The Harm Reduction Industrial Complex

Harm reduction can save lives. But when survival becomes the endpoint, the system risks losing sight of recovery—and of the harm addiction inflicts on everyone nearby.

On my first day at a new job in social services, one of the senior outreach workers took me along as she made her rounds.

During the drive, I asked about her life, her work, and what had brought her to Minnesota.

“I came here for treatment and stayed,” she told me.

“Oh, well, congratulations,” I said.

She scoffed.

“Thanks.”

It was the kind of thanks that tells you immediately that you have said something embarrassingly naïve. I didn’t yet understand why congratulating someone on recovery was embarrassing.

But I soon would.

We arrived at a temporary housing project, where I sat down behind a table covered with supplies: sterile syringes, glass pipes, filters, tin foil, rubber bands and other paraphernalia used to consume illicit drugs.

There was also a stack of $5 grocery-store gift cards.

“What are these for?” I asked.

“Incentives.”

“Incentives for what?”

“Engagement. If somebody says hi or takes some supplies or whatever, just give them one.”

The first man who approached took handfuls of supplies. I gave him a gift card.

“How much is it?”

“Five dollars.”

He threw it back at me.

The card bounced off my face.

This wasn’t my first rodeo with harm reduction. I’d already worked in shelters, street outreach and housing programs. Until then, I had regarded harm reduction with something between neutrality and cautious approval.

The basic philosophy wasn’t difficult to understand.

People deserve dignity and compassion even when they are making choices that are destructive, dangerous, or infuriating. Refusing to abandon someone in the darkest hour of his life, even when that hour lasts a lifetime, does not require approval of everything he does.

And some of it quite literally reduced harm. I had no philosophical objection to needle exchanges, for example. If someone brought in a used syringe and received a sterile one in return, a specific risk had been reduced. Research has consistently associated access to sterile injection equipment with lower transmission of blood-borne infections.

But not every harm worth reducing could be measured in infection rates.

Years earlier, I knew an older man who had been homeless for a long time and suffered from severe alcoholism. For most of the month, he drifted around the city, sleeping outside, riding trains and occasionally staying in shelters.

Then his monthly SSI check arrived.

He would drink heavily for days.

The pattern was so predictable that other people on the streets knew it, too. Once he was profoundly intoxicated, he became an easy target. He would be assaulted, forced to reveal the PIN to his benefits card and robbed of the money that was supposed to last him the month.

Then came some combination of the emergency room, detox, jail, and another stack of minor criminal charges, mostly things like trespassing on public transit or having an open bottle.

Then the cycle began again.

Simply telling him to get sober wasn’t a housing plan. But helping him find permanent housing where he could continue drinking, with a representative payee protecting his income, could keep him off the streets, protect him from the people who preyed on him when he was drunk, and slow the costly carousel through emergency rooms, detox, police encounters and jail.

He’d probably still drink. We weren’t solving his addiction, but we could reduce some of the dangers that came with it.

That version of harm reduction made sense to me.

What I didn’t understand then was how elastic the word “harm” could become.

Over the years, I attended trainings on safer drug use. Some were straightforward: recognizing an overdose, administering naloxone, understanding dangerous combinations of drugs.

Others pushed the concept considerably further.

I sat through instruction on how to advise people about injecting drugs into their genitals when other veins were no longer usable.

I was encouraged to hand out educational materials explaining how to administer drugs rectally, and how to do it more safely.

These weren’t grassroots efforts run from someone’s trunk. The money was real.

At organizations serving people in desperate poverty, I heard leadership discuss the unusual problem of having more harm-reduction money than they knew how to spend. Entire departments had grown around the work, with dedicated staff and directors often earning more than $100,000 a year.

What had once sounded to me like a simple public-health philosophy had become something closer to a harm-reduction industrial complex: grant-funded positions, conferences, trainings, travel, supplies, client incentives, and a professional language and moral framework that increasingly shaped how addiction itself was understood.

According to Minnesota’s own opioid-response spending data, more than $24 million in awards are categorized specifically as “harm reduction.” That doesn’t mean $24 million was spent on pipes and syringes. The grants also pay for naloxone, testing, salaries, outreach, training and referrals.

But I suspect most taxpayers have no idea what some of that spending looks like by the time it reaches the ground.

At some point, I started asking a question that seemed increasingly unwelcome: Where exactly is the line between reducing the harm caused by drug use and helping someone use drugs?

Harm-reduction advocates have a serious answer to that question. People with severe addictions do not generally stop using because a social worker refuses to give them a clean syringe or pipe. Withholding safer-use supplies may therefore increase the risk of infection, injury or death without preventing the drug use itself. Maintaining a nonjudgmental relationship can keep someone connected to medical care and other services that conventional systems have often failed to provide. Advocates also argue that keeping someone alive and engaged today preserves the possibility of treatment or recovery tomorrow. Even small incentives are intended not as rewards for drug use, but as a way to establish contact with people who may otherwise remain entirely outside the system.

I understood that argument. I had worked within it.

But increasingly, I wondered where it ended.

Harm reduction made sense to me as a way of managing an immediate danger. Somewhere along the way, it seemed to become an end in itself. The question was no longer only how to keep someone alive long enough to have another chance. It was how to make virtually any decision surrounding drug use safer, with remarkably little professional appetite for saying that some decisions were, in fact, worse than others.

During the early COVID era, I worked at a hotel converted into a shelter for people who had been living outside.

Like many institutions at the time, we had a mask policy.

I remember reminding residents to pull their masks over their noses while handing out bags of syringes.

Sometimes, I would walk past someone slumped in a chair, barely conscious, with a needle protruding from an arm.

A needle we had just provided.

But at least he had his mask on.

There was something absurd about it. There was also something terribly sad.

The contradiction stayed with me.

Public health had decided COVID presented enough danger to justify extraordinary intervention into individual behavior. We could tell adults what to put on their faces, where to stand and how closely they could sit together.

Addiction was obviously different from an infectious respiratory disease. But the contrast still struck me. When authorities believed a risk justified intervention, autonomy suddenly had limits.

Addiction seemed governed by a different ethic.

In my experience, respecting autonomy increasingly seemed to mean that the role of the professional was not to direct, discourage or even necessarily express alarm, but to make whatever the person had decided to do somewhat safer.

And sometimes the consequences extended beyond the person using drugs.

I encountered women who were visibly near the end of pregnancy and actively using dangerous drugs. The response remained familiar: provide safer-use supplies, maintain engagement, avoid alienating the mother.

I understood the reasoning. Addiction doesn’t disappear when someone becomes pregnant, and shame can drive people away from medical care.

But by then, my concern about children wasn’t theoretical.

Twice, I met mothers whose infants had been exposed to fentanyl in their homes. Both babies overdosed and, thankfully, survived.

Those experiences made it impossible for me to think about drug use only through the autonomy and safety of the adult using.

So when I encountered pregnant women using drugs, or children living in homes where dangerous drugs were present, I found it increasingly difficult to accept a professional culture in which preserving engagement could seem to take precedence over expressing alarm.

There was another vulnerable human being involved now.

What about the child?

Years ago, I met with a tribal elder who gave me another way of thinking about that question.

He was talking about what Native children in his community carried with them into school. If home was unstable, he explained, the instability didn’t end when they walked out the door. On the way to school they encountered people from their community profoundly intoxicated, discarded needles, and the visible consequences of addiction.

By the time they arrived at school, they had put on armor.

A teacher might spend six hours trying to penetrate it, convincing a child that this room was safe, that adults could be trusted, that his future could look different.

Then the bell rang.

He walked back through the same neighborhood, past the same needles and the same adults folded over on the train, and returned to the home he’d left that morning.

I have thought about that conversation for years because it raised a question much larger than whether handing someone a clean needle prevents an infection.

Whose harm are we counting?

The person using drugs matters.

So does the child stepping over the syringe.

The pregnant woman struggling with addiction matters.

So does the developing child she carries.

The intoxicated man on the train matters.

So does the exhausted mother several seats away, quietly deciding whether she should move her children to another car.

And I think this is where parts of the harm-reduction movement have lost their way.

At its best, harm reduction contains a profound and necessary truth: human dignity isn’t something we earn by behaving well. Sometimes the compassionate thing is simply to keep someone alive, reduce the immediate danger and refuse to give up on him.

But a philosophy built around reducing harm ought to remain unusually interested in two questions:

What harm are we reducing?

And what other harms might we be creating, tolerating or simply refusing to count?

Those questions should not be heretical. Neither should acknowledging that some outcomes are better than others.

It is better not to die of an overdose or contract HIV from a shared syringe. It is better for a vulnerable alcoholic to sleep somewhere he won’t freeze to death or be beaten and robbed.

And yes, it is better to recover from an addiction than to remain trapped inside one.

Harm-reduction advocates often repeat a slogan: “Harm reduction saves lives.”

Sometimes it unquestionably does. Naloxone saves lives. Sterile syringes prevent deadly infections. Keeping a vulnerable alcoholic indoors may save his life, too.

And keeping someone alive is no small accomplishment. Sometimes it is the only accomplishment possible that day.

But keeping someone alive is not the same thing as believing there is nothing better to hope for.

There is a difference between refusing to abandon someone because he is destroying himself and becoming so committed to making that destruction safer that we lose our willingness to say he deserves something better.

Meet people where they are. Keep them alive. Treat them like human beings. Reduce the suffering you can today, even when you cannot solve the larger problem.

But don’t become so committed to meeting people where they are that you forget to ask where we’re hoping they might go.