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Strategies and practices to reduce harm are evident in just about every area of our lives. Whether it鈥檚 seat belts, helmets, hard hats, or sunscreen, the United States has adopted rules, regulations, and recommendations that reduce the harm or potential harm of day-to-day activities. 

Recently, there鈥檚 been a concerted effort to reduce the harm of the ongoing opioid crisis.

The U.S. Department of Health and Human Services  in the United States die every day from opioid-related drug overdoses, a statistic that prompted the department to label the opioid crisis a . With opioid-related deaths reaching critical levels, it鈥檚 apparent that existing substance abuse treatments and detoxes are not a catchall solution, which is why advocates and health officials have turned to evidence-backed harm-reduction techniques.

The National Institutes of Health defines  as a public health strategy developed for adults with substance abuse problems for whom abstinence is not feasible. The intervention philosophy includes a set of policies and programs that aim to reduce the negative health and social consequences of drug use without necessarily reducing drug consumption. 

Harm reduction is not treatment, but studies have shown that drug users who engage with harm reduction services are  than those who do not.

What鈥檚 available now

Syringe exchanges have been used as a strategy for more than 30 years. The programs started in the 1980s as a way for injection drug users to dispose of their used needles and receive clean needles. Communities have developed exchanges 鈥攂lood-borne diseases that can be spread through shared needle use.

Studies show that syringe exchanges  and other blood borne diseases,  in areas surrounding the exchange, and can  a drug user does per day.

While  since the 1990s, they are still illegal in 11 states, including Arkansas, Iowa, and Texas. When the first U.S. needle exchange opened in Washington in 1988, the federal government placed a ban on the service, stating that it . Not until 2010 was legislation passed to lift the federal ban鈥攁t least partially, allowing needle exchanges to be federally funded as long as .

Under the federal ban, needle exchanges either operated under local laws that allowed the service or existed illegally鈥攕uch as current . But, as the number of overdose deaths continue to rise, states are starting to repeal their bans, Idaho and Georgia being the most recent to do so in 2019.

People鈥檚 Harm Reduction Alliance, a syringe exchange based in Seattle, has followed a drug user-centered model since its inception in 2007 by requiring 51% of the organization be ran by active drug users.

鈥淵ou wouldn鈥檛 have any other service serving a population without that population being involved in the decision making process and policy changes,鈥� alliance director of operations Lisa Al-Hakim says. Unfortunately, Al-Hakim says, drug policy has historically been made by people who haven鈥檛 been drug users and don鈥檛 understand the experience and needs. 

For example, most syringe exchanges implemented by public health departments follow a 1:1 needle exchange, meaning drug users can only receive as many needles as they return. However, carrying used syringes is illegal and can result in a felony charge. Al-Hakim said drug users pointed out that needle exchanges were asking participants to put their freedom at risk to use the services.

People鈥檚 Harm Reduction Alliance operates as a need-based needle exchange, meaning they don鈥檛 require used needles to be returned to provide clean needles. Instead, they provide people with as many needles as they request. The organization鈥檚 limit is 300 syringes per person per day, but only because they don鈥檛 have an unlimited supply of needles. That high bar allows people to stock up on clean needles if they won鈥檛 be able to access the service for a while, lowers the likelihood of the clean needles being resold on the street, and establishes the alliance as a service that trusts injection drug users to know their own needs, Al-Hakim says.

Distribution patterns depend on each person鈥檚 situation. Housed people using the needle exchange may take 300 syringes once a month and keep their home stocked, while unhoused people who are more likely to have interactions with the police or be swept from a homeless camp may take a box of 10 every other day. PHRA鈥檚 site in Seattle distributes an average of 170,772 syringes to 1,343 people per month, Al-Hakim says.

A common fear of need-based exchanges is that if drug users aren鈥檛 required to exchange their syringes, then more used syringes will be disposed of improperly. The alliance proves that wrong.

鈥淏eing need-based, we actually get more used syringes returned to us than we give out,鈥� Al-Hakim says. The CDC considers a 90% syringe return rate a success and the alliance has maintained a 98% return rate at their Kitsap County location, and has seen return rates over 100%.

Al-Hakim believes that the organization sees so many returns because of the trust and respect that has been fostered through the community.

鈥淭he most important thing you do in harm reduction is not the things you hand out, it鈥檚 the relationship[s] you build,鈥� says Al-Hakim, highlighting the support and unconditional love that the alliance fosters.

On a cold February evening, Ronald St. Clair visited PHRA鈥檚 Seattle location to gather some supplies. The exchange is a small table set up underneath an awning outside of a storage room in the basement of a church. The table has self-serve boxes for supplies that don鈥檛 have restricted quantities, including ties, paper clips, cookers, and cotton swabs. Everything else is supplied by the people staffing the exchange.

St. Clair is a semi-regular at the exchange鈥攈e was greeted with excited hugs when he walked up to the table鈥攁nd says he chooses to use the service because of the quality of the equipment and community.

鈥淭he [syringes] they sell in the store are cheap and crack easily,鈥� St. Clair explained, adding that PHRA鈥檚 equipment is the best he can get. 鈥淧lus, you get to meet cool people.鈥�

Because of the judgment drug users often receive when trying to access medical care, the alliance has expanded into a multiservice health care center, offering a same-day clinic, mental health services, case management services, fentanyl test strips, and Narcan, an overdose reversing drug. The organization also provides pipes for smoking meth, crack, and heroin. Providing effective pipes for drug users is a harm-reduction technique because it can keep people from switching to injecting.

鈥淲e鈥檝e branched out to a lot of stuff because a lot of syringe exchanges and harm-reduction programs have become people鈥檚 primary health care because they鈥檝e been treated badly when they go into a hospital setting or a clinic setting because they are drug users,鈥� Al-Hakim says.

When it comes to changing perception and influencing local policy, Al-Hakim advises harm-reduction advocates align themselves with health professionals such as hospital staff and public health leaders who both understand the evidence backing harm reduction and who the public look to as professionals. 

鈥淎 health board can make or break you,鈥� she says.

What鈥檚 to come

While syringe exchanges continue to morph into comprehensive harm-reduction health centers, some cities are preparing for the next level: safe injection sites.

A safe injection site is a designated space for injection drug users to self-inject drugs under the supervision of medically trained staff. If a patient overdoses, the staff will be able to revive them, saving their life. The site also has other harm reduction services, such as drug testing for fentanyl and connections with other community resources. 

Although the idea of a safe injection site has triggered fears of radical enabling, more than  have found that the presence of supervised injection sites increased access to health care for the most marginalized intravenous drug users and reduced overdose frequency. The same studies stated safe injection sites were not found to increase drug injecting, drug trafficking or crime in the surrounding area.

Most of those studies focus on Insite, a safe injection site in Vancouver, British Columbia. Insite was the first site to open in North America in 2003. While its success has prompted more sites to open, .

Insite is operated and funded by Vancouver Coastal Health, a health authority that provides senior administrative and health care workers at the site. The site is a cliniclike setting with partitioned metal tables where people can self-inject drugs and a secondary 鈥渃hill-out鈥� room where they are observed for potential overdose after injecting. In November 2019, 鈥攁&苍产蝉辫;, meaning an estimated 813 people visited the site in November. Of those visits, 92 overdoses were reversed. According to Vancouver Coastal Health, there have been , 6,440 overdose interventions, and no deaths since it opened in 2003.

Insite also takes a multiservice approach, offering detox and drug treatment programs on the upper floors of their three-story building and providing wound care and drug testing for fentanyl or other substances on their lower level.

While Insite is a necessary service, says Dr. Mark Lysyshyn, a medical health officer at Vancouver Coastal Health who helps develop public health responses to the opioid crisis, it鈥檚 not adaptable to the current needs of the opioid crisis.

鈥淚t鈥檚 difficult for places like Insite to innovate because they are subjected to such firm regulation by people who really don鈥檛 understand the services there,鈥� Lysyshyn says. 鈥淭he emerging models are different, they are much more community-based, lower barrier, and they don鈥檛 necessarily have health care workers working them.鈥�

According to Lysyshyn, the real innovation has come from Vancouver鈥檚 overdose prevention sites鈥攕ites that were started under an emergency order issued to combat a surge in overdose deaths in 2016. The overdose prevention sites are technically illegal, but Lysyshyn says the health authorities such as Vancouver Coastal Health have an agreement with local law enforcement that federal drug laws won鈥檛 be enforced at the sites. 

Because the overdose prevention sites were sanctioned to handle an emergency, the sites are less bound by regulations, allowing Lysyshyn and his colleagues to respond more fluidly to the needs of Vancouver鈥檚 drug users. Whereas it took five years of community consultations and planning to develop Insite, Vancouver Coastal Health was able to open a women鈥檚 only site, several hot spot sites, and peer-to-peer sites as soon as the materials and staff were coordinated.

Lysyshyn says the emergency sites have had no community pushback because they have been strategically placed 鈥渨here previously there were dead bodies.鈥�

鈥淵ou need both of these models,鈥� he says. 鈥淭he overdose prevention sites are really an emergency response model and Insite is more of a permanent solution.鈥�

Safe injection sites in the U.S.

Cities such as Philadelphia, San Francisco, New York, and Seattle have made preliminary moves to open safe injection sites, but local efforts have been  citing a statute referred to as the 鈥�.鈥� The ruling, created in 1986, prohibits proprietors from knowingly leasing or providing spaces for manufacturing, selling, or using illegal substances.

In October 2019, however, a  because the safe injection site鈥檚 exclusive purpose is to provide medical care, not facilitate illegal drug use. While that ruling provides protection for the facility itself, the people who work in the facility could still be prosecuted.

鈥淚 think it鈥檚 the philosophical opposition to the idea that you鈥檙e allowing people to facilitate drug use,鈥� Lysyshyn says about the strong opposition to safe injection sites in the U.S. 鈥淓ssentially you are doing that, but you鈥檙e allowing people to stay alive. No one can recover from drug use if they are dead.鈥�

In San Francisco, a coalition of social services aimed to change that opposition by building a mock safe injection site in 2018. 

鈥淧eople who were fearful of the injection sites admitted that in their mind when they thought of an area where people could inject drugs, they had those pop culture ideas of opioid dens and shooting galleries,鈥� says Kenneth Kim, the program director for Glide, one of the community organizations that led the mock site project, called Safer Inside.

A couple months before the mock site opened, a made the rounds in local news. When community members heard of an overdose prevention site where drug users were allowed to inject, that was the image they thought of.

Instead, tour participants saw stainless steel tables, well-lit spaces, and medical equipment similar to what one would see in a doctor鈥檚 office. Kim remembers several tour participants being surprised at how medical and sterile the mock site was. The results were promising, with several community members indicating they were interested in seeing the site open as soon as possible.

While Kim says some legislative movement right occurred after the opening, that momentum has decreased, leaving Glide and the other local organizations in the planning and public education stage. Kim says Glide is planning as extensively as possible, so when they get the green light from local lawmakers the site can be up as soon as possible. A major part of the planning, Kim says, is jumping in where leaders like Insite are now, not where they started from, and taking advice from drug users.

鈥淚t鈥檚 not enough just to build it, you also have to consider service design and what that experience is for those folks to encourage its use and effectiveness,鈥� Kim says. So far, that has meant advocating for several different types of sites like the emergency sites Lysyshyn mentioned, and modifying the design of the brick-and-mortar site to fit the requests of drug users, such as adding more flat surfaces for unhoused users to reorganize and pack their bags before they leave.

In the meantime, the organizations will continue to dispel myths about safe injection sites鈥攊ncluding that a site would increase or glorify drug use鈥攚ith education campaigns. 

From Canada, Lysyshyn points out that people are dying from preventable overdose death every day, and he encourages Americans to advocate for their emergency sanctions and develop these services without the support of the law.

鈥淥nce you start operating these sites and collecting data and showing people that you鈥檙e saving lives every day, it actually becomes very difficult to close them because those would be dead bodies on the streets,鈥� he says.