industry added 254 new clinics nationwide during the last four years.

Moreover, community-based programs distributing naloxone, an overdose-reversal medication, have boomed in the U.S. over the last two decades, from one in 1996 to 644 by 2014, according to a 2015 Harm Reduction Coalition survey.

"There are some bright spots around the country," LaBelle says.

But with some 130 fatal opioid overdoses each day in the U.S., the bright spots may not be enough. The U.S. still doesn't have a single legal safe consumption site, and although the number of methadone clinics is on the rise, the same Pew Stateline report said only 1 in 10 addicted opioid users are actually engaged in what's known as medication-assisted treatment, which can involve methadone, buprenorphine or another drug, naltrexone.

Meanwhile, many politicians and the public in general still see needle-exchange programs as controversial, last-resort strategies, acceptable only amid a public health crisis, and then, only temporarily. Exhibit A: Charleston's ill-fated program.

In 2015, with the blessings of city leaders and police, Michael Brumage, then-director of the Kanawha-Charleston Health Department, set up a clean-needle program. As word got around, the Charleston program quickly grew, as The New York Times reports: At its apex, it drew nearly 500 people in a span of eight hours, in a city of 50,000.

Then, anxious community leaders began sounding the alarm.

The mayor said the clinic had created a "mini-mall" for drug dealers and users. Police griped about carelessly discarded needles. And a 5-year-old girl accidentally pricked herself with a contaminated needle someone left in a McDonald's bathroom.

After police imposed a series of strict rules, health officials shut down the program last March.

"Part of the issue with the participants was not only the (large) number, but that they represented a class of society that many people didn't want to have around," says Brumage, now an assistant dean at the West Virginia University School of Public Health and an assistant clinical professor of medicine at the university's School of Medicine. "And so they became the object of unwanted attention."

Brumage says it's "extremely unfortunate" that "stigma and misinformation" scuttled an evidence-based program he says was working, though an audit reportedly found issues tied to its record-keeping and littered syringes, among others.

Charleston, Brumage warns, may learn about harm reduction the hard way.

"Eventually, the problems with infectious diseases like hepatitis B, hepatitis C and HIV will force the city to look at it," he says.

Dr. Laura G. Kehoe, a physician, substance abuse clinician and professor at Harvard Medical School, says that when it comes to drug addiction, fear and stigma often overwhelm science and reason. She says even some doctors don't believe in harm reduction and look down on treating drug-addicted patients.

"It's beyond stigma. It's discrimination," says Kehoe, who also is medical director of the Substance Use Disorder Bridge Clinic at Massachusetts General Hospital. Their thinking, she says, "all goes down to this deep lack of understanding: 'These are illegal drugs. People are doing it to themselves.'"

LaBelle, the Georgetown policy expert, points out out that rural Scott County, Indiana, set judgment aside in 2015 after the number of HIV cases there skyrocketed, evidence of a major IV drug-use problem. Health officials and politicians soon enacted a needle-distribution plan, and infections reportedly fell.

Yet only about a handful of Hoosier State counties grappling with the opioid epidemic have followed Scott County's lead, and at least one shuttered a clean-needle program amid legal and moral concerns. Even the Scott County program – which the state approved only after declaring a public health emergency – faced intense opposition from influential critics, and was renewed in a 2-1 vote.

Any program "should require addicts to exchange needles only a limited number of times before they must enter treatment," Indiana Attorney General Curtis Hill, a Republican, wrote after a hearing on the needle-exchange issue last year. "No one is helped when addicts are allowed to use this program in an open-ended fashion."

Kathie Kane-Willis, a researcher for the Chicago Urban League and an expert on that city's opioid crisis, says politicians like Hill misunderstand addiction and have expectations about the recovery process based on movies or reality-TV shows like "Intervention." In the real world, she says, a tough-love approach can have the opposite effect, shaming drug users away from treatment.

"Because (substance abuse disorder) is not just stigmatized – it's taboo in some ways – it's easier to make space for some narratives that are not true," says Kane-Willis, herself a former heroin user.

Harm reduction "is not just about (illegal) drug use. It's the way that we approach medicine, it's how we approach pretty much everything," she says, pointing to prescription medications that help people with hypertension and other chronic diseases.

Kane-Willis continues: "Air bags and seat belts don't prevent fatalities. But they reduce the rate," she says. "I think that what people think about harm reduction is anything goes – it's condoning drug use and it's saying, 'Sure, drugs are totally fine.'"

Instead, "what it really does is use a trauma-informed approach and meet people where they are," she says. "And it's providing real benefits to people who use drugs and society in general." By Joseph P. Williams

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