Harm reduction: An evidence-based approach to the drug war

Executive summary

Despite $2.7 trillion in public spending to address the drug overdose crisis, the United States continues to experience alarmingly high death rates, strained emergency systems, and ineffective intervention pathways. Current strategies that are largely centered on enforcement and abstinence-only treatment are not meeting the scale or complexity of the drug problem. Public systems remain reactive rather than preventative, leaving taxpayers to fund a revolving door of crisis care that fails to produce meaningful or lasting outcomes.

This policy brief presents a case for integrating harm reduction into the federal response, not as a replacement for drug treatment, but as a pragmatic complement. Harm reduction includes proven tools like naloxone distribution, syringe service programs, fentanyl test strip access, and supervised consumption sites. These interventions reduce healthcare costs, lower disease transmission, and improve individual and community outcomes without requiring drug abstinence. They represent low-cost, high-impact strategies that support public health and public safety alike.

To assess the current drug policy landscape, the brief includes a 50-state matrix evaluating implementation of five core harm reduction policies, including: syringe service programs (SSPs), naloxone access, legality of fentanyl test strips, Good Samaritan laws, and supervised consumption sites (SCSs). While two states meet all five benchmarks, others fall short due to outdated paraphernalia laws, inconsistent naloxone access, and surveillance practices that discourage participation. These gaps reduce effectiveness, create preventable costs, and deter early intervention by eroding trust in care systems.

Key policy recommendations in this paper include decriminalizing essential health tools, strengthening “Good Samaritan” protection laws, limiting surveillance in service delivery, and funding flexible, community-led initiatives. These policy reforms do not expand federal authority or create new regulatory structures. They promote local autonomy and make room for innovation by empowering the organizations best positioned to serve people on the ground.

Harm reduction is a public health approach that prioritizes safety, dignity, and evidence-based care, aiming to build trust in healthcare systems and ensure public resources are used effectively. It’s a practical path forward that aligns with the core principles of reducing government waste, investing in what works, and protecting individual liberty.

Based on the existing evidence, Reason Foundation concludes that expanding access to harm reduction services may be one of the most cost-effective, community-driven uses of funds designated to reduce the harms of the opioid crisis.

Introduction

The United States is confronting a multifaceted drug crisis that carries not only a significant economic burden but a devastating human toll as well. Opioid overdoses alone are projected to claim between 543,000 and 842,000 lives between 2020 and 2032. Beyond the personal loss, these deaths strain emergency response systems, drive up healthcare costs, and contribute to lost productivity and long-term societal expense.

Although treatment options exist, access remains uneven, and relapse rates continue to hover between 40% and 60%. Despite these challenges, many policies continue to prioritize a one-size-fits-all rehabilitation model—often centered around abstinence—which is not sufficient to meet the diverse needs of individuals struggling with substance use disorders.

Traditional treatments for substance use disorders include psychological therapies such as cognitive behavioral therapy, motivational interviewing, contingency management, and family therapy. Medication-assisted treatments (MAT) like methadone, buprenorphine, and naltrexone also offer effective options, as do mutual support groups. However, psychological therapies have an average dropout rate of 30%, and medication-assisted treatments often suffer from limited accessibility and a lack of coordination with psychological or peer-based support systems.

This current system is inefficient, as it fails to reach or retain many of the individuals most in need at great financial cost. For example, among those who inject drugs, preventable infections like HIV and hepatitis C are common due to unsafe injection practices like sharing needles. The average lifetime medical cost of one HIV infection is over $261,000, while hepatitis C treatment can exceed $38,000 per case. Preventable hospitalizations due to abscesses, infections, or overdoses also drive up costs, with each non-fatal overdose costing thousands in emergency department use alone.

In addition to their limitations in efficacy and accessibility, these approaches can unintentionally reinforce harmful stereotypes about people who use drugs. Abstinence-centered rehabilitation often assumes complete sobriety as the only path to recovery. This misconception perpetuates the false notion that one-size-fits-all treatment is effective for everyone. It shapes public opinion of substance use disorder as a moral failing instead of a health issue. It also drives policy and healthcare decisions that discriminate against people who use drugs and restrict access to harm reduction and treatment programs. The persistent ethical condemnation of drug use exacerbates the challenges of treating substance use disorder and prevents people from receiving or even seeking the assistance they need.

Substance use exists on a spectrum. Research shows that most drug use is occasional, short-term, and not associated with addiction. A clinical diagnosis of substance use disorder requires meeting specific criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), which classifies most drug use as “transient.” Unfortunately, treatment protocols often fail to reflect this definition, sidelining evidence-based approaches that could better align with actual patterns of use in communities.

Current research also supports the idea that addiction is not solely the result of individual behavior, but a complex condition influenced by biological, psychological, social, and environmental factors—including physical dependence. For many people with opioid use disorder, quitting abruptly can be dangerous. Unlike illnesses such as diabetes or cancer, which manifest with relatively uniform effects, the effects of addiction vary significantly from person to person. This complexity undermines the effectiveness of uniform treatment strategies. It also reinforces the importance of broadening public health responses to include harm reduction—a practical, compassionate approach that prioritizes health, safety, and human dignity without imposing immediate or total abstinence.

Harm reduction offers a pragmatic complement to existing treatment approaches. It prioritizes reducing the negative health consequences of drug use, particularly among individuals who are not yet ready or able to pursue abstinence. These programs include syringe service initiatives, naloxone distribution, and access to medication-assisted therapy—all of which have been shown to reduce emergency room visits, lower disease transmission, and improve long-term outcomes.

One illustrative example is Taiwan’s 2005 needle exchange program, launched during a surge in HIV among intravenous drug users. Despite the country’s strict anti-drug policies, the program reduced new HIV infections by 90% within four years—demonstrating the public health and fiscal power of targeted harm reduction policies. Similar evidence from cities like Vancouver and Lisbon supports this trend, showing how such approaches can relieve public health systems while improving the quality of life for individuals and families.

Despite the extensive data supporting harm reduction in mitigating drug-related harm, ongoing misinformation about drugs and those who use them continues to hinder widespread acceptance of these strategies in the United States.

However, other nations such as Portugal, Uruguay, the Netherlands, Canada, and Mexico have shifted towards more effective policies for mitigating the potential dangers of drug use. An international trend is emerging, with more nations adopting harm reduction approaches that uphold individual freedom and recognize the right of people to make informed decisions about drug use and treatment.

American policymakers should similarly refocus drug policies from the supply to the demand side and work primarily to reduce the harmful effects of drug use.

Full Policy Brief: Harm Reduction: An Evidence-Based Approach to the Drug War

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Source: https://reason.org/policy-brief/harm-reduction-an-evidence-based-approach-to-the-drug-war/