A look at harm reduction efforts 30 years ago in light of our current opioid epidemic
I decided to travel back in time. It’s pretty easy to do now–all you need is access to Google. I was in search of a different era, when the “war on drugs” was young and generally considered a reasonable idea.
This journey began when I decided to research the history of harm reduction practices for people who use heroin.
Many programs and tools could be considered harm reduction for heroin users. There are medication-assisted treatments and overdose antidotes. In Europe and Australia, supervised injection sites ensure a location where users of intravenous drugs can receive new needles, be resuscitated in the case of an overdose, and be referred to other services. These facilities do not exist in the U.S., but advocates are clamoring for them.
We hear arguments against harm reduction measures all the time. Think of the backlash when a needle exchange site is proposed or a state increases access to naloxone. Communities don’t want their actions to imply that they condone the presence of drug use. Fears of increased nearby violence, theft, and drug trafficking are voiced. People worry that with a safety net in place, their neighbors won’t be motivated to quit using.
In spite of these criticisms, we know that needle exchange programs improve public health (and can promote engagement in addiction treatment), that medications for heroin addiction can promote recovery (and almost always reduce mortality), and that access to naloxone does not increase injection drug use. In reality, numerous harm reduction strategies for heroin users are effective: they save lives and improve health.
And we are in the midst of an opioid epidemic. Today, one million Americans use heroin and could benefit from harm reduction services. In the last ten years, every demographic group has seen a rise in heroin use; the trend is particularly dramatic among whites, 18-25 year-olds, and women.
My question was, what can history tell us about societal acceptance of harm reduction? In the last few decades, what’s changed and what’s stayed the same?
Arriving in 1988
Some of you reading this surely remember the 1980s well, but I’m too young. So I stepped into my trusty time machine (okay, I “used the internet”) and tried to get a glimpse of what harm reduction looked like back then.
The very first search result was an article published by the New York Times titled “Inside a ‘Shooting Gallery’: New Front in the AIDS War.” What a perfect portal. I’ve often read NYT articles on topics related to substance use.
The article had been digitized since its strictly paper publication. The photos that originally accompanied it were credited, but absent. The piece debuted to the world in September, 1988. I turned a virtual page and peeped into New York’s past.
What struck me first was that access to addiction treatment seemed unnervingly like the present.
Although treatment options for heroin addiction now include buprenorphine and naltrexone, the situation sounds familiar. Back in 1988, there were medication-assisted treatment or abstinence-based approaches, both with lengthy waiting lists. Back then, people didn’t always make it through the wait, just like today.
When even the most motivated people can’t find help easily, there is a clear need for harm reduction services. This was true in the 1980s and remains true today.
Free Needles Provoked Criticism
The 1988 NYT story described an important piece of harm reduction history. It was the emergence of an exciting pilot program, something new and different in ’88: volunteers giving out free syringes. In the heart of the AIDS epidemic, contraction of HIV via shared needles was something people urgently sought to curb, and they hoped this would be part of the solution.
“The plan drew sharp criticism by those who claimed that free syringes would simply encourage drug use,” author Thomas Morgan said.
That sentiment hasn’t exactly disappeared. “You’re encouraging drug use,” is a refrain that has not ceased. I didn’t even have to change newspapers to see it again. In 2015, the very same New York Times published an article about the fact that needle exchanges were barred from receiving federal funding. To explain, it quotes a U.S. Congressperson: “We don’t want to look like we are facilitating drug use.”
It’s discouraging when quotes that are nearly thirty years old could be clipped and presented as modern commentary.
Back to The Future
Reading deeper and doing a little more research, I did see that the atmosphere around harm reduction has shifted substantially over time. It’s not been an easy ride: New York City briefly had needle exchanges, then they were banned in the early ’90s. Activists fought back, and the NYC area currently boasts over 15 such entities.
While New York did indeed start giving out clean injection equipment around the time my time travel focal point was published, to many other cities this 1988 article could be from 2016. Needle exchange programs are frequently blocked by local governments which see them as condoning deadly choices and encouraging drug use.
Certainly, it’s not all bleak. Within the last six months, an ongoing fight achieved a significant victory. Remember that article from December 2015 about how needle exchanges can’t receive funding from the U.S. government? It’s already become part of the past. Organizations that supply needles not only legally exist in most U.S. states, they can receive federal funding like any other non-profit organization. But the win is not complete: the opportunity to receive federal funding does not apply to the actual purchase of syringes. However, staff member salaries, office rental, and the other assorted costs of running an organization can use federal dollars.
Keep in mind that progress has largely benefited urban dwellers, however. According to the CDC, less than a third of our nation’s needle exchange programs are located in suburban or rural areas while more than half of our citizens who inject drugs live outside of major metropolitan areas.
Injection drug use led to a startling HIV outbreak in tiny Scott County, Indiana, and has created sky-high hepatitis C throughout Appalachia, particularly among teens and twentysomethings. Just as the AIDS epidemic pushed New Yorkers to open up to the idea of harm reduction in 1988, the transmission of infectious disease may be what changes attitudes in rural pockets of America.
Twenty-eight years from today it will be 2044. Maybe someone will dig up this article on whatever has replaced smartphones and say, wow, she had no idea what would happen. Maybe there’ll be a supervised injection site providing safer supplies, health education, and referrals to treatment in every major American city. Maybe we’ll have better ways of getting harm reduction services to people in rural areas. Whatever it is, change can and will happen.