What do overdose survivors say about harm reduction programs?

August 2, 2022

Fatal drug overdoses have reached record highs, accounting for over 100,000 American lives in 2021. Harm reduction organizations (e.g., syringe services programs) have operated in the US since the late 1980s and have expanded widely in recent decades despite a lack of federal funding and remaining illegal in many states. Harm reduction organizations provide critical low-threshold overdose and infection prevention services including access to sterile syringes and other sterile drug supplies, access to naloxone (an overdose reversal medication), access to fentanyl test strips (a tool to test drugs for fentanyl, a highly potent synthetic opioid), and referrals to health providers or social services.

Decades of research has documented that harm reduction organizations are highly cost-effective, reduce the risk of HIV and HCV infection, facilitate substance use disorder treatment initiation, reduce overall health costs, and can reduce fatal overdose. Expanding support for harm reduction is one of the Core Strategies, or approved uses, of settlement funding.

The voices of people with lived experience can help inform funding priorities across states (see Principle 5). Researchers from the Bloomberg School of Public Health’s Bloomberg Overdose Prevention Initiative team recently interviewed opioid overdose survivors (N=23) to learn about their overdose experiences and use of harm reduction and substance use disorder treatment services during the COVID-19 pandemic.

Many organizations closed for a variety of reasons during the pandemic, reducing access to substance use disorder treatment and other services. In contrast, participants often noted their harm reduction programs largely continued to provide critical services.

But they (the harm reduction program) didn’t just shut down… It’s still pretty accessible. It was great that they didn’t close down. Because even our medical detox is closed. 

– 33-year-old Hispanic female, Michigan

Other participants described some changes in their program’s operating models, including curbside delivery or appointment-only services, a modification that some participants found more convenient. However, a few participants noted intermittent shortages of supplies (e.g., sterile syringes and naloxone), indicating the need for further support for programs across states.

We have it (naloxone) in the house. I have it very available, from the health department exchange down there… You just got to tell them you used it and why and where, and they’ll re-up you. Right now they don’t have a long rig (hypodermic needle), so I ain’t going to the health department. And so the availability is kind of down. 

– 66-year-old White male, West Virginia

Some participants having trouble obtaining supplies found a solution in harm reduction programs that delivered supplies to their homes. These services are currently not available or legally authorized in all states.

They (the mail-delivery harm reduction program) would say, “How many do you need? We like to send a month’s worth of clean supplies,” or something like that. And so we’re like, “We need 300 needles,” and they would send it to us, no questions asked. It would be so stinking helpful. I literally cannot thank them enough. And if I ever win the lottery, I definitely want to make a big donation to them because they’re awesome establishments. 

– 23-year-old white female, Maine 

Some participants described not feeling safe sharing that they had experienced an overdose with their treatment provider for fear of dismissal but felt safe confiding in harm reduction program staff. Thus, the trust and rapport between programs and people who use drugs are potentially life-saving.

They’re all really wonderful people. Like I tell them, hopefully when I am clean, I’ll still come visit you guys at work. It won’t be about this stuff, but hopefully, I will. 

– 30-year-old Hispanic female, New Mexico

Access to harm reduction services is critical in mitigating the risk of infection and overdose. One participant noted that if she’d had earlier access to harm reduction services, she likely would not have acquired HIV. Addressing stigma through education about the evidence-base for harm reduction organizations can help effectively scale up programs across states.

I just want them (people) to know that the harm reduction and the needle exchange program is something that is [critical] to saving lives and keeping down diseases… They’re not supplying their habit or encouraging it. That is something that is needed out there desperately. I ended up contracting HIV while being out there…So I’m a big supporter of it…It’s a great program. It’s needed. Had it been around whenever I needed it, I might not be HIV positive today. Even though I’m sober today, I think that it’s something I fully support.  

– 41-year-old white female, Ohio

Evident in these quotes, harm reduction organizations provide critical low-threshold services for people who use drugs. However, many current state laws do not adequately support the full range of harm reduction services. These insights from people who use drugs and who are directly impacted by the overdose crisis also highlight the importance of including people with lived experience in spending decisions (see Principle 5).

How can states, cities and counties support harm reduction? First, they should review existing policies to ensure harm reduction programs can operate effectively. 

1. Legally authorize harm reduction organizations to operate (without requiring further approval by local authorities), distribute all types of equipment (e.g., sterile syringes, pipes, and fentanyl test strips), provide safe places to use drugs, and provide drug checking services.
2.  Legally authorize harm reduction services to be delivered by any organization (e.g., community based organization, health department) through any modality (e.g., mail order delivery, mobile services, vending machines, retail pharmacy).
3. Amend paraphernalia laws that criminalize the possession of drug equipment that may be obtained from a harm reduction organization.

When exploring funding investments of litigation dollars, jurisdictions can:

1. Target unrestricted funding from the opioid litigation to scale up harm reduction in areas with the greatest need.
2. Invest in anti-stigma campaigns to improve support for the people who use harm reduction services.

Samantha J. Harris, PhD, MPA, the contributing author of this post, is a health policy and management researcher at the Johns Hopkins Bloomberg School of Public Health. Her work focuses on the organization and delivery of substance use disorder and harm reduction services. She is currently a postdoctoral fellow working with the Bloomberg Overdose Prevention Initiative, a collaborative partnership to reduce fatal overdose across states. The results in this post are from the COVID HARTS project, with Principal Investigators Susan Sherman and Brendan Saloner.