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The Pendulum Swings Between Zero Tolerance and Harm Reduction

Harm reduction related to alcohol and drug addiction is a practice of pursuing the least harmful interventions in order to minimize negative outcomes, especially minimizing loss of life. Some of the ways harm reduction is practiced include:

  • Wide distribution of Narcan (naloxone), which can immediately keep a drug overdose from becoming fatal.
  • Clean needle distribution to reduce the reuse of needles and the spread of infectious diseases.
  • Distribution of drug testing strips that detect the presence of fentanyl in drugs, leading to reduced overdose deaths.
  • Suspending driver’s licenses of people suffering from alcohol use disorder to reduce vehicular homicides.

The Substance Abuse and Mental Health Services Administration (SAMHSA) is a big fan of a harm reduction approach to substance use disorder. SAMHSA’s harm reduction guidelines state:

Harm reduction is an evidence-based approach that is critical to engaging with people who use drugs and equipping them with life-saving tools and information to create positive change in their lives and potentially save their lives.

According to SAMHSA, fewer than 10% of those who suffer from substance use disorder get treatment for it. Harm reduction is designed to dramatically increase those numbers through increased, humane contact with addicts to encourage treatment. Harm reduction presents the addict with a realistic series of steps to help minimize the pain they cause themselves and others as a result of their drug dependency.

The benefits of pursuing harm reduction are substantial, according to SAMSHA:

Harm reduction plays a significant role in preventing drug-related deaths and increasing access to healthcare, social services, and treatment. These services decrease overdose fatalities, acute life-threatening infections related to unsterile drug injection, and chronic diseases (such as HIV and hepatitis C).

Another benefit of the harm reduction approach is reducing the stigma that is a barrier to treatment for those suffering from substance use disorders. Harm reduction replaces a devastating cycle of homelessness and incarceration that results in addicts avoiding treatment or contact with healthcare professionals with compassion and a plan to curb the addiction and avoid incarceration.

Harm reduction employs a community reinforcement approach (CRA) which undercuts support for substance abuse while increasing rewards for abstinence. CRA programs emphasize not just abstinence but the substitution of positive new habits for dangerous bad habits. CRA programs often include a loved one or friend who agrees to participate in the training and help the recovering person remember their coping strategies.

There is a backlash against the harm reduction approach. Those bastions of liberalism, Portland, OR, and San Francisco, CA, have recently reinstated criminal penalties for public drug use. Harm reduction programs distributing needles and naloxone have reduced drug overdose deaths but have also brought drug use more into the open. The new rules in Oregon seek to use the threat of prosecution to coerce addicts into treatment programs.

Last week, a panel of addiction experts examined the swing from harm reduction back to zero tolerance at the STAT 2024 Breakthrough Summit West in San Francisco. In a summary of the panel discussion, STAT News reported that Dr. Ayesha Appa at UCSF cited a failure to market the benefits of harm reduction. She also indicated that harm reduction should not be blamed for the opioid epidemic — which now includes a variety of synthetic drugs. Harm reduction is proven to be a much less costly approach to substance use disorder than police, courts, hospitals, and jail.

Written by Steve O’Keefe. First published May 22, 2024.


“Defining harm reduction,” Drug and Alcohol Review, 1995.

“Harm Reduction,” Substance Abuse and Mental Health Services Administration (SAMHSA), April 24, 2023.

“The Community Reinforcement Approach for Substance Use Disorders,” AddictionNews, April 15, 2024.

“Amid backlash to harm reduction, addiction experts warn against reprising ‘war on drugs’,” STAT News, May 16, 2024.

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