Harm reduction in the United States

Drug checking describes the processes by which a user may test a substance for the presence of a variety of drugs to determine what drugs the substance contains before consumption.{{Cite journal |last1=Fregonese |first1=Martina |last2=Albino |first2=Andrea |last3=Covino |first3=Claudia |last4=Gili |first4=Alessio |last5=Bacci |first5=Mauro |last6=Nicoletti |first6=Alessia |last7=Gambelunghe |first7=Cristiana |date=22 February 2021 |title=Drug Checking as Strategy for Harm Reduction in Recreational Contests: Evaluation of Two Different Drug Analysis Methodologies |journal=Front Psychiatry |volume=12 |page=596895 |doi=10.3389/fpsyt.2021.596895 |pmid=33692707 |pmc=7938318 |doi-access=free }} One common form of drug checking is fentanyl test strips (FTS). FTS are an affordable product available as small paper strips that can detect the presence of fentanyl.{{Cite web |title=Fentanyl Test Strips: A Harm Reduction Strategy |url=https://www.cdc.gov/stopoverdose/fentanyl/fentanyl-test-strips.html |website=Centers for Disease Control and Prevention|date=16 February 2023 }} The Centers for Disease Control and Prevention (CDC) determined synthetic opioids, like fentanyl, to be the main culprit in increased U.S. opioid-related deaths.{{Cite web |last=CDC Health Alert Network |date=17 December 2020 |title=Increase in Fatal Drug Overdoses Across the United States Driven by Synthetic Opioids Before and During the COVID-19 Pandemic |url=https://emergency.cdc.gov/han/2020/han00438.asp?ACSTrackingID=USCDC_1026-DM45245&ACSTrackingLabel=December%202020%20Drug%20Overdose%20Updates&deliveryName=USCDC_1026-DM45245 |website=Centers for Disease Control and Prevention}} In 2017, 38.9% of drug overdose deaths in the U.S. involved fentanyl.{{Cite journal |last1=Hedegaard |first1=Holly |last2=Bastian |first2=Brigham A. |last3=Trinidad |first3=James P. |last4=Spencer |first4=Merianne Rose |last5=Warner |first5=Margaret |date=25 October 2019 |title=Regional Differences in the Drugs Most Frequently Involved in Drug Overdose Deaths: United States, 2017 |url=https://www.cdc.gov/nchs/data/nvsr/nvsr68/nvsr68_12-508.pdf |journal=National Vital Statistics Reports |volume=68 |issue=12 |via=Centers for Disease Control and Prevention}} According to the CDC, the "12-month count of synthetic opioid deaths increased 38.4% from the 12-months ending in June 2019 compared with the 12-months ending in May 2020."

In April 2021, the CDC and the Substance Abuse and Mental Health Services Administration (SAMHSA) announced that federal funding can be used in the purchase of rapid FTS.

Syringe exchange programs (SEPs), syringe services programs (SSPs), or needle exchange programs (NEPs), involve the implementation of safe used syringe disposal as well as access to clean syringes.{{Cite web |title=Syringe Services Programs (SSPs) FAQs |url=https://www.cdc.gov/ssp/syringe-services-programs-faq.html |website=Centers for Disease Control and Prevention|date=7 December 2020 }}

Intravenous drug use places the user at an increased risk of contracting human immunodeficiency virus (HIV) as well as hepatitis C virus (HCV).{{Cite journal |last1=Hagemeier |first1=Nicholas E. |last2=Dowling-McClay |first2=KariLynn |last3=Baladezaei |first3=Mahnaz |last4=Curtis |first4=Sabrina J. |last5=Spence |first5=Matthew |date=April 2021 |title=Pharmacists' nonprescription syringe dispensing perceptions and behaviors: A three-state descriptive analysis |url=https://doi.org/10.1016/j.drugalcdep.2021.108597 |journal=Drug and Alcohol Dependence |volume=221|page=108597 |doi=10.1016/j.drugalcdep.2021.108597 |pmid=33631542 |s2cid=232057697 }} According to the CDC, HIV can survive on a syringe for up to 42 days, which means that an HIV-negative individual who uses a syringe can potentially contact the virus weeks after it was used by an HIV-positive individual.{{Cite web |title=HIV and Injection Drug Use |url=https://www.cdc.gov/hiv/basics/hiv-transmission/injection-drug-use.html |website=Centers for Disease Control and Prevention|date=30 March 2022 }} Sharing syringes is the second biggest risk factor for contracting HIV after receptive anal sex. Of the 3,216 reported cases of acute HCV in the U.S. in 2017, 1,059 individuals reported participating in injection drug use.{{Cite web |title=Hepatitis C Tables and Figures |url=https://www.cdc.gov/hepatitis/statistics/2017surveillance/TablesFigures-HepC.htm#tabs-1-11 |website=Centers for Disease Control and Prevention|date=10 February 2021 }}

As of February 2023, according to the North American Syringe Exchange Network (NASEN), 45 states in the U.S. had some form of syringe exchange in at least one location, with the exceptions being Kansas, Mississippi, Nebraska, South Dakota, and Wyoming.{{Cite web |title=Harm Reduction Locations |url=https://nasen.org/ |website=NASEN}}

In some places, such as Seattle Washington, foil and drug pipes purchased at tax payer expenses for distribution to drug users.{{Cite web |last=Rantz |first=Jason |date=2024-09-23 |title=Public Health Seattle distributes drug kits with pipes, instructions |url=https://mynorthwest.com/3988709/rantz-it-was-shockingly-easy-for-me-to-get-taxpayer-funded-drug-kits-with-pipes-cookers-more/ |access-date=2024-11-04 |website=MyNorthwest.com |language=en}}

The Federal Consolidated Appropriations Act of 2016 allows for state and local health departments may allocate federal funding from the Department of Health and Human Services (DHHS) to SEPs.{{Cite web |title=Determination of Need for Syringe Services Programs |url=https://www.cdc.gov/ssp/determination-of-need-for-ssp.html#:~:text=Under%20the%20Consolidated%20Appropriation%20Act,to%20purchase%20needles%20or%20syringes. |website=Centers for Disease Control and Prevention| date=2 March 2022 }} However, federal funds are not permitted to be used in the purchase of syringes or needles. Health departments interested in DHHS funding for SEPs are required to consult with and present evidence to the CDC that the community they serve is either currently in or at risk for an outbreak of HIV of hepatitis infections as a direct result of syringe drug use. The use of Federal grant for the purchase of smoking supplies, such as drug pipes is prohibited.{{Cite journal |last=Russoniello |first=Kellen |last2=Vakharia |first2=Sheila P. |last3=Netherland |first3=Jules |last4=Naidoo |first4=Theshia |last5=Wheelock |first5=Haven |last6=Hurst |first6=Tera |last7=Rouhani |first7=Saba |date=January 2023 |title=Decriminalization of drug possession in Oregon: Analysis and early lessons |url=https://journals.sagepub.com/doi/10.1177/20503245231167407 |journal=Drug Science, Policy and Law |language=en |volume=9 |doi=10.1177/20503245231167407 |issn=2050-3245}} Federal law also prohibits the sale, importation and mailing of drug paraphernalia.{{Citation |last=Sullivan |first=Kevin |title=Code of Federal Regulations Title 31 Section 103.18 |date=2015 |work=Anti–Money Laundering in a Nutshell |pages=171–173 |url=http://dx.doi.org/10.1007/978-1-4302-6161-2_11 |access-date=2024-11-04 |place=Berkeley, CA |publisher=Apress |isbn=978-1-4302-6160-5}}{{Cite web |title=Drug Paraphernalia Fast Facts |url=https://www.justice.gov/archive/ndic/pubs6/6445/index.htm |access-date=2024-11-04 |website=www.justice.gov}}

A safe consumption facility, or a safe injection site, is a supervised environment in which an injection drug user can inject externally acquired substances in the presence of a licensed health care professional.{{Cite journal |last1=Beletsky |first1=Leo |last2=Davis |first2=Corey S. |last3=Anderson |first3=Evan |last4=Burris |first4=Scott |date=February 2008 |title=The Law (and Politics) of Safe Injection Facilities in the United States |journal=Am J Public Health |volume=98 |issue=2 |pages=231–237 |doi=10.2105/AJPH.2006.103747|pmid=18172151 |pmc=2376869 }} On-site staff may not assist in the injection of drugs, but may provide services like wound care, overdose monitoring, and safe supply. The CDC urges drug users to never use drugs alone to lower the risk of a fatal overdose. Safe injection facilities create a space in which users do not have to inject drugs alone and are in the presence of personnel who can administer naloxone or provide emergency medical care if needed.

The Third Circuit of the U.S. Court of Appeals ruled in January 2021 that opening of site for consumption of illegal drugs is a federal crime.{{Cite web |last=U.S. Department of Justice |date=13 January 2021 |title=Appellate Court Agrees with Government that Supervised Injection Sites are Illegal under Federal Law; Reverses District Court Ruling |url=https://www.justice.gov/opa/pr/appellate-court-agrees-government-supervised-injection-sites-are-illegal-under-federal-law |website=U.S. Department of Justice}} This decision was rooted in the Controlled Substances Act, which bans an entity from providing a space intended for illicit drug use.

Medication-assisted treatment (MAT) combines behavioral therapy and counseling with the use of medication.{{Cite web |date=14 February 2019 |title=Information about Medication-Assisted Treatment (MAT) |url=https://www.fda.gov/drugs/information-drug-class/information-about-medication-assisted-treatment-mat |website=U.S. Food and Drug Administration}} MAT is used effectively in the treatment of opioid use disorders (OUD). The U.S. Food and Drug Administration (FDA) has approved buprenorphine, methadone, and naltrexone for use in MAT.

Title 42 of the Code of Federal Regulations (CFR) Part 8 details the certification and accreditation process for opioid treatment programs.{{Cite web |title=Title 42 Chapter I Subchapter A Part 8 |url=https://www.ecfr.gov/current/title-42/chapter-I/subchapter-A/part-8?toc=1 |website=Code of Federal Regulations}} This process is overseen by SAMHSA.{{Cite web |title=Medications for Substance Use Disorders: Statutes, Regulations, and Guidelines |url=https://www.samhsa.gov/medications-substance-use-disorders/statutes-regulations-guidelines |website=Substance Abuse and Mental Health Services Administration|date=15 June 2015 }}

Heroin-assisted treatment (HAT), also called heroin maintenance, consists of, diacetylmorphine, or pharmaceutical-grade heroin, being administered in clinics under medical supervision.{{Cite journal |last1=Nadelmann |first1=Ethan |last2=LaSalle |first2=Lindsay |date=12 June 2017 |title=Two steps forward, one step back: current harm reduction policy and politics in the United States |journal=Harm Reduction Journal |volume=14 |issue=37|page=37 |doi=10.1186/s12954-017-0157-y |pmid=28606093 |s2cid=7279103 |pmc=5469032 |doi-access=free }} This treatment approach is designed for individuals who use illicit heroin but wish to stop.

The North American Opiate Medication Initiative (NAOMI) disclosed plans in 1999 for three U.S.-based sites to administer HAT as part of a randomized controlled trial of HAT, but were unable to proceed due to regulatory barriers.

Since heroin is categorized as a Schedule I drug by the U.S. Drug Enforcement Administration (DEA), it cannot be prescribed legally at this time.{{Cite web |title=Drug Scheduling |url=https://www.dea.gov/drug-information/drug-scheduling#:~:text=Schedule%20I%20drugs%2C%20substances%2C%20or,)%2C%20methaqualone%2C%20and%20peyote. |website=United States Drug Enforcement Administration}} Schedule I drugs are considered by the DEA to lack a current medical use as well as possess a high risk of abuse.

Naloxone, often referred to by the commercially available brand name Narcan, is an antagonist that can reverse an opioid overdose.{{Cite journal |last1=Berardi |first1=Luca |last2=Bucerius |first2=Sandra |last3=Haggerty |first3=Kevin D. |last4=Krahn |first4=Harvey |date=February 2021 |title=Narcan and Narcan't: Implementation factors influencing police officer use of Narcan |journal=Social Science & Medicine |volume=270|page=113669 |doi=10.1016/j.socscimed.2021.113669 |s2cid=231610927 }} Narcan is distributed as a nasal spray, though other forms of naloxone are administered intravenously. For example, the FDA has approved Evzio as a naloxone auto-injector, which includes verbal instructions for use.{{Cite web |date=March 2017 |title=Naloxone for Opioid Overdose: Life-Saving Science |url=https://permanent.fdlp.gov/websites/www.drugabuse.gov/publications/naloxone-opioid-overdose-life-saving-science/naloxone-opioid-overdose-life-saving-science%20(4).htm |website=National Institute on Drug Abuse}} In the U.S., at least 26,500 overdoses were reversed through the administration of naloxone by civilians between 1996 and 2014.{{Cite web |last1=Wheeler |first1=Eliza |last2=Jones |first2=T. Stephen |last3=Gilbert |first3=Michael K. |last4=Davidson |first4=Peter J. |date=19 June 2015 |title=Morbidity and Mortality Weekly Report (MMWR): Opioid Overdose Prevention Programs Providing Naloxone to Laypersons – United States, 2014 |url=https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6423a2.htm |access-date=2023-03-03 |website=www.cdc.gov}}

Since its inception in 2017 through 2019, NEXT Harm Reduction distributed naloxone kits by mail to 3,609 individuals and received 335 reports of overdose reversals by naloxone provided by NEXT and its affiliates.{{Cite journal |last1=Yang |first1=Carol |last2=Favaro |first2=Jamie |last3=Meacham |first3=Meredith |date=April 2021 |title=NEXT Harm Reduction: An Online, Mail-Based Naloxone Distribution and Harm-Reduction Program |journal=American Journal of Public Health |volume=111 |issue=4 |pages=667–671 |doi=10.2105/AJPH.2020.306124|pmid=33600254 |s2cid=231963654 |pmc=7958031 }}

According to the CDC, naloxone is available in all 50 states.{{Cite web |date=25 January 2023 |title=Lifesaving Naloxone |url=https://www.cdc.gov/stopoverdose/naloxone/index.html#:~:text=Naloxone%20is%20available%20in%20your%20state.&text=However%2C%20in%20most%20states%2C%20you,local%20pharmacy%20without%20a%20prescription.&text=You%20can%20also%20get%20naloxone,and%20most%20syringe%20services%20programs.&text=Recognizing%20the%20signs%20of%20opioid%20overdose%20can%20save%20a%20life. |website=Centers for Disease Control and Prevention}} State laws vary in terms of immunity for legal liability in the prescription, distribution, and administration.{{Cite web |date=January 2023 |title=Naloxone Access: Summary of State Laws |url=http://legislativeanalysis.org/wp-content/uploads/2023/02/Naloxone-Access-Summary-of-State-Laws.pdf |website=Legislative Analysis and Public Policy Association}}

20 states have codified the prescription of naloxone accompanying the prescription of an opioid, known as co-prescription.

Mount Sinai Hospital's Respectful and Equitable Access to Healthcare Program (REACH) received Opioid Overdose Prevention Status (OOPP) in 2017.{{Cite journal |last1=Riazi |first1=Farah |last2=Toribio |first2=Wilma |last3=Irani |first3=Emaun |last4=Hughes |first4=Terence M. |last5=Huxley-Reicher |first5=Zina |last6=McBratney |first6=Elisa |last7=Vu |first7=Trang |last8=Sigel |first8=Keith |last9=Weiss |first9=Jeffrey J. |date=2021 |title=Community Case Study of Naloxone Distribution by Hospital-Based Harm Reduction Program for People Who Use Drugs in New York City |journal=Frontiers in Sociology |volume=6 |page=619683 |doi=10.3389/fsoc.2021.619683 |pmid=34307540 |pmc=8292929 |issn=2297-7775 |doi-access=free }} REACH acquired funding from the New York City Department of Health and Mental Hygiene for the creation of overdose education and naloxone distribution. As a result, 4,235 naloxone kits were distributed to 3,906 individuals and REACH conducted both bystander training and clinic staff training.

On November 29, 2021, New York City officials authorized the nation's first two supervised injection facilities in Manhattan, one in East Harlem and one in Washington Heights. These sites are operated by OnPoint NYC.{{Cite news |last1=Mays |first1=Jeffery C. |last2=Newman |first2=Andy |date=30 November 2021 |title=Nation's First Supervised Drug-Injection Sites Open in New York |language=en-US |work=The New York Times |url=https://www.nytimes.com/2021/11/30/nyregion/supervised-injection-sites-nyc.html |access-date=6 March 2023 |issn=0362-4331}} Former mayor Bill de Blasio authorized the center shortly before his departure and the succeeding mayor Eric Adams shows support, however Federal prosecutor for Manhattan said the site is illegal. It remains uncertain if or what actions will be taken.{{Cite news |date=2023-08-08 |title=Federal Officials May Shut Down Overdose Prevention Centers in Manhattan |language=en |url=https://www.nytimes.com/2023/08/08/nyregion/drug-overdoses-supervised-consumption-nyc.html |access-date=2023-08-11}}

In November 1988, Prevention Point was started as an all-volunteer organization to distribute unused, sterile syringes in two neighborhoods.{{Cite journal |last1=Watters |first1=John K. |last2=Estilo |first2=Michelle J. |last3=Clark |first3=George L. |last4=Lorvick |first4=Jennifer |date=1994 |title=An Evaluation of Needle and Syringe Exchange in San Francisco |url=https://www.ncbi.nlm.nih.gov/books/NBK236639/ |journal=National Research Council (US) and Institute of Medicine (US) Panel on Needle Exchange and Bleach Distribution Programs}} Prevention Point operated illegally but was not frequently disrupted by law enforcement in its early years. The client pool grew quickly, with 7,821 syringes exchanged in the spring of 1989 compared to 343,833 syringes exchanged in the spring of 1992. The prospect of sanctioned drug consumption site in San Francisco is in doubt following the announcement related to New York City.{{Cite web |date=2023-08-10 |title=Drug Crisis: Future of SF Safe Consumption Sites in Doubt |url=https://sfstandard.com/2023/08/10/prosecutors-warning-casts-doubt-on-san-franciscos-safe-consumption-plans/ |access-date=2023-08-11 |website=The San Francisco Standard |language=en}}

The San Francisco Health Commission unanimously passed a resolution adopting harm reduction as a policy on September 5, 2000.{{Cite web |title=Harm Reduction Policy |url=https://www.sfdph.org/dph/comupg/oservices/mentalhlth/substanceabuse/harmreduction/default.asp |website=San Francisco Department of Public Health}} This was passed as a means for drug users' health as well as the prevention of sexually transmitted infections and HIV.

{{see|Opioid crisis}}

A working paper published in August 2021 suggests that expanded access to naloxone increased the distribution of fentanyl.{{Cite journal |last1=Doleac |first1=Jennifer L. |last2=Mukherjee |first2=Anita |date=6 March 2018 |title=The Effects of Naloxone Access Laws on Opioid Abuse, Mortality, and Crime |doi=10.2139/ssrn.3135264 |ssrn=3135264 |s2cid=4661876 |url=https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3135264}} This paper also found a positive correlation between naloxone access and the number of uses and/or potency of each use of opioids.

Dr. Laura G. Kehoe, medical director of the Massachusetts General Hospital Substance Use Disorder Bridge Clinic, shared in a U.S. News article that she believed stigma surrounding drug use to be a driving factor in the push against harm reduction initiatives.{{Cite news |last=Williams |first=Joseph P. |date=24 January 2019 |title=A Fight to Do No Harm: Strategies embraced elsewhere to curb the impact of drug addiction still face obstacles in the U.S. |work=U.S. News & World Report |url=https://www.usnews.com/news/healthiest-communities/articles/2019-01-24/opioid-crisis-harm-reduction-struggles-for-acceptance-in-us}}

• Drug Policy Alliance

{{Reflist}}

• [https://www.samhsa.gov/find-help/harm-reduction SAMHSA page on harm reduction]
• [https://nida.nih.gov/research-topics/harm-reduction NIDA page on harm reduction]
• [https://harmreductionhelp.cdc.gov/s/ The National Harm Reduction Technical Assistance Center], a joint project of the Centers for Disease Control and SAMHSA
• [https://harmreduction.org/ National Harm Reduction Coalition]

United States

Category:Drug policy of the United States