Guest Blog by Sheila Vakharia PhD MSW in Brooklyn, NY from twitter with permission.

Comments in [ ] are from MSTH to offer a Canadian context and/or definitions.

There are serious consequences to learning about/being exposed to the concept of “harm reduction” in regards to a single class of drugs (i.e. opioids) and believing that it is about providing interventions and materials rather than an entire philosophy and approach to caring when I look at any drug use and try to support harm reduction, I think of the 3 domains where harm and risk can be reduced-

the drug itself,
the set/person who is using, and
the setting- immediate environment, but also policy and structural factors.

So when we look at the “drug” factors and how to reduce harm, it means ANY drug. And acknowledging that the Prohibitionist policy setting contributing to adulterated drugs may mean that harm reduction is a safe regulated supply or viable substitutes/alternates.

This includes offering a supply in the same class of drugs with safe equipment to use it (injectable agonists), the same class of drug with alternative safer mode of consumption (ecigs, Rx stims), another class of drug that might still “scratch the itch” (marijuana adjuncts), etc.

To be a harm reductionist, i cannot exceptionalize any drug and must be able to view its harms and risks through the eyes of the user. No drug is taboo. No drug is bad. (These thoughts inevitably contaminate relationship w user and threaten any foundation of respect).

If you were trained in what you think is harm reduction but it was substance-specific—opioids, not stimulants; Alcohol, not benzos; Marijuana, not fentanyl; Tobacco, not LSD; you need to acknowledge this limitation and work to zoom out.

This is why I struggle with new organisations and “allies” who are only “harm reductionists” by substance- and even then, have limited imaginations for the ways harms can be reduced- particularly through decrim and regulatory models. All these professionals (public health, medicine, nurses, etc) who agree that we need syringe access, naloxone, methadone and bupe [Suboxone]. But stop at injectable agonists, safer consumption spaces, or all drug decrim. If you struggle with some, not others- I’m sorry, that’s not harm reduction.

You’ll advocate to “decrim plants” [MSTH: The author is based in the US where Cannabis is still not legal in most states] but not drugs made in a lab? Y*ng said drugs should be decriminalized yet believed that people who OD should remain hospitalized for 3 days.

I know of a legislator somewhere who supports Safer Consumption Spaces but also is okay with homeless folks with substance use and mental health challenges being involuntarily committed.

You’re not worried about your license for off-label prescribing stimulants to 8 year olds yet a full grown adult user of potent adulterated street meth is “too much of a risk”.

You know the criminal justice system harms your patients with opioid use disorder but you’re fine with marijuana prohibition [MSTH: In the US] which puts young black and brown men in contact with this system everyday?