During the coronavirus pandemic, the overdose crisis in the United States has only continued to worsen, with the Centers for Disease Control and Prevention reporting last week that overdose deaths increased by 15% from 2020 to 2021.
Despite those rising, alarming statistics, harm reductionists — experts, advocates and others who help people who use drugs stay safe — see some hope as policies meant to reduce overdoses change. However, many of those policies are connected to the coronavirus pandemic and government leaders, leading to concern that they may only be temporary.
“Half of me is hopeful, and really, I have seen much more momentum,” said David Frank, Ph.D., a medical sociologist and research scientist at the New York University School of Global Public Health. “I’m more hopeful than I have been ever before, but I won’t be surprised if they take it all away from us.”
What is harm reduction?
Harm reduction is broadly defined as the development of public health policies that are designed to make risky activities safer. When it comes to harm reduction for drug use, major policies include advocating for safe consumption sites (places where people can use drugs in a clean, medically supervised environment), the distribution and use of naloxone, a drug that reverses opioid overdose; the use of testing strips that can check drugs for fentanyl; and exchanges or giveaways of clean syringes to prevent infection or disease transmission. All of these policies aim to make drug use safer for the person using drugs and have been implemented around the world.
While it’s commonly applied to drug use, harm reduction can be applied to other activities, such as encouraging people to engage in safe sex.
The coronavirus pandemic has changed the field
Harm reductionists interviewed for this story agreed that there have been major policy shifts since the coronavirus pandemic began in 2020.
“Sadly, it took a pandemic to lift regulations that should have been lifted a very long time ago, specifically around methadone and buprenorphine,” said Jasmine Budnella, director of drug policy at VOCAL-NY, referring to two medications used to treat addiction by affecting brain receptors to limit opioid cravings. Their use is referred to as medically assisted treatment or medical maintenance.
Until 2020, most patients using these medications had to pick up their prescription daily, going to a clinic and taking a dose under staff supervision. Frank, who has been on methadone maintenance treatment for 20 years, said he’s seen these mandates wreak havoc.
“If you had to go somewhere every single day at 6 in the morning, that would interfere with anyone’s life,” Frank said. “It’s so ironic because the clinics want you to do things like get a job or go to school, and their very policies can make that impossible.”
As the pandemic began, the Substance Abuse and Mental Health Services Administration (SAMHSA) issued guidelines advising medical maintenance clinics to consider allowing patients to take home doses of methadone, instead of requiring daily visits. While some people, like Frank, have had access to take-home doses since before the pandemic, he said that the guidance from the federal level made the policy more common, though it still wasn’t guaranteed.
“I’ve talked to people that hadn’t been getting any take-homes and then are suddenly getting a week or two weeks’ worth because of COVID,” Frank said. “They’re like, ‘Oh my god, I can get my kids off to school, I don’t have to rush around and wake up at four in the morning to drive to the clinic so I can make it to my job on time. ... I’m more stable.’”
The rise in telemedicine also changed the game, especially in areas where clinics are harder to access.
“We’re doing a lot more telemedicine, which has become an easier way for us to be able to meet where our participants in our program actually are at,” said José Benitez, the executive director of Prevention Point Philadelphia. “When the pandemic is over, hopefully we will be able to continue that, because ... we’re finding a lot more success. It’s something that has helped us.”
Other tools, such as naloxone, commonly known by the brand name Narcan, and fentanyl testing strips, have become more commonly used. For Shaun August, California state director of NEXT Distro, an organization that distributes supplies, one of the clearest manifestations of how harm reduction has changed is a vending machine in California that dispenses necessary items like naloxone.
“That allows people to get supplies, individually, anonymously, and in a COVID-avoidant way,” he explained. “It’s just all been a lot of creative solutions to to continue make sure that our folks get what they need.”
Vending machines aren’t the only way harm reductionists reached out to communities during the coronavirus pandemic: Some programs, like the Kentucky Harm Reduction Coalition, increased their efforts to bring help to people in need by expanding the use of their mobile units.
“In recovery, you need community, and during a pandemic we had to tell everyone to isolate. ... Our mobile unit allowed us to keep meeting our participants where they are and literally be on the street to provide services,” said Shreeta Waldon, the executive director of the Kentucky Harm Reduction Coalition, adding that people often ask her organization about methadone, rehabilitation and other treatments, as well as harm reduction.
During the pandemic, there has also been a political shift: In March 2022, President Joe Biden became the first president to address harm reduction in a State of the Union speech, according to Pew, and he also has authorized the SAMHSA to accept grant applications for harm reduction policies. The agency expects to issue $30 million in funding. Harm reductions see his recognition of their work as a step forward, but one that could be easily reversed.
“From administration to administration, federally, on a state level and locally, we can see dramatic shifts that can happen within an election cycle,” said Sheila Vakharia, Ph.D., deputy director of the department of research and academic engagement at the Drug Policy Alliance.
For Benitez, nothing summarizes the impact that state and federal leaders can have more than a lawsuit over a safe consumption site in Philadelphia.
In 2019, Philadelphia harm reduction group Safehouse moved to open the country’s first official safe consumption site. The organization was sued by the Justice Department, and the project stopped, with the Supreme Court recently declining the case after a federal appeals court ruled against Safehouse.
“Essentially, the government sued us. ... That’s really where this started, having the Trump administration sue us,” said Benitez. Now, though, Safehouse lawyers and the Biden administration are in “ongoing conversations” that Benitez said are “moving towards a positive resolution.”
In New York City, two safe consumption sites opened in late 2021 as part of a pilot program. Staff at these sites have reversed at least 260 overdoses since they opened their doors; however, momentum to expand the pilot program has stalled, according to Budnella.
“There’s a bill that we could pass that could authorize overdose prevention centers across the whole state,” Budnella said. “We’re losing 15 New Yorkers to overdose a day. (I) imagine scaling the sites up, but we just don’t have the political will.”
Vakharia said that the politics aren’t as simple as red states and blue states: In New Jersey, a state with a Democratic governor, a syringe service program was shut down by the largely Democratic Atlantic City City Council in 2021. The program is the largest in the state; a lawsuit is currently fighting to keep the site open. Until a decision is made by the court, the site will continue operating.
“We have to celebrate our victories, but we have to be ready to defend them because the tides can shift very quickly, and unfortunately, the shifting can happen in a bipartisan way,” Vakharia said.
“We’re doing so much good, and we’re saving so many lives, but the lives saved aren’t tracked the same way lives lost are, and with record numbers of people dying due to overdose, it can be easy to say ‘Look, we’re not doing enough,’ and it’s true,” Vakharia continued. “We’re not doing enough, but also, that number could have been a lot higher. ... We have to acknowledge that even our best lead harm reduction efforts are still not at the scale that they ought to be to have that maximal impact."