Harm Reduction at a Crossroads

By Tessie Castillo 11/10/14

A report from the 10th National Conference of the Harm Reduction Coalition.


It was a raucous morning in Baltimore on October 23 as the Harm Reduction Coalition kicked off its 10th national conference at the Downtown Renaissance Harborplace Hotel. Hurrying in from a late breakfast, I scored a seat in the front row for the opening plenary, close enough to feel spittle fly from the rabble rousers who energized the morning crowd with promises of sex, drugs and rock ’n’ roll. The audience whooped and cheered, everyone except for a man in a starched suit and tie who sat to my immediate left looking decidedly uncomfortable. Judging by the security agents who hovered around him with mysterious coils behind their ears and bodies from Pumping Iron, I guessed he was from the government—probably someone important.

Moments later, my suspicions were confirmed when the gentleman was introduced as our opening speaker, Michael Botticelli, Acting Director of the Office of National Drug Control Policy (ONDCP). He stood up to give a rather bland speech about the ONDCP’s commitment to sentencing reform, prescription drug abuse prevention, and promotion of medication-assisted treatment to help people stop using illicit drugs. I felt the audience collectively flinch as he used trigger words such as “addict” and ”drug abuser,” words that the harm reduction community is trying to phase out of existence due to their negative implications. But at the end of his speech, Botticelli received a warm standing ovation before being whisked out of the room by his entourage. Good thing he left early because the next speakers emphasized the need for safe injection facilities where people can legally use drugs and playfully reminisced about protesting government inaction on HIV while dressed in drag.

As the opening session came to a close, I was left pondering the dichotomy between the audience, largely made up of current or former drug users, and the presence of government officials who just a few years ago refused to even utter the words ‘harm reduction’ and continue to avoid many of the movement’s central issues, such as federal funding for syringe exchange. But at this year’s conference, not only did Botticelli make a personal appearance, representatives of other federal agencies such as the Substance Abuse and Mental Health Services Administration (SAMHSA) and the U.S. Health and Human Services Department (HHS) also attended to participate in conversations on previously taboo topics and to prove their willingness to meet on common ground. It’s a remarkable shift in federal interaction with harm reduction, and one that has taken nearly three decades of hard work to achieve.

During the late 1980s and early 1990s, urban areas such as New York City and San Francisco were being pummeled by drug use and the twin epidemics of HIV and hepatitis C. The first harm reduction programs in the United States were born when drug users began pushing for health services, notably for access to sterile syringes to stem the tide of viral infections from shared needles. The programs were exceedingly controversial in their early days (and continue to be in most of the United States). Critics argued that providing access to sterile syringes encouraged drug use. Harm reduction methods were shut out of discussions on how to end the HIV epidemic, despite a growing amount of scientific research demonstrating that syringe exchange programs do prevent new infections.     

Allan Clear, who has served as Executive Director of the Harm Reduction Coalition in New York City since 1995, recalls the early days when harm reduction was considered radical and enabling:

“We were trapped in culture wars,” he says. “Harm reduction has always been about public health and dignity for drug users, but in a highly-politicized environment, we were portrayed as dirty and dangerous by federal administrations, and by extension, health departments. The CDC was forbidden from funding harm reduction programs and the ONDCP and SAMHSA wouldn’t meet with us. But throughout that time we diligently went about our work and gathered an enormous amount of empirical evidence showing that harm reduction is an effective, humane approach to public health.”

Daniel Raymond, Policy Director for the Harm Reduction Coalition, says that it wasn’t until the Obama administration lifted the federal ban on funding for syringe exchange in 2009 (Congress reinstated the ban in 2011) that harm reduction began to be seen as legitimate.

“Until a few years ago, researchers were still told they couldn’t use the words ‘harm reduction’ if they wanted to study populations such as sex workers or injection drug users,” says Raymond. “But the current administration is looking at drug policies in a new light. They no longer use the words ‘War on Drugs’ for example. And that has allowed us to have a different relationship with officials.”

Once the government became open to dialogue, harm reductionists were ready to talk. They’d spent two decades amassing scientific evidence on the effectiveness of access to sterile syringes on reducing disease transmission without facilitating an increase in drug use. But soon the conversation turned sharply towards the prescription drug crisis. Ever since drug overdoses surpassed auto fatalities as the leading cause of accidental death in 2008, government officials had been scrambling for answers. They found them within the harm reduction community, where experts had 15 years of experience in overdose prevention, medication-assisted treatment for addiction, and distribution of naloxone, a medicine that reverses opioid drug overdose. These are the same programs that ONDCP is now promoting.

According to Raymond, the watershed moment occurred in 2012 when the Food and Drug Administration (FDA) convened a workshop on naloxone. There, for the first time, harm reductionists were invited to present as experts in a room of officials from ONDCP, HHS, SAMHSA, and other government agencies that had previously excluded them.  

“The government started to realize that harm reductionists have a set of experiences in the public health arena that no one else has,” says Clear. “When the prescription drug epidemic hit, health departments and authorities didn’t know what to do, so they came to us, because we do know what to do. We have been running overdose prevention programs for almost two decades.”

Harm reductionists are finally being recognized for their work in public health and human rights. But as with all movements that experience a sudden surge of popularity, the challenge is to ensure that opportunities translate into consistent, meaningful participation in the public health debate and not merely into 15 minutes of fame.

When introducing Director Botticelli during the conference, Daniel Raymond emphasized that the ONDCP is “open for business and ready to receive their marching orders” from the community. He says that if the harm reduction movement wants to keep up its momentum it has to continue to feed ideas, strategies and evidence-based solutions to governments and public health departments, not only around drug overdose, but around other issues such as hepatitis C, syringe access, and drug treatment.

“We need to be proactive in showing that we are experts on the ground,” he says. “We have ideas and solutions, but we also bring the voices and experiences of people who use drugs into that dialogue.”

Representing the voices of marginalized groups brings up another issue, one that haunts many community-based movements that move towards mainstream. Can a movement of drug users evolve without losing sight of its roots?

The tension behind this question was palpable during the conference as outspoken drug users talked about “taking back the movement,” while many white-collar professionals insisted that caution and compromise were the best tools for success. I found myself likening the debate to the civil rights movement and silently cheered on the drug users, even as I realized that I am the embodiment of the white, professional, non-drug users who are increasingly involved in harm reduction. As a writer, it’s a dilemma I struggle with, as I give a voice to people whose experiences I have never shared. I wonder if being a good writer also qualifies me as a good harm reductionist.

Moving forward, it will be challenging to find middle ground between capitalizing on opportunities at the state and federal level while staying true to the heart of the movement. Daniel Raymond points out that the recent growth of drug users unions (who met at the conference to hammer out a national agenda) is a positive move to hold the harm reduction community accountable to its values and principles. 

This year the conference theme was “Crossroads and Intersections,” which implies that harm reduction is standing at a juncture. Doors are opening and the movement is enjoying a legitimacy and rapid progress that it has never experienced before in the United States. But at the same time it is important not to sacrifice authenticity for quick wins and to ensure that the drug users and sex workers who have spent 30 years in the trenches fighting to save lives are at the forefront of decision-making, and not merely spoken for by professionals. Because harm reduction is not just about overdose prevention, syringe access, or temporary health solutions.

At some point the movement will need to tackle the root causes of addiction, such as poverty, disenfranchisement, and the human tendency to punish and stigmatize people who are perceived as different. And to do that, it will need the best of what users and non-users have to offer and that may involve some cringing as people misstep and accidentally offend. But that’s okay. It’s all part of the learning process. And the point of any conference, when it comes down to it, is to learn, to share, and to do together what cannot be done apart.

Tessie Castillo is the Advocacy and Communications Coordinator at the North Carolina Harm Reduction Coalition. She writes a regular column for The Huffington Post on overdose prevention, drugs, sex work, HIV/AIDS, law enforcement safety and health. She last wrote about the rise of naloxone distribution programs and joined The Fix's new Ask An Expert section.

Please read our comment policy. - The Fix
tessie castillo.jpg

Tessie Castillo is a writer and drug policy advocate in Raleigh, North Carolina. Her articles explore topics such as criminal justice reform, drug policy, and harm reduction. Castillo previously served as the Advocacy and Communications Coordinator for the North Carolina Harm Reduction Coalition (NCHRC), a statewide nonprofit that advances drug policy and criminal justice reform. During that time, she played a pivotal role in helping to legalize syringe exchange programs and expand access to naloxone, a medicine that reverses opioid overdose. Find Tessie at her website or on Facebook, TwitterInstagram, and LinkedIn.