A conversation with Julia Pinsky, co-founder and executive director of Max’s Mission in Southern Oregon

You may have heard the term “harm reduction” and wondered what it means.

Simply put, harm reduction means what it says—reducing harm. Specifically, reducing the social and physical harms associated with substance use, including death. It centers around the idea that all people deserve safety, dignity and autonomy, and that substance use is not a moral failing.

International Overdose Awareness Day (Aug. 31) is the “the world’s largest annual campaign to end overdose, remember without stigma those who have died and acknowledge the grief of family and friends left behind.”

Those principals are at the core of harm reduction.

Harm reduction is not new in the United States. We can trace it to the early days of methadone treatment for heroin dependence in the 1960s, through the 1980s with syringe service programs in response to the HIV/AIDS crisis. Syringe service programs are now recognized as one of the most highly effective, evidence-based HIV prevention interventions for people who inject drugs.

To better understand the methods, concepts and benefits of harm reduction, we spoke to Julia Pinsky, co-founder and executive director of Max’s Mission – a nonprofit dedicated to saving lives in Southern Oregon through harm reduction education and distribution of the opioid overdose reversal medication naloxone. Pinsky lost her 25-year-old son, Max, to a heroin overdose in 2013. Three years later Pinsky and her husband David launched Max’s Mission.

Describe harm reduction and the core principals behind it.

Julia: The term “harm reduction” is a perfect descriptor, meaning exactly what it implies: reducing harm. At its core is the understanding that people willingly engage in risky behaviors, as they have throughout human history. Recognizing that the outcomes of those behaviors – in this case the use of legal and illegal drugs and substances – can sometimes result in significant injury and tragic consequences, harm reduction strategies try to reduce the rate and severity of these occurrences.

We also recognize that not everyone is willing or able to stop engaging in risky behaviors, so harm reduction strives to meet people where they’re at. It is a non-judgmental, non-stigmatizing comprehensive approach to meeting people actively using drugs and providing services to them.

The success of harm reduction is measured in the improvement of quality of life without focusing on stopping substance use. We are there to build relationships and trust, as many people actively using have lost contact with family and old friends. We are then able to provide guidance and access to services when someone is ready to find treatment. You never know when that might be, however. For some it will never happen, but that does not mean we cannot provide them significant help.

Harm reduction recognizes that all people deserve respect and dignity; that the self-determination of people who use illegal substances is sacred; and that race, economic status, past and current trauma, sexual discrimination, the unwarranted stigma born of sexual and gender identity, and other factors contribute to potential outcomes.

It is the entire person and not merely their risky behavior that is of the utmost importance, as well as the notion that any positive step is worth pursuing.

What are some examples of harm reduction?

Julia: Harm reduction is a common, everyday practice in most people’s lives. Seat belts, bike and motorcycle helmets, sun block, locking doors and many other activities are examples of routine, often second nature, harm reduction.

As it applies to substance use, harm reduction includes (but is not limited to) distribution and training on the use of the opioid overdose reversing drug naloxone; providing new injection and smoking equipment; safe consumption sites; the distribution of condoms and new sharps containers; the collection and disposal of used syringes and other drug use equipment; the distribution of educational information about safer use practices and dangers within the illicit drug supply (e.g., counterfeit drugs containing fentanyl, xylazine or other dangerous compounds); the distribution of drug testing strips to identify the presence of fentanyl or xylazine in drugs; wound care and connecting people with professional health care services; never using alone; the distribution of survival supplies (tents, clothing, sleeping bags, tarps, gloves, food, water, etc.); and providing treatment for those who feel they need help to lower their risk of harm or stop their substance use.

Who can practice or engage in harm reduction?

Julia: Harm reduction can be practiced by anyone. It is simply a matter of creating positive change, in any context. In terms of substance use, one of the easiest ways to accomplish this is to always carry naloxone and know how to use it. You could give a naloxone kit, for example, to anyone you think may need it, from someone living on the street to a teenager you think may be experimenting or just going to a party. Naloxone is now an over-the-counter drug (no prescription required) that is finally affordable for many at approximately $40 at local pharmacies, large box stores, etc.

In more formal settings, among harm reduction agencies around Oregon, the majority of people providing outreach have personal experience struggling with substance use and have benefited from harm reduction programs. They have earned formal peer qualifications and get ongoing training to better serve those in need. For many of these individuals, or “peers,” working in the harm reduction field is a significant part of their ongoing recovery.

How do we know harm reduction works?

Julia: Harm reduction programs have proven to be enormously successful in virtually every environment where they’ve been used. Harm reduction efforts, certainly, have been critical in helping people who struggle with mental health and substance use issues, and who frequently face a far greater degree of adversity, to improve their quality of life. And – it shouldn’t be overlooked! – simply to live.

The ability to access naloxone and learn how to use it, at no cost, has saved countless lives world-wide. Access to new syringes and other equipment has decreased the number of cases of HIV, Hepatitis-C (HCV), endocarditis and a host of other life altering and often fatal illnesses. According to the CDC, persons who inject drugs are about 50% less likely to contract HIV or HCV when they access syringe service programs.

Harm reduction programs are particularly valuable in hard-hit rural committees where services are scarce. They can provide effective and consistent access to treatment, wound care, new injection equipment, access to no-cost naloxone and other services to improve one’s quality of life.

The benefits of harm reduction also extend to the community, reducing the frequency of hospital visits and length of stays, and the degree to which medical intervention is required, particularly for injection drug users. One recent study found that the return on investment for syringe service programs in Philadelphia was around $240 million and that, at the same time, Baltimore saw a $62 million return. These are savings not only for taxpayers, but they help ease pressures on an already overburdened health care system.

People who take advantage of harm reduction services are often the most marginalized and stigmatized members of any community. They tend not to trust – let alone rely on – others. Syringe service programs can meet these people where they are in a non-threatening and non-judgmental manner and, over time and through multiple positive interactions, build relationships and trust. Those relationships can have very positive outcomes.

Additionally, research shows that people who begin using syringe service programs are five times more likely to seek treatment than those who do not. Those who use syringe service programs regularly are also three times more likely to stop using drugs than those who don’t.

Some believe that harm reduction promotes drug use and enables drug users, rather than helps them. What is your response to that?

Julia: In many ways harm reduction is the opposite of enabling. What we do prevents illness and death. Unfortunately, there is not enough treatment capacity for all the people who would like treatment today, tomorrow or next week. We are there helping people’s loved ones and those that have no one. No person is left behind.

It is also crucial to understand how extremely difficult if not impossible it is for someone to just stop using drugs if they have been using regularly, even for a brief period of time, without professional/medical help. This is even more true as drugs become increasingly potent and more addictive. Although one’s ability to simply quit can change over time, it’s key to how harm reduction works in the moment. Certainly, it’s a humanitarian failure and injustice to ignore the positive impact that can be made within the lives of those not ready to address their substance use issues.

Outreach—including naloxone distribution and training events, syringe service programs, and medical services offered in the field, among others—is the primary opportunity harm reduction organizations have to meet face to face with their participants. These meetings frequently lead to long-term relationships which build and nurture mutual trust and respect. It then becomes possible to have meaningful dialogue with participants, including assessing and addressing their willingness to consider treatment opportunities. Recent research shows that harm reduction participants who develop these relationships are far more likely to make positive changes in their living situations and substance use. Using a syringe service program has also been shown to help reduce feelings of powerlessness in people struggling with substance use issues.

Harm reduction also reduces the spread of blood-born illnesses such as HIV and viral hepatitis, as well as preventing illnesses and infections such as endocarditis, necrotizing fasciitis, wound infections and abscesses.

Is harm reduction worth the cost?

Julia: Harm reduction can save huge sums of money spent on fighting the illnesses I mentioned in the previous answer. The cost of one person’s life-long treatment for HIV is estimated to cost between $420,000 and $1 million. In the United States, the hospital costs associated with opioid overdose is nearly $2 billion a year, and the annual cost of overall opioid-related health care is approximately $35 billion. Billion.

In Oregon, the total cost of hospitalizations for injection drug use-related infections in 2018 was more than $150 million, with an average cost of $13,000 per hospital admission. Compared to the cost of a few new syringes and some community outreach, it’s hard to argue against harm reduction on financial grounds.

Is there anyone for whom harm reduction is not appropriate?

Julia: No, harm reduction is appropriate for everyone and in any context. Simply put, if a person is engaged in risky behavior, regardless of the nature of that risk, there are many ways to minimize or prevent negative outcomes.

While harm reduction can be a controversial topic among the general public and policy makers, is there any disagreement among those on the front lines of fighting the overdose crisis in terms of the effectiveness and/or strategies of harm reduction?

Julia: There is no disagreement that I am aware of among people on the front lines concerning the effectiveness of harm reduction. There are, of course, disagreements about what strategies best meet the needs of the participants. Meanwhile, there is virtually universal belief that harm reduction is an overwhelmingly useful strategy in combating many of the negative outcomes associated with substance use.

However, destructive misunderstandings often exist between policy makers and those directly involved in the practice of harm reduction, as well as in the public’s perception of harm reduction. The idea that “workers and clinicians” do not overwhelmingly support harm reduction is incorrect. The truth is “workers and clinicians” are too often unable to provide effective and critical harm reduction because of ill-conceived and ill-informed policies.

Obviously, many policy decisions are driven by public opinion (or backlash, as is frequently the case). The War on Drugs thinking stemming from the Nixon administration in the early 1970s sadly still predominates and is an overwhelming factor in the general lack of understanding and acceptance of the realities of people struggling with substance use issues—issues often compounded by homelessness. Persuading people these points of view are outmoded and unhelpful is perhaps the biggest existential battle with which harm reduction is forced to continue to grapple.

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