By Clarissa Donnelly-DeRoven

In December, the federal Substance Abuse and Mental Health Services Administration announced something that could change many lives: for the first time ever, the agency planned to distribute $30 million in grants to fund harm reduction services nationwide. Harm reduction practices aim to reduce some of the negative impacts of drug use. The theory goes that by providing people who use substances with certain things, they can use drugs more safely, and hopefully, stay alive. 

This new federal money could be used for syringes, since the new grant pulls its funds from the American Rescue Plan Act, which doesn’t carry the same restrictions on syringe purchases that most other federal grants do. It could also go toward, among other things, fentanyl test strips, naloxone and kits for more safely smoking illegal substances. 

This technical bit of news was exciting to those who work in harm reduction. These agencies often scrape by on shoestring budgets, especially when it comes to buying actual supplies to make drug use safer. 

Then, on Feb. 7, the conservative Washington Free Beacon learned about the grant program and published the headline: “Biden Admin To Fund Crack Pipe Distribution To Advance ‘Racial Equity.’”

The blowback was fierce. White House spokesperson Jen Psaki said that actual pipes were “never a part of the kit.” Sen. Marco Rubio (R-FL) and Sen. Joe Manchin (D-WV) introduced the Preventing Illicit Paraphernalia for Exchange Systems — or PIPES — Act, which would extend the same restrictions on syringe purchases that exist for most other federal funds to ARPA funds. Sen. Thom Tillis (R-NC) along with 13 other Senate Republicans wrote a letter to the Biden administration, adamantly opposing the funding of safe smoking kits, along with the allowance of some of the country’s first safe injection sites which recently opened in New York City. 

The letter, riddled with cherry-picked facts and inaccuracies, argues at one point that these harm reduction services are not “evidence-based” and “will negatively impact Americans suffering with substance use disorder.”

The uproar over the grant has left many who work in and study harm reduction even more tired, especially after a year that saw soaring death rates from overdoses. They point to much peerreviewed evidence and personal experience that demonstrate how harm reduction does, in fact, work — particularly when it comes to the distribution of safer use supplies like needles and pipes. Robust harm reduction programs have also been key in reducing overdose deaths and drug-use related infection in other countries

Smoking as harm reduction

Supplies for people who smoke illicit drugs, such as crack or methamphetamine, play an often overlooked role in the continuum of harm reduction care. 

“Any drug that you can smoke, you can also inject. Any drug that you inject, you can also smoke,” said Loftin Wilson, the harm reduction programs manager at the North Carolina Harm Reduction Coalition. “Basically, all drugs work for both routes of administration. And your risk of overdose is drastically lower if you’re smoking rather than injecting, and your risk of both bacterial and viral infection is way, way, way lower when you’re smoking versus injecting. 

“And so, basically, smoking is, in and of itself, a harm reduction strategy,” he said. 

While smoking substances such as fentanyl is generally safer than injecting it, sharing pipes can increase the transmission risk of respiratory diseases, such as COVID-19 and tuberculosis. A 2012 study in Toronto found that among people who smoked methamphetamine, many reported dry, cracked lips, and cuts and burns on hands and mouths from using improvised pipes or old pipes. 

The researchers found that sharing pipes was common. When people who have open sores share pipes, the glass can serve as a vector for certain bloodborne diseases such as hepatitis C and HIV, though the data on source of infection is often less clear in these situations. 

Distributing safer smoking kits — including pipes — could help reduce those risks, the researchers reasoned.

In 2016, France authorized drug check sites, safe places drug users can bring their samples to see if there are any unknown substances in them. Warnings of dangerous discoveries are put out through the country’s extensive harm reduction network. Photo credit: Taylor Knopf

A recent study from the Research Triangle Institute, a North Carolina-based nonprofit research organization, found that among a group of people in California who used opioids, smoking rather than injecting is on the rise.

Between 2018 and 2020, researchers followed a cohort of 395 people who used opioids. They found that from January to June 2019, 14 percent of the people in their survey reported smoking fentanyl every day over the last month, as opposed to injecting it. Then, between January and June 2020, the number of people smoking had risen to 28 percent.

People who switched consumption methods described having a more evenly paced high, getting more for their money, and experiencing fewer abscesses and soft tissue infections. They also described decreased stigma, due to fewer and fading scars from injection, which led some to feel more optimistic about the prospect of getting a job.

“The way people look at you, I feel like that, that stigma is a little less harsh when it comes to smokers. To whip out a foil on the street and take a hit is not so frowned upon like, [taking out] a needle and taking a shot,” one survey participant said. “It’s making me realize that I’m capable of doing more than just being a junkie.” 

There’s high demand for access to safer smoking equipment according to Jennifer Carroll, an assistant professor of anthropology who studies drug use and harm reduction at North Carolina State University. 

“A significant part of disease and overdose prevention through harm reduction relies upon recognizing and responding to demands,” she said. “The goal is, first and foremost, to get people to walk through the door and say hello.”

Improvements to the entire community

Though the federal harm reduction grant made no mention of supervised injection sites, the Senate Republicans’ letter to Biden expressed dismay at the possibility of federal funds going toward such a program. They claimed “supervised injection sites have led to an increase in crime, discarded needles, and social disorder in the surrounding neighborhoods,” citing their source as an opinion piece written by the conservative Heritage Foundation, which itself cites a report that’s been criticized by scholars.

Real data on safe consumption sites does exist, showing the opposite is actually true. 

Another study from the Research Triangle Institute looked at the impact a clandestine safe consumption site had on the surrounding community over a 10-year period. The site opened in 2014. Looking at data from 2010 to 2020, the researchers compared crime rates in the years before the site opened to the years after, and compared the location to two control sites. 

graph of two lines
The green line represents arrests in the 500 meter area around the unauthorized consumption site. The dotted line delineates when the site opened: five years of data before, five years of data after. “What you see there is that it was actually increasing in that neighborhood, steadily, the five years before. And then really, the line was very clear, that after it opened, it steadily started decreasing,” said Alex Kral, a researcher who co-authored the study. The red line shows arrests in a similar neighborhood during the same time period. “Our main point here is that at worst, the site looks just like another neighborhood that doesn’t have this,” Kral said. Credit: Alex Kral, RTI
a graph with a blue and a green line
The green line, again, shows arrest data in the 500 meter area surrounding the safe consumption site. The blue line represents arrests in a similar neighborhood, the second control group in the study. In this case, crime in the area without a safe consumption site increased, while crime surrounding the site declined. Credit: Alex Kral, RTI

Following the introduction of the site, the researchers found that the site either had a neutral impact on crime in the surrounding community, or a positive impact. In no case, did crime rise and the surrounding neighborhoods did not become more dangerous.

A 2016 study in Toronto found that when an unsanctioned inhalation facility was shuttered, public drug use rose. People who used drugs shared anecdotal evidence of experiencing more violence — people getting stabbed for their pipes, for example — and arrests. One person shared a story of seeing someone put a hot pipe into their pocket when the police came by, so they wouldn’t get caught and arrested. The pipe burned through their pocket and to their skin.

The RTI study mirrors what research in other countries has shown and builds on the belief that harm reduction programs don’t only benefit people who use their services — they can benefit an entire community.

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Alex Kral, an independent researcher at RTI who co-authored both studies, explained that when we think about harm reduction, it’s a mistake to think these programs help either people who use drugs, or the broader community. They help both. 

“What happens to people who are using drugs is really touching just about everybody in the United States at this point,” he said.

Expanding harm reduction services, whether that’s through safe consumption sites or safer smoking supply distribution, expands the reach of a harm reduction agency. 

“There are a lot of people who use drugs by way of smoking,” said Wilson, from the NC Harm Reduction Coalition. But, smokers aren’t typically reached by harm reduction programs that focus on people who inject drugs. Wilson said that means these smokers miss out on other services harm reduction agencies can offer, such as connections to community resources and peer support.

“I can give somebody everything they need to inject safely, but not what they need to smoke safely,” he said. “What that does is it actually pushes people toward the riskier option.”

Connecting people with harm reduction and syringe service programs increases their likelihood of accessing treatment for substance use disorder. A Seattle study found those who accessed syringe service programs were five times more likely to enter treatment than those who didn’t.

“Why would we deny people, who have not yet begun injecting, access to that pathway?” said Carroll. “People don’t come to syringe access programs the first time because they want treatment. They come to syringe access programs because they recognize that they’re at risk. They want to reduce that risk.”

Safer smoking distribution illegal in North Carolina

Despite the benefits, distributing and possessing pipes for smoking crack or methamphetamine is illegal in North Carolina under the state’s drug paraphernalia laws (there are some carve outs for the sale of “glass tubes or spitters” though the process is highly regulated). 

A 2016 law legalized syringe service programs in the state, but its reach is narrow. It applies only to syringes received from one of the official syringe exchange programs, not those bought at a pharmacy as NC Health News previously reported, and not any other safer use supplies.

Since the law was written, it has bothered people in harm reduction. The fracas last week over safer smoking supplies reinforced how securing funding for these products remains very much an uphill battle, despite evidence of effectiveness.

“It’s almost impossible to get federal funding to pay for syringes anyway,” Wilson said. Money for safer use services often comes from a hodgepodge of places — foundations, grants, donations, county health departments — and it’s almost never enough.

“It creates the situation where a lot of times we have money to do everything we need to do except the linchpin of what these problems are about, which is putting sterile syringes in people’s hands, right?” Wilson said. “Because nobody wants to bite that political bullet and say, like, ‘Yeah, that’s actually what we need to do and pay for.’”

All the uproar has made one thing especially clear to Carroll, from N.C. State: the science should guide these decisions, not knee-jerk reactions. 

“It is the height of hubris,” she said, “for senators who are not public health experts, are not medical experts and are not harm reduction experts to declare — based on their gut logic — what the appropriate response to the harms of substance use are in our communities.”

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Clarissa Donnelly-DeRoven covers rural health and Medicaid. She previously worked at the Asheville Citizen Times where she reported on the police, courts, and other aspects of the criminal justice system....