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Messaging on Harm Reduction: How to Talk to Stakeholders

By: Sarah White

Harm reduction is a social justice movement centered on respect for people who use drugs; in part, it aims to reduce the negative consequences related to drug use, like overdose and infectious disease transmission from injection drug use, without seeking to stop drug use itself (See Harm Reduction 101).

 As part of their response to stark increases in the rate of overdose deaths, the U.S. federal government has incorporated harm reduction in its Overdose Prevention Strategy for the first time. This national strategy includes permitting federal funds to be spent on fentanyl test strips, distributing grant funding for syringe service programs and naloxone distribution, and supporting research networks focused on harm reduction.

Despite harm reduction’s demonstrated effectiveness at reducing overdose deaths, the U.S. has been slow to adopt harm reduction interventions in many locations in need. Slow adoption has been driven by interrelated factors including: stigma towards people who use drugs; the historical framing of drug use as a moral failing; and the corresponding preference for interventions aimed at abstinence from drug use. As states and local governments think of investing opioid settlement dollars, policymakers and advocates should consider what the evidence says about harm reduction messaging and how to promote opioid abatement strategies backed by science. 

Addressing Stigma

Messages used to communicate about harm reduction are critical in garnering public support in the U.S. for adoption of harm reduction approaches. Previous studies have demonstrated that messaging strategies can increase public support for particular harm reduction interventions, like naloxone distribution and safe consumption sites, through factual messages about harm reduction and sympathetic narratives humanizing people who use drugs. Another study found that messages re-framing “safe consumption sites,” where people can legally use pre-obtained drugs under medical supervision, as “overdose prevention sites” increased audience support for legalizing these sites. However, a study conducted in 2017 showed that U.S. adults found arguments against harm reduction services (e.g., that they enable drug use) more persuasive than arguments supporting their implementation (e.g., that they prevent overdose deaths).

While the limited previous work has measured the effectiveness of messages related to particular harm reduction interventions, no prior work has tested the impact of messages describing harm reduction interventions as integrated programs that include connections to drug treatment and social services. In a recent study from the Johns Hopkins Bloomberg School of Public Health’s StigmaLab, we conducted a mixed methods study to better understand how to effectively communicate on harm reduction. We fielded a survey to a nationally representative online panel of U.S. adults to test the effectiveness of a series of messages that were developed based on interviews with harm reduction advocates from across the country.

Qualitative Interviews with National Experts

In the first part of this study, we conducted qualitative interviews with harm reduction advocates from across the nation including leaders from organizations focused on advocacy and implementation of harm reduction services, drug policy, or other similar topics like mental health services or hepatitis prevention. When describing their previous work, nearly all interviewees had experience advocating directly to policymakers at the national- or state-level, two-thirds had advocated for implementation of services at the local-level, and two interviewees were members of Survivors’ Unions, which include local advocacy chapters of people who use drugs. Overall, interviewees agreed that messages focusing on the scientific evidence of the effectiveness of harm reduction approaches are important but insufficient to persuade audiences. 

Interviewees stressed the need for tailored message strategies to four key audiences: policymakers; law enforcement; religious groups; and the family and friends of people who use, or have used, drugs.

  • Messages for Policymakers: For policymakers, interviewees noted that arguments on the cost-effectiveness of harm reduction interventions, or a “value-for-money” framing, were sometimes useful. However, interviewees also reported that these messages should be paired with meaningful stories from constituents and messages emphasizing harm reduction’s role in promoting their community’s goals. Further, interviewees stressed that, while not always effective, it was critical to be able to cite specific data regarding the efficacy, cost effectiveness, and impact of the harm reduction interventions being discussed.
  • Messages for Law Enforcement: For law enforcement, interviewees recommended framing harm reduction as a set of interventions that contribute to public safety, including the safety of both communities and officers. Interviewees’ examples included messages about how overdose prevention centers can decrease public drug use and its impact on officers and communities, and messages about how syringe service programs can decrease officers’ (and communities’) contact with used syringes. Interviewees also recommended focusing on “any positive change” with law enforcement audiences, noting that support from audiences in the criminal justice system is often more muted than other audiences.
  • Messages for Religious Groups: For religious groups, interviewees recommended tailoring messages toward the compassionate values of that religion. Interviewees primarily discussed strategies for U.S. Christian audiences and framing harm reduction as aligning with Christian values around redemption. Interviewees highlighted international examples of faith leaders championing harm reduction programs, as well as domestic examples like Project Lazarus and Faith in Harm Reduction. However, interviewees also recognized that harm reduction efforts have historically been less accepted by U.S. individuals who identify as religious conservatives. Advocates expressed a particular need for individuals trusted by this audience, like religious leaders, to deliver authentic messages that resonate with the compassionate values of their religion.
  • Messages for Friends and Family: For family and friends of people who use drugs, interviewees reported framing harm reduction as an approach that values the life of their loved one. Interviewees noted that they often encounter, and must attempt to counter, oppositional messages that drug use devalues a person’s life. These oppositional messages may have previously resonated with the family and friends of people who use drugs; so, an additional strategy noted by interviewees as helpful for loved ones was utilizing stories of “changed minds”—peers in similar family situations that changed their minds about the value that harm reduction could provide to their loved one and their family.

 Interviewees also reported it was persuasive in their experience to position harm reduction as part of the comprehensive solution needed to address concerns of drug use and overdose in their community. Interviewees noted that audiences’ concerns were often influenced by personal and anecdotal experiences, and that persuasive messaging strategies should address the concerns raised by those experiences. For example, when audience concerns focused on enabling drug use, interviewees described contextualizing how harm reduction does not encourage new users and offers needed, immediate, and integrated support to people in their community. 

Testing Harm Reduction Messages

Following the best practices recommended by national experts through our qualitative interviews, we developed a set of messages and tested them using a nationally representative online panel of U.S. adults to measure their perceptions of and support for harm reduction.

Experts recommended we test messages that provided facts about harm reduction services and a narrative that humanizes someone benefiting from harm reduction engagement. For this, we developed a narrative of a mother whose son began using drugs in high school and dropped out before receiving his diploma; the narrative occurs in the emergency room following an overdose with the mother being referred to a harm reduction program by a nurse and the mother feeling hopeful for the first time in a long time following the encounter.

Messages included:

  • Facts about harm reduction services.
  • Facts about harm reduction services integrated with social services and drug treatment.
  • Facts about harm reduction + the narrative ending with the son engaging in harm reduction services.
  • Facts about harm reduction integrated with social services and drug treatment + the narrative ending with the son engaging in harm reduction services and being connected to a GED program.
  • Facts about harm reduction integrated with social services and drug treatment + the narrative ending with the son engaging in harm reduction services, being connected to a GED program, and ultimately entering addiction treatment.

Each narrative included a picture of the mother telling the story so we included a picture that depicted the mother as either Black or white. The three groups that read the narrative messages were equally split between those that depicted the mother as Black versus white to see if race had an impact on the narrative’s impact.

What Kinds of Messages Work Best?

We found that all messages, including factual messages and the factual messages paired with narratives, increased U.S. adults’ perception that overdose deaths can be effectively reduced using an integrated approach that includes harm reduction, social services, and addiction treatment. Two of the three narratives (but none of the factual messages) increased individuals’ perception that harm reduction alone can effectively reduce overdose deaths. 

We found that all messages reduced willingness among U.S. adults to have a harm reduction program in their neighborhood. Further, in two of the three narratives, willingness among respondents was  significantly reduced when the mother was depicted as Black versus white. 

The findings of this study suggest that messages framing harm reduction as part of an approach integrated with connections to social services and drug treatment can have mixed effects on public attitudes about harm reduction. These messages increase U.S. adults’ perception that an integrated approach is effective at reducing overdose deaths but simultaneously increase not-in-my-backyard attitudes towards having a harm reduction program in their neighborhood.  We found minimal difference on the impact of narratives that did versus did not frame harm reduction as a stepping stone to drug treatment, suggesting that there may be openness to the value of harm reduction independent of drug treatment. Finally, we found high support for increasing government spending on an integrated approach to reducing overdose deaths across all sampled U.S. adults despite our tested messages not increasing support further. 

Read the full article on the qualitative interviews here and the survey experiment here.

Sarah White is a Research Associate in the Department of Health Policy and Management at Johns Hopkins Bloomberg School of Public Health. Her work has focused on the implementation of state policies on substance use disorder treatment, understanding the impact of policies on patients with chronic pain or substance use disorders, and developing an evidence-base for communication strategies on harm reduction and medications for opioid use disorder.