Amid backlash to harm reduction, addiction experts warn against reprising ‘war on drugs’

SAN FRANCISCO — Amid what feels like an ever-worsening drug crisis here, locals and politicians alike are fed up. Overdose death rates remain near all-time highs. The Tenderloin, a historic downtown neighborhood, remains rife with open-air substance use and drug dealing. Public health officials are increasingly at a loss.

In recent years, much of the backlash has come to focus on harm reduction, the philosophy and practice of reducing the most acute drug-related harms without expecting abstinence from drug users.

But the solution is not a return to the “war on drugs,” a panel of addiction experts warned on Thursday, even as they acknowledged that the public has come to view hands-off drug policies, tolerance for open-air drug markets, and a culture of unabashed fentanyl use as synonymous with harm reduction itself.

“The hard part, as people that work in this industry, is to see that conflation,” said Ayesha Appa, a University of California, San Francisco, physician-researcher who specializes in infectious disease and addiction medicine. As a result, she said, the public appears to have concluded: “That’s not working, so let’s go back to a criminal approach.”

The remarks came during a panel discussion focused on political backlash to harm reduction, which took place Thursday here at STAT’s Breakthrough Summit West.

San Francisco, fairly or not, has become emblematic of progressive drug policies and their perceived failures. But the Bay Area’s continued drug crisis is not evidence of harm reduction’s failure, Appa argued — instead, it’s a failure to market harm reduction’s measurable successes at reducing death and disease, as well as a misperception that harm reduction tactics necessarily result in a breakdown of law and order.

Still, public figures have increasingly scapegoated harm reduction amid the country’s failure to contain its substance use crisis.

London Breed, San Francisco’s mayor, blames harm reduction tactics for the city’s continued crisis, arguing during a recent political rally that the strategy “is not reducing the harm” of substance use.

Earlier this year, Oregon’s legislature repealed an initiative voters had passed in 2022 that largely decriminalized drug use. But amid surging overdose death rates and public safety concerns, the new law quickly grew unpopular.

Despite the backlash, casting harm reduction as inherently opposed to order and public safety is a false choice, argued Keith Humphreys, a psychologist and professor of psychiatry at Stanford University.

“We seem to have trouble treating things as dials,” he said, casting the public’s apparent view as: “You can have a carceral, racist drug war — or a free-for-all, and you can’t do anything.”

Common examples of harm reduction programs include syringe exchanges that allow people who use drugs to use substances without fear of contracting an infectious disease from a shared needle, or distributing drug testing strips so that people consuming certain stimulants or party drugs can do so knowing the substances don’t contain fentanyl. A large body of academic literature shows that syringe exchange and similar tactics are effective at reducing drug use’s most acute harms.

The Biden administration has been historically open to harm reduction strategies, publicly supporting the use of fentanyl test strips and syringe exchanges, and generally encouraging a treatment-focused approach as opposed to one reliant on policing and enforcement.

Even as the White House has increasingly supported bold overdose-reduction strategies, however, the U.S. drug supply has grown more toxic thanks largely to fentanyl and xylazine, and drug deaths have increased steadily. Preliminary data released this week showed that overdoses decreased slightly in 2023 for the first time in five years, but remain at near-record levels, with synthetic opioids like fentanyl accounting for a large majority of deaths.

Critics who say harm reduction enables or encourages drug use miss the mark, said Braunz Courtney, the executive director of the HIV Education and Prevention Project of Alameda County, an Oakland-based harm reduction organization.

“People say: Why don’t you just get clean?” he said. “Well, that sounds good. But in reality, let’s think about our own behavior change, and when your doctor says: Don’t eat all those donuts; stop drinking two cups of coffee; stop smoking all those cigarettes.”

San Francisco’s drug crisis is not intractable, Humphreys argued, thanks to proven strategies like harm reduction and treatment. And while he cautioned against returning to the enforcement-first drug policies of decades past, he acknowledged not only the public’s declining perception of harm reduction but also that locals, in many cases, are right to be frustrated.

“The challenge is that addiction is a real disease, it is a health problem, and people do things when they’re addicted and when they’re on drugs that harm others,” Humphreys said. “And people who don’t use drugs are part of our city and our country, too. So we have to provide that compassionate care, but also say, of course, it’s your home — you want to be able to walk down the street.”

STAT’s coverage of chronic health issues is supported by a grant from Bloomberg Philanthropies. Our financial supporters are not involved in any decisions about our journalism.