Since the start of President Donald Trump’s second term, advocates have documented major cuts to the U.S. Centers for Disease Control and Prevention (CDC), the National Institutes of Health (NIH), and the Substance Abuse and Mental Health Services Administration (SAMHSA)—all of which contribute to a nationwide network of addiction support services. The attacks have impacted federally funded programs rooted in harm reduction care, a public health approach to substance use that aims to reduce the consequences of drug use rather than requiring abstinence. The cut to harm reduction services, disguised as curbing efforts that “facilitate illegal drug use,” has been devastating to organizations across the country that provide interventions like syringe exchanges, naloxone kits used to reverse opioid overdoses, fentanyl testing strips, and supervised consumption sites. The goals of harm reduction include reducing overdose deaths and preventing the spread of diseases that can be transmitted through injection, including hepatitis C and HIV.
The National Harm Reduction Coalition (NHRC) was founded in 1993 in response to the AIDS epidemic. The organization addresses the impacts of substance use among individuals and communities through a public health and social justice lens—confronting the ways poverty and the lack of access to health care and housing exacerbate drug-related harm. As a result of the attacks on harm reduction efforts, the organization has lost more than $560,000 in federal funding. The Progressive spoke with Laura Guzman, NHRC’s executive director, in March. This interview has been edited for length and clarity.
Q: Can you explain what harm reduction is?
Alexa Treviño
Laura Guzman: [Harm reduction is a] framework that upholds the dignity and respect of people who use substances, and also upholds, in particular, their autonomy with regard to their substance use. We seek to minimize those harms by developing interventions and particular services that have been really impactful in the past thirty years to show that harm reduction can prevent hepatitis C, HIV, and overdoses, and overall create conditions so that people who use drugs can hopefully live wonderful lives.
We don’t condone or condemn drug use; we accept it as a reality that people use drugs—humans have been using drugs since we’ve been humans. We work to minimize harmful effects [of drug use], rather than ignoring or condemning [the users]. We also believe that services should be nonjudgmental and noncoercive. We like to provide resources like syringe exchange or naloxone distribution without moralizing or enforcing, and ensuring a stigma-free, come-as-you-are environment. These are two very important and, at this moment, challenged principles, because we continue to see incredible stigma directly impacting people who use substances. And we [as a society] are going back to this idea that hasn’t worked—and it doesn’t work—which is to coerce treatment on folks.
We also prioritize quality of life and overall well-being, rather than just demanding the cessation of drug use. User involvement [is important]: ensuring that people who use drugs and those with lived experience have a central voice in designing and implementing policies and programs, because they know it best. They’re experts in their experience. We treat individuals who use drugs as the primary agents of reducing their own harm. We believe in fostering their self-determination, and, equally important, addressing social inequalities. We recognize that systemic issues like racism, poverty, and social isolation all directly affect a person’s vulnerability to harm.
Q: What do you say to somebody who is unfamiliar with harm reduction and believes it does “facilitate illicit drug use,” as the White House says?
Guzman: Harm reduction is a pragmatic, realistic, evidence-based approach, which is designed to minimize the negative health, social, and legal impacts associated with drug use and other high-risk behaviors. We prioritize the safety, dignity, and human rights of individuals without requiring immediate abstinence or punishing relapse, because we know that doing so is not realistic, and punishing relapse actually makes it worse for some people, to the point of losing their lives.
We believe in a compassionate approach that meets people where they’re at but doesn’t leave them there; that continues the engagement of people while we provide an array of services that are critically important. It’s not just drug treatment. For a lot of people, sometimes being housed or sheltered is their primary need, and then, once they’re stabilized, we can get them to engage in considering treatment.
Q: What does coercion look like today?
Guzman: We have seen a renewed interest in policymaking by politicians, where they’re coming back to criminalizing people who use drugs—between the carrot or the stick, at this point it is the stick. There’s this idea that if you force treatment, people recover. This is quintessentially different from research of sixty-plus years that shows that—not just with substance use, but for any behavioral change—it really requires that people are ready, willing, and able. Therefore, mandated treatment does not result in immediate positive results in which people go through something like drug court, and immediately give up using substances. We know that those kinds of changes are gradual, that they’re very unique and individualized, and that a lot of barriers get in the way for people.
For example, we provide capacity building to syringe service programs that are working in California, with a population that is 75 percent unhoused, and many of them are unsheltered. Even if they’re ready, willing, and able to engage in drug treatment—let’s say with methadone—the barriers, such as transportation and stigma, that still exist for them to go through those treatments are so impactful that even if you mandate treatment, people might not be able to. Methadone is a good example: You have to get to a place that administers it and dose your medication at six in the morning every day.
This illusion that mandated treatment will result in everyone being treated and drug-free is actually an oxymoron. It does not exist in general, let alone for people who are poor and impacted by substance use.
Q: What does harm reduction look like in practice?
Guzman: I’m going to start with an example that we pioneered as a harm reduction movement, which is putting naloxone distribution in the hands of the community. Until probably the early 2000s, in the United States, the only people that carried naloxone were EMTs and paramedics. Naloxone was not a medication that could be put in the hands of people who use drugs. In the early 2000s, some key people in our movement managed to bring naloxone from Italy, which was distributed among people who injected drugs. We started to do the training and provide kits to reverse opioid overdoses; today, naloxone distribution and overdose prevention is a key example of harm reduction in practice even though the federal government is separating overdose prevention from harm reduction.
Syringe service programs are really critical harm reduction programs, because they provide sterile needles to reduce HIV and hepatitis C transmission. [Syringe service] has also evolved into what we call “safer use supplies.” We also distribute smoking kits to prevent, in particular, hepatitis C transmission for people who smoke or inhale certain substances.
Newer in the last ten years has been [the development of] drug-checking community services. Across the country, we have harm reduction community programs. University of California, Los Angeles, has a particular drug check-in service where we go into the community and on the streets and use test strips for fentanyl or xylazine. This is the best way for people on the ground to know whether their substances are tainted. Drug check-in services are critical, because as we keep criminalizing drugs, a more tainted and dangerous drug supply emerges. The more that we see the criminalization of illicit drugs, the more we see the creativity of drug dealing that actually develops even more lethal drugs, because they tend to be more synthetic, and they tend to be in combination—creating real-life challenges to people who are affected by substance use.
There’s also medication-assisted treatment, providing methadone or buprenorphine for addiction. We have been supporting the liberation of methadone [distribution] because it is currently provided in a way that is very punitive.
Then, and these are still very controversial, supervised consumption sites or overdose prevention centers that offer a safe medical setting to reduce fatal overdose risk.
Q: How is the current presidential administration approaching harm reduction programs?
Guzman: Before this administration, there were small steps in the right direction from the federal government in that they had been allocating money—though not an incredible amount—to SAMHSA and the CDC. There was an effort toward having more funding available to support harm reduction, with real guidelines that could support how funding is allocated. That increase in funding was absolutely reversed by the Trump Administration. There has been a clear target on harm reduction. In spite of showing almost forty years of evidence-based positive health impacts in the lives of people who are affected by substance use, harm reduction is now named as a nonevidence-based practice.
There has been continuous funding of overdose prevention efforts, but separated from harm reduction. There were clear guidelines through SAMHSA last year that deprioritized harm reduction as a funding field. States that receive block grants from SAMHSA are also now instructed to change their priorities or otherwise change the way that harm reduction is described. This administration has decided that anybody in the field of housing, homelessness, and harm reduction—that is what they call “enabling illicit drug use”—should be defunded, should not be prioritized. This has had devastating consequences across the country, but it’s also pushing the envelope in states and localities.
Q: How has that influenced your operations as an organization?
Guzman: We’re operating with a deficit and trying to see how to redirect our work toward other funding. [A project we were working on] is now devoid of the wisdom and the skill set that staff in recovery programs, treatment programs, and overdose prevention programs could have received from the National Harm Reduction Coalition.
Our hope is that the public gets informed and doesn’t follow the delusion of criminalizing, punishing, and enforcing—which will not result in what people want to see. We hope everybody wants to see our communities thriving. We know what it takes to get people to stay alive and live healthier lives. It’s very important that people do more due diligence in reading between the lines. We’ve done criminalization, we’ve done forced treatment, and it hasn’t worked, and it hasn’t resulted in people being safer. When our most vulnerable people are not safe, none of us are safe.