What Is Harm Reduction?

Massachusetts saw more than 2,300 opioid overdose mortalities in 2022, the most of any year. The rising prevalence of fentanyl in the drug supply, as well as the mixing of opioids with stimulants has created a challenging landscape for those working with people who use drugs. One tool that outreach workers use to mitigate these challenges is harm reduction.

At its core, harm reduction centers on the humanity of people who use drugs, by meeting individuals where they are and not making abstinence from drugs a condition of treatment. The modern harm reduction movement in the U.S. shares lineage with the Black Panthers and LGBTQIA + activists during the HIV/AIDS epidemic — people with lived experience of HIV/AIDs who largely felt marginalized and stigmatized by the healthcare system.  Interventions and strategies encourage safer and more managed substance use and broadly address the conditions of their use. These methods include syringe services programs (such as needle exchanges) and overdose prevention centers where people can continue to use in safer and controlled environments.

In addition, harm reduction favors education and encouragement over punitive methods of incarceration and is widely-considered integral to stemming the overdose crisis. Boston Medical Center’s Grayken Center for Addiction uses harm reduction as one of its core principles throughout its programs and services. Theresa Rolley, CARC, a wellness and recovery advocate at the Grayken Center’s Addiction Consult Service, supports people who use drugs and/or have substance use disorder (SUD) using the core tenets of harm reduction in her practice.

Relying on advocacy and lived experience

Rolley’s natural love of people and a desire to give back have buoyed her career. With her supervisor’s permission she added “wellness and recovery” to her job title as an attempt to start the conversation with patients about different ways to achieve wellness.

“For some people, that’s just using clean needles or using condoms,” she explains. “For others that might be getting them connected with a provider who can prescribe methadone or someone who is ready for residential treatment.”

“I want to come in each day and show a face of a person who’s not scared to advocate.”

But the most important thing, Rolley says, is to provide someone a safe place free of judgment and stigma.

And, like many providers and outreach workers who employ harm reduction as a framework, she uses her own lived experience to foster support among those that she works with.

“I’m in long-term recovery myself,” Rolley says. “I want to come in each day and show a face of a person who’s not scared to advocate.”

Effective harm reduction and building trust in addiction care

Rolley discusses another essential aspect of harm reduction: resource sharing. She says this includes street outreach, handing out harm reduction kits and supplies for people using drugs, such as tourniquets, alcohol swabs, naloxone (also known as Narcan), fentanyl test strips, clean pipes, and more. Pushback to the harm reduction movement claims that this is “enabling,” but Rolley says this is an outdated perspective and that letting shame and stigma dictate care actually harms rather than helps.

“If you’re not going to stop using, that’s your choice. But we [as providers] want you to know we’re here for you. We want you to use as safely as possible,” says Rolley. “If it were up to me, I’d say stop. But that’s not up to me; it’s up to you. I am here to support you either way.”

From a clinical and public health perspective, needle exchanges help prevent bloodborne pathogens and infectious diseases. Naloxone training helps reverse an opioid overdose. Fentanyl test strips help detect unwanted drugs and prevent accidental overdoses.

Ideally, Rolley says, harm reduction also offers people with substance use disorder agency: “It’s a chance to say, ‘You know what? I’m done using,” and a chance for them to seek alternative treatment options.”

Harm reduction, when used to its full extent, can make people feel connected to the world again.

How does harm reduction open the doors for people to find treatment for substance use disorder? Harm reduction, when used to its full extent, can make people feel connected to the world again. Because of the stigma surrounding people who use drugs, they can opt out of care for fear of being shamed or ostracized — creating a barrier to effective treatment. But harm reduction in its most effective sense builds a connection between a care provider and a person with substance use disorder. These initial connections through receiving a harm reduction kit or a needle exchange or even striking up a conversation with an outreach worker can lead to deeper connections that may pave the way to seeking other help, such as an annual checkup, a connection with social services for stable housing, or support at a residential treatment center. The art of harm reduction is in showing the patient that they are supported and cared for on their journey.

“Showing up for our patients is important to me — I have a phone just for them. Sometimes they’ll call me and maybe we’ll meet for coffee and talk. If they’re nervous about going to a certain appointment, I’ll offer to meet them there. I’ll let them know that they always have a place here,” Rolley says. “They just need a friendly, supportive voice. That makes a huge difference.”