Helping Drug Users Survive, Not Abstain: ‘Harm Reduction’ Gains Federal Support

GREENSBORO, N.C. — The thin young man quietly took in the room as he waited for the free supplies meant to help him avoid dying: sterile water and cookers to dissolve illicit drugs; clean syringes; alcohol wipes to prevent infection; and naloxone, a medicine that can reverse overdoses. A sign on the wall — “We stand for loving drug users just the way they are” — felt like an embrace.

It was the first day the drop-in center in a residential neighborhood here had opened its doors since the coronavirus forced them shut in the spring of 2020. “I’m so glad you all are open again,” the man, whose first name is Jordan, told a volunteer who handed him a full paper bag while heavy metal music riffed over a speaker in the background. He asked for extra naloxone for friends in his rural county, an hour away, where he said it had been scarce throughout the pandemic.

Overdose deaths rose by nearly 30 percent over the 12-month period that ended in November, to more than 90,000, according to preliminary federal data released this month — suggesting 2020 blew past recent records for such deaths. The staggering increase during the pandemic has many contributing factors, including widespread job loss and eviction; diminished access to addiction treatment and medical care; and an illegal drug supply that became even more dangerous after the country essentially shut down.

But the forced isolation for people struggling with addiction and other mental health issues may be one of the biggest. Now, with the nation reopening, the Biden administration is throwing support behind the contentious approach that the center here takes, known as harm reduction. Instead of helping drug users achieve abstinence, the chief goal is to reduce their risk of dying or acquiring infectious diseases like H.I.V. by giving them sterile equipment, tools to check their drugs for fentanyl and other lethal substances, or even just a safe space to nap.

Some former regulars at the Greensboro center have died or disappeared. Many lost housing or work. At the same time, the center has been inundated with new clients and is now having trouble keeping enough supplies on hand.

“The amount of struggle people are having in this moment, unrecognized and unanswered, is really difficult,” said Louise Vincent, executive director of the Survivors Union.

Still, many elected officials and communities continue to resist equipping people with supplies for drug use, including the recent addition of test strips to check drugs for the presence of illicitly manufactured fentanyl, which shows up in most overdose deaths. Some also say that syringes from harm reduction programs end up littering neighborhoods or that the programs cause an increase in crime. Researchers dispute both claims.

West Virginia just passed a law making it far more difficult for syringe service programs to operate, even though it is seeing a surge in H.I.V. cases driven by intravenous drug use. North Carolina’s legislature weighed a similar proposal this spring, and elected officials in Scott County, Ind., whose syringe exchange helped curb a major H.I.V. outbreak six years ago, voted this month to shut it down. Mike Jones, a commissioner there who voted to end the program, said at the time that he feared the syringes it distributed could be contributing to overdose deaths.

“I know people who are alcoholics, and I don’t buy them a bottle of whiskey,” he said. “And I know people who want to kill themselves, and I don’t buy them a bullet for their gun.”

Many harm reduction programs are run by people who have used drugs in the past or still sometimes do, and their own struggles with addiction, mental illness or other health issues also flared up during the pandemic. In Baltimore, Boston, New York and elsewhere, beloved leaders of the movement have themselves died from overdoses, chronic health problems and other causes over the last year, their deaths leaving holes in efforts to keep providing services.

Ms. Vincent, whose own addiction to opioids stemmed from a long struggle with bipolar disorder, briefly returned to using illicit drugs this spring. She was anxious to stave off withdrawal, she said, after trying unsuccessfully to switch from methadone to another anti-craving medication, buprenorphine. She later learned that the small amount of fentanyl she used was mixed with xylazine — an animal tranquilizer that can cause oozing skin ulcers. She landed in the hospital, her hemoglobin level so low she needed a blood transfusion.

Early in the pandemic, Ms. Vincent said, the price of street drugs soared. Then drugs being sold as heroin, methamphetamine or cocaine started getting cut with unfamiliar additives. Fentanyl was ever-present — including, increasingly, in counterfeit pills sold as prescription painkillers or anti-anxiety drugs. But so were substances like xylazine, which has been showing up in illicit drugs from Philadelphia to Saskatchewan.

“It’s just poison,” said Ms. Vincent, who is back on methadone treatment. “The drug supply is like nothing we’ve ever seen before.”

On the afternoon of the center’s reopening, a young woman asked for a refresher on how to inject naloxone, and if Ms. Vincent could explain what a meth overdose looked like. An older man asked if there was any food to be had along with clean syringes; a volunteer stuck a pastry in the microwave for him.

In addition to running the program here, Ms. Vincent promotes harm reduction services around the country as executive director of the National Urban Survivors Union, a larger nonprofit. In 2016, her 19-year-old daughter died from a heroin overdose while she was at an inpatient treatment center that had no naloxone on hand, she said.

Naloxone is more widespread now, but Ms. Vincent would like to see another lifesaving tool become common: drug-checking programs that would allow people to find out exactly what substances are in illicit drugs before they take them. Such programs exist legally in other countries, including Canada, the Netherlands and New Zealand. Another type of harm reduction program used in other countries — where people use illicit drugs under medical supervision in case they overdose — remains illegal here after a group seeking to open one in Philadelphia has lost in court so far.

“We could have a real time surveillance system instead of waiting for coroner death reports,” Ms. Vincent said. “It would change the game, right?”

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