We Need Harm Reduction Built for and Led by Youth Who Use Drugs

Young people use drugs. We need to accept this reality, and give them what they need to survive and thrive. We need to do this in the context of a deadly illicit drug supply and deepening poverty and inequality, plus other forms of structural oppression along axes of race, gender, sexuality and ability. Why are youth often denied the things that would help them, even more than is the case with older populations?

Instead of addressing structural oppression, abstinence-based and top-down institutional approaches to treatment and care can actually make it worse. Yet for youth in particular, these remain the default.

We know that harm reduction saves lives. It can also build lives and communities of care, including among young people who become involved in harm reduction organizing and activism.

It remains so hard for many people to get their heads around the importance of harm reduction programs and spaces dedicated to young people.

Bottom-up, grassroots harm reduction movements and programs are essential to lift young people up, empower them in relation to their wellbeing and care, foster shared activism, and push for meaningful policy reform.

It remains so hard for many people to get their heads around the importance of harm reduction programs and spaces dedicated to young people. Older adults remain inclined to “protect” and “save” youth in ways that often do more harm than good—particularly for those experiencing structural oppression. For older populations, society is slowly moving away from abstinence-only models toward harm reduction approaches that are empowering and far better evidenced. It is illogical and harmful to exclude young people from this shift in practice, policy and thinking.

Vancouver and Lisbon, where two of us live, are celebrated sites of established, progressive drug policies and harm reduction programs. But even in these places, young people who use drugs (YPWUD) have been left out and left behind.

In the Canadian province of British Columbia, where Vancouver is located, almost 2,000 people under 30 have died of drug poisoning since 2016. We remember and miss so many who are gone.

While Portugal is not in the midst of an overdose crisis, there are high and rising levels of substance use and overdose in Lisbon, and harm reduction programs and spaces (e.g., mobile consumption rooms) have been hard-won even in the context of decriminalization. Those that do exist are more explicitly targeted towards higher-income and older (over 18) YPWUD, such as those who use drugs at music festivals.

We remember and miss so many who are gone, and are fighting for what young people have not had, and for what might have saved many lives: youth-dedicated and youth-led spaces in which to come together, connect, build relationships and shared causes (namely, fighting the drug war), and learn to use drugs more safely.

That means harm reduction spaces led by, and meeting the needs of, young people who use drugs in the context of unstable housing and homelessness, including large numbers of Indigenous, Black, Brown and LGBTQ+ YPWUD and young women.

YPWUD often face caregivers and providers who do not want to listen, or who adopt a paternalistic “I know best” or “I need to save you” approach.

In the context of entrenched urban poverty, drugs are a source of sociality, pleasure and fun. They’re also a means of survival—of navigating physical, psychological and emotional pain, trauma, boredom, and historical and ongoing oppression including settler-colonialism, white supremacy and cis-heteropatriarchy.

But YPWUD often don’t get the chance to explain their drug use along these lines to the older people in their lives. Instead, they often face caregivers and providers who do not want to listen, or who adopt a paternalistic “I know best” or “I need to save you” approach.

Indigenous, Black and Brown YPWUD in particular encounter paternalistic and judgemental attitudes, because systemic racism means that their bodies and bodily practices are often viewed as inherently “at risk,” “risky” and in need of intervention—oftentimes via hospitalization and incarceration.

Facing institutionalization, many young people learn to evade and avoid even low-barrier shelters, safehouses, mobile programs and drop-in centers, preferring to take care of themselves and each other on the streets and in camps. While these can be important spaces of sociality, support and care, they can also present numerous threats to wellbeing.

Instead of driving young people away from lifesaving care, we should be working to draw them into services in meaningful ways.

To these ends, we have undertaken a community-based participatory action research project based in Vancouver, in collaboration with the younger members of the Manas collective in Lisbon. The Vancouver team is currently composed of four university researchers and a Youth Health Advisory Council (YHAC) of 10 people aged 17 to 28, with lived and living experience of substance use and mental health concerns in the context of unstable housing and homelessness.

Youth voices should be better integrated into both bottom-up, grassroots and top-down, state-sponsored harm reduction movements.

Since our first meeting in October 2018, YHAC members have contributed to numerous research and knowledge mobilization activities, including taking the lead role in planning and hosting a one-day youth summit in Vancouver, focused on critically evaluating local responses to the overdose crisis. The event included a “chill space” where participants could use substances during the event in the presence of trained overdose responders (including a youth peer worker). It represented one of the few examples of a for-youth-by-youth supervised consumption site in British Columbia.

In a paper published in the Harm Reduction Journal last year, we collectively argued that grassroots, youth-led harm reduction philosophies, practices, and spaces are essential to this project. Here are our harm reduction calls to action:

1. Stop focusing exclusively on getting young people to stop using drugs.

2. Stop pathologizing YPWUD and trying to “save” or “fix” us.

3. Invest in low-barrier, youth-dedicated, and youth-led harm reduction programs and spaces, including housing (e.g., safehouses, permanent government-subsidized housing), shelter, and safer consumption or overdose prevention sites. These should have a non-clinical, non-institutional, relaxed and welcoming feel to them, and include private spaces for safer consumption. They should be staffed by a mix of youth with living experience and providers who are non-judgemental, caring, supportive, and friendly to YPWUD. The focus should be on relationship-, trust- and future-building, not damage, deficits and the past.

4. Keep young people’s engagement with harm reduction programs and spaces confidential.

5. Youth-led harm reduction programs and spaces must account for the needs of youth who use stimulants and polysubstance-using youth, Indigenous, Black and Brown and queer, trans and Two Spirit youth, and self-identified young women. Mobile outreach vans and safer consumption rooms are critical for those not residing in city centers.

6. We demand an end to compulsory or involuntary abstinence-based prevention, treatment and reintegration programs. In Portugal, appearance before the Commissions for the Dissuasion of Drug Addiction should be conditional on the consent of the young person, who should be able to decide whether to undergo any type of evaluation, diagnosis and therapeutic intervention. In Vancouver, we strongly caution against the growing involuntary detainment of YPWUD, including following an overdose event. The services and systems that YPWUD traverse must be redesigned to foster their self-determination in relation to their drug use, harm reduction, care and families.

7. In Vancouver, we add our voices to those demanding the decriminalization of all drug use, while at the same time cautioning that decriminalization—as it has played out in Portugal, for example—does not in and of itself constitute an end to the drug war.

8. In Vancouver and Lisbon, we add our voices to those demanding an affordable and widely available safe supply of drugs via peer-led compassion clubs that sell pharmaceutical-grade cannabis, heroin, cocaine and meth to those over 18 years of age. We are not going to solve the overdose crisis with prescriptions of pharmaceutical-grade stimulants and opioids; both medical and community-based models such as compassion clubs are needed.

9. Youth voices should be better integrated into both bottom-up, grassroots and top-down, state-sponsored harm reduction movements and initiatives, with a focus on fostering youth-led change.

10. YPWUD in the context of greater privilege, as well as allies, should focus energy on fostering and extending the activism of YPWUD in the context of unstable housing and homelessness, creating vertical connections to power as well as horizontal connections across communities of people who use drugs.

This article was co-authored by Danya Fast and the Youth Health Advisory Council at the British Columbia Centre on Substance Use (BCCSU), located on unceded and occupied Musqueam, Squamish and Tsleil-Waututh First Nations territories. Danya Fast is an assistant professor in the Department of Medicine at the University of British Columbia and a Research Scientist at the BCCSU in Vancouver.