Harm Reduction: History and Context

Introduction 

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Harm reduction is a term that holds different meanings to different communities, making it difficult to define and easy to misunderstand.¹ At its most fundamental, harm reduction is simply any intervention or strategy used to reduce the harm from a potentially risky activity or situation.² Driving a car involves a certain amount of risk; seatbelts reduce crash-related injuries and death by approximately 50% and saved almost 15,000 in 2017.³ Sexual activity carries the risk of contracting sexually transmitted infections (STIs) and unwanted pregnancy; external condoms are highly effective at preventing STIs, HIV, and pregnancy.⁴ Even simply being in the sun carries an increased risk of sunburn and skin cancer; sunscreen reduces the risk of skin cancer.⁵ Seatbelts, condoms, and even sunscreen are all examples of harm reduction interventions. We use harm reduction strategies every day to reduce the risk of harm from the world around us, even if they aren’t recognized as such. 

Today harm reduction is most commonly thought of in relation to drug use. According to the National Harm Reduction Coalition, harm reduction simultaneously refers to tangible and practical strategies to reduce negative outcomes of drug use, and to the social justice movement that advocates for the respect and rights of people who use alcohol or drugs.¹ More specifically, harm reduction holds to the following four components:⁶

Services most commonly associated with harm reduction usually focus on injection drug use and include interventions such as overdose prevention and naloxone distribution, syringe exchange, overdose prevention sites, and distribution of fentanyl test strips.⁷ However, harm reduction includes strategies for reducing the harms of alcohol and tobacco use, risky sex behaviors, and more.⁸ Research studies have explored using an e-cigarette to manage nicotine withdrawal and craving while avoiding the risks associated with smoking cigarettes and alternating water between drinks of alcohol as harm reduction strategies.^{9, 10} In December of 2021, SAMHSA announced an unprecedented $30 million in harm reduction grant funding to increase access to community harm reduction services to help combat the ongoing opioid use and overdose crisis in the United States.¹¹ This investment in harm reduction services indicates a recognition by the federal government of the efficacy and value of these services, but harm reduction—both as a set of practical strategies and as a social justice movement—has a long history, spearheaded by people who use alcohol or drugs and their communities. 

History 

The history of harm reduction in the United States is complex and intricately entwined with the history of drug policy in the United States. The modern harm reduction movement was a response to the HIV-AIDS crisis in the 1980s and grew out of civil disobedience and grassroots advocacy among communities of people who used drugs. It is still perceived to be politically contentious today. The still-present strain between advocates of harm reduction and many systems in the United States such as law enforcement, the medical system, lawmakers, and even substance use treatment providers, springs from a history of drug policy rooted in 1) tying morality to drug use^{12, 13} and 2) the political use of drugs and drug policy to scapegoat minoritized populations in the United States.^{14, 15, 16} This stigmatization of people who use alcohol or drugs, whether due to perceived moral failings or due to identification with a stigmatized minority group, created a climate in which abstinence was the only acceptable outcome for people who used drugs, and criminal law enforcement was seen as an acceptable means to facilitate this outcome.¹⁷ This emphasis on abstinence within our drug policies and treatment models continues today. 

Birth of Harm Reduction 

Harm reduction strategies such as methadone treatment were in place in the United States as early as 1964,¹⁸ but the birth of harm reduction as the movement recognized today is most often attributed to the initiation of syringe exchange in response to the HIV/AIDS crisis in the early 1980s.¹⁹ In 1980, groups in the Netherlands led by people who used drugs advocated for policy changes that would allow for the legalization of needle exchange to combat injection driven risk of HIV transmission. The US followed suit shortly after; creating underground networks of syringe exchange  led by people who used drugs, advocates, and grassroots organizations. Early  needle exchanges operated outside the purview of the law, and many early  advocates risked arrest and prison time.^{6, 19} It wasn’t until the late 1980s and the peak of the HIV/AIDS crisis that harm reduction and syringe exchange started receiving institutional recognition and support.²⁰ Despite growing evidence of the efficacy of harm reduction programs,^21,22 the federal government resisted funding and implementing harm reduction programs and syringe exchange programs, which prevented further expansion of harm reduction  services in the United States.²³ In 1998, the U.S. Secretary of Health and Human Services concluded that syringe exchange and harm reduction were both safe and effective, yet there is still a ban on using federal funding to purchase syringes, although federal funding can be used to support other functions of syringe exchange programs.^23,24

Components of Harm Reduction 

According to the National Harm Reduction Coalition, harm reduction is a fluid practice in which the interventions and policies are designed to match individual and community needs. Therefore, there is no universal definition or guide to practicing harm reduction. However, the following are core tenants of any harm reduction practice.^{1, 25} 

Patient-Centered Care 

A commonly repeated mantra of harm reduction practice is "meet people where they’re at." This may have literal implications, such as physically bringing services directly to the people that need them, but also speaks to an overarching philosophy of patient-centered care. The definition of patient-centered care is that a person’s specific health needs and desired health outcomes are the driving force behind all healthcare decisions and quality measurements. Harm reduction is, at its core, patient-centered care. In a harm reduction model, goals and desired health outcomes are set by the patient themselves as they then work with their provider to achieve that goal. Sometimes that goal may be complete abstinence, but often that goal falls somewhere else on the spectrum of drug use. By "meeting people where they’re at," harm reduction allows people to set the pace and direction of their own well-being.^{1, 25} 

Bottom-Up Approach 

From its inception, harm reduction has prioritized including and elevating the voices  and experiences of people who use drugs, and this continues to be an important cornerstone of harm reduction practice. The National Harm Reduction Coalition indicates that a core component of harm reduction practice should include ensuring  that people who use drugs and people with lived experience of drug use should be involved in the development and implementation of harm reduction programming.²⁵ In a harm reduction model, it is important to hire staff with lived experience of drug use, either past or present, and programs should regularly solicit input and  advice from the communities.²⁵ This can look like supporting patient advisory boards, conducting quality improvement surveys, or seeking input from participants   when developing new programming. In this model, providers and programs would  adapt services to fit what participants request. This goes beyond harm reduction  programs or treatment programs. In a harm reduction model, policy makers and governmental leaders would seek input and direction directly from the affected community. 

Low-Threshold Services 

Another key characteristic of harm reduction-based practice is making services and programs as low-threshold as possible. In a harm reduction context, low-threshold means that services should be welcoming and inclusive, that the range of services provided reflects the range of goals within the target population, and that the services are readily available to people when and where they need the service. This could look like same-day enrollment into detox, switching  to a walk-in model or having flexible policies for late or missed appointments, engaging with and bringing services directly into the communities that need them, and providing services for people who may still be actively using as well as for people ready to maintain abstinence.²⁶ Conversely, services that have a high bar for entry discourage anyone who isn’t at a high level of functioning from engaging in services, potentially excluding those who need services the most.²⁷ 

Judgement-Free Approach 

In a harm reduction model, services should be provided in a judgement-free way  that reduces stigma. Harm reduction posits that someone’s drug use history—what  they use, how they use it, how many times they’ve relapsed, and even whether or  not someone wants treatment—does not affect their value as a person and should not affect their ability to receive respectful and comprehensive services. One way that harm reduction practitioners work toward reducing stigma is by practicing  judgement free, person-first language. Terms like person with substance use disorder, person who uses alcohol, or person who uses drugs, are used in place of terms like addict, alcoholic, or abuser. Instead of using words like clean or dirty to refer to the results of a drug screen, advocates recommend simply stating whether the test was positive or negative.²⁸ This focus on reducing judgement toward people who use drugs is key to reducing the stigma and discrimination that have been shown to discourage people from seeking health services such as syringe exchange, hospitalization following an overdose, treatment for injection-related skin infections, and medication assisted treatment such as methadone.²⁹ Stigma and discrimination have also been associated with increased odds of overdosing, mental health issues, reduced engagement in care, and decreased well-being.^{30, 31, 32}

Summary 

Harm reduction strategies shift and adapt depending on the community of focus, making it difficult to define. However, at its core, harm reduction in any context is patient-centered care that implements a judgment-free and bottom-up approach to working with people who use drugs. A key characteristic of a harm reduction model is making services as low-threshold as possible so that they are accessible and sustainable for all people, at any point in their recovery journey. The harm reduction movement was built by marginalized communities of people who used drugs during the height of the AIDS epidemic and have faced political adversity over the past decades. While the most recognizable harm reduction interventions tend to be focused on injection drug use, harm reduction approaches have utility for people who use alcohol, tobacco, and other drugs, as well as those who partake in a variety of risky behaviors. In response to the current overdose crisis, harm reduction services have continued to expand in scope and funding, despite enduring controversy. However, this expansion is not uniform across the United States and is instead strongly tied to the political climate within individual states.