In her forthcoming book, Dr Sheila Vakharia presents her thesis of The Harm Reduction Gap – “the void in our current continuum of care between abstinence-based prevention programs and abstinence-only treatment programs, where people who currently use drugs are left without access to the knowledge, skills, and tools to stay safe”. In this edited excerpt, Dr Vakharia describes the ethos of harm reduction and the roots of the harm reduction movement.

Even if you’ve never heard of the term ‘harm reduction’ before, you have probably benefited from some harm reduction tools and practices in your day-to-day life. For instance, social distancing, wearing a mask, and vaccination are harm reduction strategies many of us have used to stay safe during the COVID-19 pandemic. Since we cannot eliminate the risk of catching the coronavirus, we learned which steps to reduce that risk as much as possible. Some familiar drug-related harm reduction examples include having a designated driver when drinking alcohol, and switching to nicotine gum instead of smoking cigarettes.

“The Harm Reduction Gap: Helping Individuals Left Behind by Conventional Drug Prevention and Abstinence-only Addiction Treatment” is published by Routledge

Harm reductionists know it is possible to arm those who use drugs with the tools and skills to stay as safe as possible right now. And they believe that this is far more practical and realistic than simply hoping people who use drugs can figure out how to keep safe on their own after they outgrow the ‘Just Say No’ and abstinence-only messages they’ve been inundated with since they were kids. Harm reductionists believe that anyone can be supported in being safer, including people who do not meet the criteria for a substance use disorder diagnosis and those who may not need formal treatment. It also means that harm reductionists are willing to help people without fixating on the unrealistic and overly idealistic belief that people with substance use disorders can be helped only if they agree to stop all drug use.

Harm reductionists advocate for dozens of broader policies at the local, state, and federal levels to promote community health and safety, such as those that provide supportive and affordable housing, guarantee a living wage, reform our criminal legal system, fund the social safety net, and expand access to healthcare and other lifesaving services. In addition, harm reductionists support drug policy changes that would end the criminalization of people who use illegal drugs. They also want policies to allow for a safer supply of drugs, be it through a legally regulated model and/or by having access to tools to test and check what is in the drugs they may choose to use. Harm reductionists want access to various non-stigmatizing, trauma-informed, evidence-based treatment options if they seek formal assistance for medical or mental health needs. Harm reductionists are critical of the widespread use of the criminal legal system to punish people through incarceration, surveillance, and lifelong criminal records when those resources could be more wisely spent on community enrichment for greater public safety and well-being. Together, these policies can help save lives by addressing our current health and social issues, improving the material conditions of our communities, and ensuring people feel safe when they seek help.

There are many incredible leaders, both past and present, who have made an impact on the harm reduction movement (1 2). Someone might reference the Young Lords and Black Panthers, who fought for community-driven care and shared resources in the 1960s and 1970s when government institutions failed to address poverty, food insecurity, and lack of healthcare in their communities. Others may look to the union junkiebond in the Netherlands that started the first needle exchange for people who inject drugs in the 1980s during hepatitis B and HIV outbreaks. Many of us were introduced to harm reduction by the LGBTQIA+ and sex worker mutual aid groups who passed along the first ‘bad date’ lists and helped one another stay safe on the streets, or we may draw inspiration from the ACT UP activists who fought for access to HIV/AIDS treatments and funding in the 1980s and 1990s. Others were moved to do this work by great individuals like Edith Springer, Imani Woods, Joyce Rivera, Alan Marlatt, Keith Cylar, Dan Bigg, and Dave Purchase. Others followed the lead of the Vancouver activists who opened the first overdose prevention centers in North America, or the harm reductionists who started underground naloxone distribution among people who use drugs. Meanwhile, some of us joined the movement because it saved our lives; perhaps the local harm reduction program supported us when we needed it the most. Regardless of the individuals or groups one credits as their inspiration or entry point into harm reduction, many core values and principles guiding early harm reduction practice and advocacy still inform the work today.

Harm reduction is an ethos of unconditional care with deep roots in mutual aid and a commitment to building power within communities through shared knowledge and resources. It was born from low-income communities that were criminalized, marginalized, and subjected to structural violence due to their drug use, as well as from their racialized identities, being LGBTQIA+, engaging in sex work, working in other underground economies, and/or being unhoused. In the face of criminalization and oppression, these communities developed strategies to navigate myriad risks and dangers, such as:

  • the unpredictability of the illicit drug supply
  • a lack of sterile syringes and other drug-using equipment
  • interpersonal and state violence
  • the constant threat of police contact and criminalization
  • poverty and financial instability
  • a lack of safe and stable housing
  • the risk of HIV and other blood-borne or sexually transmitted infections
  • a lack of access to health and mental healthcare
  • and much more

Thousands were doing this work and helping one another to stay safe long before the term ‘harm reduction’ was coined in 1987, and countless people are doing this work around the world every day without using the term or label. The ‘harm reduction movement’, as we know it, is simply an extension and a recent iteration of generations of resistance, advocacy, and mutual aid movements among marginalized communities who could not rely upon formal institutionalized structures and systems to meet their needs. For decades, harm reductionists have taken matters into their own hands while navigating systems that did not acknowledge their humanity and actively threatened their fundamental rights to health and safety. Fundamentally, harm reductionists have always understood that we are all safer when we find solutions together and resist the forces that oppress us, marginalize us, and neglect our needs.

by Sheila Vakharia

This extract was edited for the SSA website by Natalie Davies. The book, “The Harm Reduction Gap: Helping Individuals Left Behind by Conventional Drug Prevention and Abstinence-only Addiction Treatment”, will be published by Routledge on 9 February 2024, and is available for pre-order in paperback and eBook format from 19 January 2024.

Sheila Vakharia PhD MSW is an author, speaker, and expert on harm reduction and drug policy. She is currently the Deputy Director of the Department of Research and Academic Engagement at the Drug Policy Alliance – a US advocacy organisation fighting to end the war on drugs. Dr Vakharia brings over 15 years of combined experience in clinical social work in both treatment and harm reduction settings, research, teaching, and policy advocacy to her work.

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