I’m commonly asked this question by well-intentioned folks when I say I am a harm reduction advocate, or whenever it is suggested that we need more access to harm reduction services in the community.

The people who ask me this are diverse and come from all races, genders, ages, socioeconomic backgrounds and political leanings. They are parents, community members, journalists, health care providers, recovery advocates, students and just about everyone else. They ask this question with sincere curiosity and good intentions. They care.

After all, one of the more notable recent shifts in public opinion is that more people than ever now view addiction as a treatable health condition. And this is a good thing. It is progress.

The issue is that now many people see treatment as the only solution. So in their minds, if treatment is the ultimate solution and end goal, why would we need more harm reduction, or even need harm reduction at all?

I try to approach these conversations as teachable moments. And I start by telling them I am a former treatment provider myself. I explain that I know how life-changing treatment could be, because I saw firsthand how it helped my former clients to achieve stability in their lives.

But then I talk about how working in treatment also made it clear to me how difficult it is for the average person to find, access, afford and complete treatment in its current state. And that the treatments that are the easiest to access are not always the ones that are evidence-based and proven to work.

I also clarify that while some people are helped by traditional addiction treatment, there are others whose needs are far greater or more complex than our treatment system can address, but are still sent to treatment because there is nowhere else to go. I explain how most people who start treatment in any given year do not successfully complete it, and that then there are few options for support once they are discharged from services.

All these factors mean that while treatment is a needed support for many people, it will never meet all the needs of everyone who uses drugs, even those with addictions.

Finally, I talk about how over 90 percent of people who have addictions do not receive any treatment each year, so that they are left without any other options for support or safety in the community.

All these factors mean that while treatment is a needed support for many people, it will never meet all the needs of everyone who uses drugs, even those with addictions. And when treatment does not or cannot meet people’s drug-related needs, they will need more options in the community for help.

I want people to understand that being a harm reduction advocate means I want people to have an even larger safety net to fill the gap. I want people to have a broader range of available services in the community in addition to and beyond treatment.

That’s it. 

Most People with SUD Do Not Want Treatment

The truth of the matter is that most people with SUD, 37.5 million of the over 38 million people with addictions who did not receive treatment, did not even want treatment.

It could be because they do not want to stop using drugs, it could be that they don’t think the severity of their problems rises to the level of needing services, or it could be because they think they can handle it on their own. It could be that some had negative experiences with treatment and do not want to return. There are countless reasons why someone may not want treatment.

Unfortunately, many people look at this as evidence that these people are “in denial” about the substance-related problems in their lives, when the truth may be far more complicated.

But it shouldn’t mean that they are left on their own with nowhere to turn. It doesn’t have to be this way. A greater availability of community-driven harm reduction programs, developed by and for people who use drugs, could help provide a source of support outside of the formal treatment system, for these people have their own reasons for not engaging in services.

Considering the tens of millions of people who fall into the harm reduction gap this way, we should want to build and support the development of a more robust continuum of services.

Most will never walk into a treatment program but may be more willing to access resources on a website and order harm reduction supplies to be delivered to their home; or they may walk through the doors of a local syringe service program, where they are made to feel welcome.

Considering the tens of millions of people who fall into the harm reduction gap this way, we should want to build and support the development of a more robust continuum of services and programs in our community that include the range of harm reduction services, so people can find the options they want when they are ready to get help. This includes providing grant funding to harm reduction programs that develop innovative, accessible services to target this otherwise-disconnected population of people who use drugs.

Treatment Will Not Fill the Harm Reduction Gap

The way that our current treatment system is set up and structured has helped to create the harm reduction gap. Our current addiction treatment system is intended for people who want it, can afford it, can access it, can adjust their lives around it and can comply with its many rules. Even those who complete treatment may have multiple treatment episodes. Change does not happen overnight, and substance-related patterns can take time to adjust; as a result, they often return to problematic use again after leaving.

Rather than seeing these realities as signs that their services could be improved, adjusted or revised to keep clients connected to support, many treatment facilities justify their approach by placing sole responsibility on the client population for their inability to comply. And for those who ultimately drop out or are terminated from treatment, few alternatives exist. There is no safety net to catch them. We should be most concerned that most people with diagnosable SUD do not receive treatment because most of them do not want it, and they are left to fend for themselves.

It is naïve and unrealistic to assume that over 30 million people could somehow receive services in our formal, costly, highly structured, one-size-fits-all treatment system.

The formal treatment infrastructure should be viewed as an extension of a broader health care system that is largely inaccessible, unaffordable and stigmatizing toward people who are seen as undesirable or undeserving. This can include the people who use the most stigmatized illegal drugs, low-income and homeless people, people with complex mental health and medical needs, queer communities, and racial and ethnic minorities who have had negative experiences in these settings. Meanwhile, community-based and community-driven harm reduction programs where these services are integrated can be a safe and appealing touchpoint for care. 

In states across the country, SSP are becoming sites where clients can receive buprenorphine in a setting that is accommodating to their needs and literally “meets them where they’re at” where they already receive services. In addition, SSP are integrating more health services on site, with New York State’s model of Drug User Health Hubs being a great example, showing that harm reduction sites staffed by caring and knowledgeable staff can better meet community health and harm reduction needs in the same place. These sites where people can get both harm reduction and treatment can help people to seamlessly transition between them, without ever being disconnected from support.

Our unprecedented overdose crisis, combined with the fact that alcohol- and tobacco-related health harms claim lives every day, show that we must do more for people who are otherwise not connected to the formal treatment system. 

It is naïve and unrealistic to assume that over 30 million people could somehow receive services in our formal, costly, highly structured, one-size-fits-all treatment system comprised of just over 16,000 facilities. In any given year, these facilities conduct about 1.5 million admissions. The current system is not equipped for a sudden influx of this population into services, and is likely not appropriate for all of them anyway. 

What if people had more options for help to choose from, such as services with few requirements and that were easily accessible on their terms?

Many of the people I speak to talk about how we need more treatment in our communities, and that is a completely valid point. We do need more treatment along the continuum of care in all parts of the country, including online and via telehealth options for people who could benefit from that accessibility. And these options should be affordable and available to the people who want them. 

But we must acknowledge that our current system does not have much to offer the millions who will never set foot in a treatment facility.

What if they had more options for help to choose from, such as services with few requirements and that were easily accessible on their terms? What if the education and tools to engage in safer or less risky drug use were more readily available to them, in their communities, at SSP, via mail order and in other settings? What if they could go to an overdose prevention center or other safe location to use when they are worried about adverse effects or a potential overdose? What if they knew there were harm reduction psychotherapy providers who were willing to work with them on staying safe, and who would not impose abstinence on them to be able to get help?

This is how we fill the harm reduction gap. 

Top photograph via Pxhere/Public Domain

This article is excerpted, with permission, from The Harm Reduction Gap: Helping Individuals Left Behind by Conventional Drug Prevention and Abstinence-Only Addiction Treatment, authored by Sheila P. Vakharia and published by Routledge in 2024.  

The Harm Reduction Gap is now available to order from Routledge, among other outlets.

Cover of The Harm Reduction Gap designed by Matt Schoch.

The post When People Ask Harm Reductionists, “What About Treatment?” appeared first on Filter.

The accompanying post suggested that if more social workers were hired, we could “provide crisis intervention, referrals to human service and other agencies, short-term counseling, follow-up services, mediation” and other services. At publication time, the post had been shared over 1,600 times, received over 950 reaction emojis (all positive), and garnered 135 comments. The large majority of comments were generally in agreement with the sentiment that, yes, police departments do need more social workers. 

I was deeply troubled, both because the statement itself is so clearly off-base, but also because the responses to it reveal so much about the broader challenges plaguing our profession. 

This strategy will not fundamentally change even one of the myriad harms inflicted.

The statement feels especially offensive and problematic in this current moment. For the past several weeks, protesters and activists around the world have been rising up to denounce racist police brutality and demand systemic change (including making calls for the abolition of policing itself). This month also marks the fifty-first anniversary of Stonewall, a riot led by Black and Latinx trans women in response to ongoing targeting and abuse at the hands of police. So little has changed over half a century later, as we witness all-too-frequent incidences of police violence towards Black cis and trans women with no justice, nor even equal recognition or outcry as when victims are Black men. 

The suggestion that social workers should join precincts denies the reality that this strategy will not fundamentally change even one of the myriad harms inflicted, on the very communities we claim to serve, by police. There is little evidence that our presence will reduce their disproportionate use of lethal force against Black, Latinx and Indigenous people; it will not prevent them from patrolling certain communities over others while serving the interests of gentrifiers; it will not demilitarize them; and it will not hold them accountable for misconduct or abuse. 

If anything, our alignment with policing would exacerbate our profession’s already fraught role as agents of social control. It would make us even more complicit with yet another system—in addition to prisons and jails, other forms of “correctional control” like probation, or so-called Child Protective Services—that victimizes our society’s most marginalized. 

Social workers say we want to end discrimination and injustice. But as a profession, we have not taken a clear stance on the harms of policing, incarceration and criminalization—harms that disproportionately impact communities of color and promote health, social and economic inequities. This is in embarrassingly stark contrast with the allied profession of public health, whose flagship journal, the American Journal of Public Health, dedicated an entire special issue to documenting and addressing the health impacts of carceral systems, including policing, just a few months ago.

What new policies and community systems are needed for social workers to no longer be necessary? 

At a time when communities are imagining a world without policing and, in many cases have begun to build their own non-carceral community systems of support and accountability, we should be asking ourselves this: What would it take to work ourselves out of a job, rather than further entrenching ourselves in the harmful status quo of a violent system?

Despite the challenging nature of this exercise, social workers should stop imagining new settings in which to work, and instead consider what it would take to create a world where our profession is rendered obsolete. What new policies and community systems are needed for social workers to no longer be necessary? 

So much of the work that many of us do at the individual or programmatic level is often to mitigate and navigate larger policy and systemic failures. Not enough of us are even equipped to engage in making these changes, since community organizing and policy practice courses at the Baccalaureate, master’s and doctoral levels are rare and often have less enrollment than clinical courses. 

Our Code of Ethics states that our profession’s mission includes promoting social justice and ending oppression, but much of our advocacy agenda involves reimbursement parity and improving our own employment conditions.

As Mariame Kaba, the abolitionist organizer and writer, has said: “You can’t just focus on what you don’t want, you have to focus also on what you do want. The world you want to live in is also a positive project of creating new things.” 

Social work as a profession must engage in a reckoning of its own: What kind of world do we truly want, and what new things could and should we help to create? Because we do have options beyond remaining either passive bystanders or willing accomplices to the carceral state.

The author’s employer, the Drug Policy Alliance, has previously provided a restricted grant to The Influence Foundation, which operates Filter, to support a Drug War Journalism Diversity Fellowship.

Photo of the NYPD 78th Precinct building in Brooklyn by Autopilot via Wikimedia Commons

The post “Social Workers Belong in Police Departments” Is an Offensive Statement appeared first on Filter.

In contrast to dozens of previous SCS studies spanning decades, this analysis had suggested that there was little-to-no reduction in drug-related health harms associated with SCS. Its retraction means we can now strike that false claim from record and, once again, lean back on the body of research that does show that they are an effective harm reduction intervention.

However, this victory only came after serious damage had already been done.

The original analysis could not have been released at a worse time. It came on the heels of the latest CDC data that indicated we lost over 72,000 people to overdose just last year—and as advocates across the country were making tremendous progress towards opening the first legal SCS here in the US. It also preceded a highly publicized op-ed from Deputy Attorney General Rod Rosenstein that said SCS were “dangerous and would only make the opioid crisis worse.”

Media outlets jumped on the opportunity to highlight the study, and its suggestion that SCS would not have the effect on the overdose crisis that harm reduction advocates were promising. While some pieces advised that we take the findings with a grain of salt by acknowledging that SCS could still be helpful, most failed to provide a deeper analysis about the limitations of the study—or place it in the context of the other research that contradicted it.

Opponents of SCS also used the study to argue against opening SCS in California and other parts of the country. Just this Sunday, California Governor Jerry Brown vetoed AB 186, a bill that would allow San Francisco to open the nation’s first SCS. In a letter explaining his decision Governor Brown said that he did not “believe” that SCS would “reduce drug addiction.”

The retraction came, and that matters. But a retraction never receives the same kind of attention as the original study.

When a new study comes out and purports to add to our understanding of a controversial topic … it is our responsibility to pause to ask ourselves some vital questions.

And this isn’t the first “gotcha” study on a harm reduction intervention that received a lot of press; it’s just the first to be retracted.

Earlier this year, researchers Jennifer Doleac and Anita Mukherjee released a widely publicized study about the “moral hazard” of naloxone distribution. Naloxone is a medication that can reverse an opioid overdose and has been credited with saving thousands of lives. Their study, which also contradicted earlier research, provided fodder for those who wanted to argue that naloxone distribution is ineffective—or worse, that it increases crime because it keeps more people who use opioids alive.

As we’ve all heard by now, correlation does not equal causation. The Doleac and Mukherjee study also assumed that everyone immediately had access to naloxone in states that had naloxone laws on the books. In fact, there are many barriers to naloxone that mean access is still limited even in these states.

These two recent examples are instructive. We need to be wary of controversial new studies that grab headlines, and be more measured and reasoned in evaluating their claims.

When a new study comes out and purports to add to our understanding of a controversial topic, especially when it contradicts larger trends in the body of research, it is our responsibility to pause to ask ourselves some vital questions:

Why does this study look so different from all the others in that area?

What methods did they use?

What are the inclusion criteria

What variables and outcomes did they measure?

Is there something about the analysis itself that accounts for the different findings?

Are the authors of the paper experts in this area?

Who funded this research?

Do the authors have any conflicts of interest?

Policymakers, the media, and advocates need to partner with well-trained researchers who have the expertise to carefully evaluate the strengths and weaknesses of such studies before making claims (or policy) based on them.

There is no shortage of stigma, misinformation, fear, or panic surrounding drug use and harm reduction-informed public health policies. Poorly devised studies just make it worse.

If we really want to save lives and prevent more harm, we all have a responsibility to take a step back, look critically at the evidence, and base our efforts on high-quality, rigorous research—not on “belief,” sensationalized headlines, or shoddy studies.

*This article was co-written with Jules Netherland, director of the Office of Academic Engagement for the Drug Policy Alliance.

The post Faulty Study Questioning Effectiveness of Safer Consumption Spaces Now Retracted—But the Damage Was Done appeared first on Filter.