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Q&A: How harm reduction can help mitigate the opioid crisis

Maia Szalavitz is the author of the upcoming book "Undoing Drugs: The Untold Story of Harm Reduction and the Future of Addiction."
Photos courtesy of Maia Szalavitz
Maia Szalavitz is the author of the upcoming book "Undoing Drugs: The Untold Story of Harm Reduction and the Future of Addiction."

Harm reduction is an approach to drug use and addiction that emphasizes reducing the negative consequences associated with drug use. The concept often faces challenges or resistance, especially in southern states, where there has been pushback to proposals like needle exchanges or free overdose reversal medications.

The Gulf South is receiving hundreds of millions of dollars from settlements with some of the nation’s largest opioid manufacturers and distributors. The money is meant to help mitigate the damage caused by the opioid crisis, and some are pushing for more of the funds to be used for harm reduction that may help more people and their families.

Leading the charge in the U.S. is Maia Szalavitz, the author of “Undoing Drugs: The Untold Story of Harm Reduction and the Future of Addiction.”

In a conversation with the Gulf States Newsroom’s Drew Hawkins, Szalavitz discusses how harm reduction can help mitigate the opioid crisis.

The following conversation has been edited and condensed for clarity. 

Let’s start with this idea of harm reduction. What is it, where does it come from and what are some examples of it?

Basically, harm reduction is a drug policy that focuses on stopping people from getting hurt rather than stopping them from getting high. It's a very simple idea, but it has enormous implications. In the United States, it's mostly associated with clean needle programs to prevent the spread of HIV.

It originated in Liverpool, in the U.K., when they were faced with a potential HIV epidemic among IV drug users. They'd seen that Edinburgh had this horrific epidemic and Liverpool had the same bad economic conditions — a lot of unemployment, a lot of youth unemployment in particular, a lot of heroin use — but the virus had not yet gotten to Liverpool. In fact, Liverpool did not have the kind of HIV epidemic in drug users or in its general population there that the United States did or that Edinburgh did because of harm reduction.

Some people might think that drug use and addiction don't impact them. But as you say in your book, punitive drug policies can actually hurt people who legitimately need pain medication. Can you talk about how that happens?

Historically, America has had this pendulum that swings back and forth with regard to opioids. Every 10-20 years, or so, we go from “opioids are great, they're not addictive,” to “Oh my God, opioids are horribly addictive, nobody should have them.” The reality is in the middle. The reality is that some people need opioids for pain. End of life is obviously one area, cancer another. But there are also some chronic conditions that nothing else works for.

People on the backlash side have been spreading the idea that opioids never work for chronic pain, or they stop working for chronic pain or anybody in chronic pain who needs opioids long-term is actually just addicted. This is simply not true. The reality is that 70% of the adult population has taken opioids medically. Perhaps, at the highest, 4% of the population has opioid use disorder. So obviously, the vast majority of people who take these medications do not get in trouble with them.

Now, if you are an 18-year-old, risk-taking, motorcycle-riding kind of guy, you might have a higher risk. Doctors should be very careful when prescribing to such people. If you are a 55-year-old woman who has never had a drug problem with anything in her life, the odds are really low that that person who has a replacement, or has whatever surgery they need, is going to suddenly turn into a pharmacy robber.

In your book, you explore the research around drug use and addiction, as well as your journey with drug use. Can you talk about the effectiveness of harm reduction, both in the academic literature as well as your own experience? 

The literature is basically unequivocal on harm reduction. Every expert organization that ever evaluated the research on clean needle programs found that they do not increase the risk that teenagers will use drugs, they do not increase crime and they do reduce HIV spread. That data is some of the best data in public health. It's been studied a lot because it was so controversial.

When you look at even more controversial things, like the countries where they prescribe heroin to people who are addicted, again, you see improvements in health, decreases in crime and you see no reduction in people accessing more traditional forms of treatment. The big fear that people have about harm reduction is that it enables people and that it means that people are not suffering enough consequences from their addiction. If you can just make things bad enough for people, they will quit. Now, the problem with that idea is that addiction is, by definition, compulsive drug use that occurs despite negative consequences.

People who are addicted notoriously lose their families, their spouses, their houses, their jobs — everything that's important. If negative consequences were going to fix this, people should never become homeless from addiction, right? This is not how addiction works. There's just no data anywhere that shows that harm reduction causes the things that people fear that it causes.

In my own life, I was injecting drugs in New York City in the 1980s, and HIV was incredibly prevalent. About half of all people who injected drugs at that time were already infected. I happened to be at a friend's house, and another friend was there, and she was actually visiting from San Francisco to try to get my friend into rehab.

What happened is she saw that we were about to use because everybody needs to have their last binge before rehab. And she was like, “You know, you're at risk if you share needles.” And I was like, “What? I thought that only affected gay men.”

I was a pretty informed person. I read two newspapers a day. I watched TV news. I didn't know. And so she taught me to use bleach to clean my needles, and I then avoided becoming infected with HIV. I was at serious risk because it turned out that the friend that I was about to share with potentially was already positive. At that time, it was pretty much 100% fatal.

So, harm reduction basically saved my life. It did have the name of harm reduction, but I didn't know it and neither did the person who taught me. But, it was beginning. It was just beginning to sort of take off as an idea and as a movement. And, if you think about it, harm reduction goes back to Hippocrates. “Do no harm.”

With the opioid settlements, there are going to be millions of dollars coming to states that are meant to be used for remediation, for assistance, for help with the opioid crisis in the Gulf South. It's really murky where a lot of that money is going. In Louisiana, for example, a big chunk of it is just going straight to sheriff departments. And in places like Mississippi and Alabama, we just don't really know where a lot of it's going because they're not required to report it. Does that raise any concerns for you?

Yeah, that raises enormous concerns. In the United States, we've spent decades and decades and decades arresting people for having drug problems, and arresting people for possession of drugs does not work. The United States arrests more people for possession of drugs than any other country in the world. We arrest more people and incarcerate more people in general than any other country in the world. And we have the world's worst overdose problem. So if this is going to work, you would expect that it might have worked by now.

The reality is arrest is punishment and it is a negative consequence. And addiction is defined by continuing despite negative consequences. If you want to actually help people recover from addiction, you have to offer them better alternatives. We just misunderstand the problem. And when you misunderstand the problem, you end up with solutions like [arresting] people for, having drug problems.

I like to think of it like dieting. If we were to arrest people for breaking their diet, do we think that would be a more effective way of weight control? I can tell you right now it wouldn't be. If you have any medical condition, I don't care what it is, do you really think you're better off being treated for any medical condition in jail compared to a regular medical setting?

This is not a complex question. It's very easy to answer. Either we believe addiction is a medical disorder, or we believe it's a sin and we can punish our way out of it. We've tried punishing our way out of it for the last 100 years or so, and it doesn't work.

In your mind, what would be a better use of this big chunk of money that's coming to the states? Do you see there being any unique social, cultural or economic factors in the Gulf South that might influence approaches to drug use and harm reduction? 

The one thing that we know is that we have two medications, methadone and buprenorphine, that if you stay on them, cut the death rate by 50% or more. That's huge. If we want to help and we want to reduce overdose risk, we need to get these medicines to people, and we need to do it in a way that is much easier to access than it currently is. Right now, it's way easier for somebody who is actively using to find a drug dealer and get their drugs than it is to access these medications. We need to make it so that it's almost as easy as that.

This requires regulatory change, particularly for methadone, but we need to be able to make it easier for people to access. If you want … even talking for one day, you should get it for one day. That day you're not taking fentanyl. This is good. If you start to feel better, you're like, “Oh, well, maybe I'll do this again tomorrow.” This is how you get people into treatment.

But if you're like, “You have to do a urine test and you have to fill this form out,” and you have to do all these degrading things, people are just going to not do it. So the number one thing we need to do is make these medications more accessible. You have to meet people where they are in harm reduction. In the Gulf region, I think faith-based solutions can work for some people. Again, you can't be forcing people into that, but for people who are already there and already looking for that, those communities should be supported in providing evidence-based care.

Now, again, it can't just be like the same old stuff where you must get abstinent. If you support people in harm reduction work where they are, whether that be a church or wherever, I think that is enormously helpful. You need to have safeguards so that the money is actually being spent in ways that are effective and not in telling people, “Come off that damn medication.”

This story was produced by the Gulf States Newsroom, a collaboration between Mississippi Public BroadcastingWBHM in Alabama, WWNO and WRKF in Louisiana and NPR. Support for health equity coverage comes from The Commonwealth Fund.

Drew Hawkins is the health equity reporter for the Gulf States Newsroom. He covers stories related to health care access and outcomes across the region, with a focus on the social factors that drive disparities.