Harm Reduction or Enabling? Fentanyl Safety Measures and Addressing the Harm Reduction Stigma

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Article posted by Maddie Louder, MA, LMHCA

Harm reduction. What is that? In short, harm reduction is a way to make a harmful thing less harmful. Most people can get on board with reducing harm; however, harm reduction somehow causes a lot of controversy. For example, what if I tell you that doctors prescribe opioids so that their patients don’t obtain drugs off the street (NPR, 2022)? Pause. What? This is where harm reduction can be controversial; some might even say enabling. For someone who is using substances or using drugs from dealers off the street, a doctor prescribing a controlled substance is safer than taking a drug from a dealer that could be laced with more dangerous or lethal substances like fentanyl. It is reducing harm. Critics of the harm reduction approach may say that it is enabling. Sure, being prescribed the substance doesn’t decrease the substance use at all. But remember, the goal of harm reduction isn’t to stop use; it’s to reduce harm. So, let’s take a deeper dive into this.

Criticisms for Harm Reduction

The word “harm” can be quite arbitrary in itself, which makes this whole harm reduction thing slightly more complex (Hathaway, 2001). Harm reduction also doesn’t approve or disapprove of substances; it offers an alternative – one where we are destigmatizing the drug user and providing humanistic values and rights to the user (Keane, 2003). It could also be argued that harm reduction approaches don’t actually reduce harm to the substance user; after all, they are still using. However, harm reduction approaches can reduce harm for the communities that the user is a part of by reducing the spread of disease, reducing stigma, and reducing death. But isn’t it enabling? Some argue that in cities where needle exchange programs are present, drug use increases. Although the use might have increased, but the spread of Hepatitis C and HIV/AIDS has decreased because needles aren’t being shared between people (Keane, 2003). The harm reduction model is an intervention method that was not there before. Let’s look at some of these interventions.

Fentanyl Test Strips

Fentanyl test strips are tests that can help detect the presence of fentanyl in any substance (Goldman et al., 2019). Here’s the thing: big drug dealers don’t care what is laced into their supply. They care that they make money. If there happen to be trace amounts of other chemicals in what they’re selling, it’s not their priority to clean the drug. So what if they lose a few buyers to fentanyl poisoning? They made money. Critics of fentanyl test strips argue they enable use. On the contrary, test strips can help the user be more careful when using. In one study in Rhode Island, self-reported substance users were given fentanyl test strips. The majority of participants found the test strips useful, and those who came across a positive test strip (that is, they found fentanyl poisoned in their drug supply) changed their drug use behaviors (Goldman et al., 2019). This could include discarding their drug supply, using with something else for safety, or keeping life-saving Naloxone nearby. Fentanyl test strips reduce harm to the user.

Naloxone (NARCAN)

Naloxone is an opioid antagonist, which is a fancy word for saying it reduces the effects of opioids on the brain (Kahn et al., 2022). Naloxone, also known as NARCAN, can save a life if someone is experiencing a poisoning or overdose due to an opioid like fentanyl. Some Naloxone reversal survivors describe taking the opioid one minute and waking up the next, withdrawal symptoms, and disorientation (Kahn et al., 2022). The most common response was that Naloxone saved their life. Although many addicts who received a life-saving Naloxone reversal went back to using opioids to avoid withdrawal symptoms, but are more likely to carry NARCAN on them in the future, either for themselves or to help someone else.

Education

We’ve all been there; we’ve lived through some drug prevention program in elementary, middle, or high school (shout out to the D.A.R.E. kids). Although some of the education methods of the past may not have been the most effective, a little bit of education can go a long way in reducing harm. Education programs in Middle and High Schools nowadays try to share as much information as possible about how drugs impact a teenager’s body in order for a teen to make educated choices. Parents argue that providing information can plant ideas in their child’s brain about experimenting with substances that weren’t there before. However, educating people on safe use techniques, how diseases spread, and what to look out for with substances can create more precautions when making choices around substance use (Mistler et al., 2021). For individuals who have the knowledge of what to look for and suspect fentanyl in their drugs, many engage in more harm reduction behaviors including abstaining from use altogether, using more slowly, using a test strip, or using less of the drug (Rouhani et al., 2019). Information does hold power.

Stigma Reduction

Stigma and drug use are rather intertwined. People who hold onto the viewpoint that harm reduction is enabling stick to the mindset that substance use is a matter of willpower and choice. The American Society of Addiction Medicine states this is far from the truth and addiction is a disease. The biggest harm we can do as a society to substance abusers is hold onto this stigma (López-Ramírez et al., 2023). Substance users did not happen to wake up one day and decide to start using heavy drugs. They were born into circumstances and a system that contributed to where they ended up. Of these circumstances, we can note genetics, socioeconomic classes, childhood adversity, education levels, race and ethnicity, just to name a few. Breaking the stigma starts by treating substance users as people; this is the pivot point of harm reduction approaches. Check yourself:

  • How do you view someone who uses drugs?
  • Do you associate them with good or bad connotations?
  • Do you blame a substance user for their substance use?
  • How are your beliefs contributing to harming this community?

What do you think? Is harm reduction enabling, or do harm reduction approaches save lives? The answer to both of these could be yes. Carrying Naloxone can save a life from overdose, but it may not change the use of the user. Providing education about substance use and safe use can decrease the spread of fatal diseases such as HIV/AIDs, but it may not change the minds of substance users. The biggest thing to note is that harm reduction doesn’t seem to be going anywhere anytime soon. So, instead of pointing fingers at substance users and blaming them for their problems, it might be worthwhile to understand that users are humans too. You have the power to be a part of the change and break the stigma.

References

Goldman, J. E., Waye, K. M., Periera, K. A., Krieger, M. S., Yedinak, J. L., & Marshall, B. D. (2019). Perspectives on rapid fentanyl test strips as a harm reduction practice among young adults who use drugs: a qualitative study. Harm reduction journal, 16(3), 1-11. https://doi.org/10.1186/s12954-018-0276-0

Hathaway, A.D. (2001). Shortcomings of harm reduction: Toward a morally invested drug reform strategy. International Journal of Drug Policy, 12(2), 125-137. https://doi.org/10.1016/S0955-3959(01)00085-8

Kahn, L. S., Wozniak, M., Vest, B. M., & Moore, C. (2022). “Narcan encounters:” overdose and Nnaloxone rescue experiences among people who use opioids. Substance abuse, 43(1), 113-126. https://doi.org/10.1080/08897077.2020.1748165

Keane, H. (2003). Critiques of harm reduction, morality, and the promise of human rights. International Journal of Drug Policy, 14(3), 227-232 https://doi.org/10.1016/S0955-3959(02)00151-2

López-Ramírez, E., Huber, M. J., Matías-Pérez, D., Santos-López, G., & García-Montalvo, I. A. (2023). Opioid harm reduction and stigma: proposed methods to improve the perception of people with addiction. Frontiers in Psychiatry, 14, https://doi.org/10.3389/fpsyt.2023.1197305

Mistler, C. B., Chandra, D. K., Copenhaver, M. M., Wickersham, J. A., & Shrestha, R. (2021). Engagement in harm reduction strategies after suspected fentanyl contamination among opioid-dependent individuals. Journal of Community Health, 46, 349-357. https://doi.org/10.1007/s10900-020-00928-3

NPR. (2022, September 15). Controversial harm reduction strategies appear to slow drug deaths [Audio podcast]. NPR. https://www.npr.org/2022/09/15/1123108839/controversial-harm-reduction-strategies-appear-to-slow-drug-deaths

Rehabs.com. (2023, August 23). The pros and cons of harm reduction treatment. Rehabs.com. https://rehabs.com/blog/the-pros-and-cons-of-harm-reduction-treatment/

Rouhani, S., Park, J.N., Morales, K.B., Green, T.C., & Sherman, S.G. (2019). Harm reduction measures employed by people using opioids with suspected fentanyl exposure in Boston, Baltimore, and Providence. Harm Reduction Journal, 16(39) (2019). https://doi.org/10.1186/s12954-019-0311-9