As Baltimore and other beleaguered cities struggle to fight the ongoing overdose crisis, harm reduction expert Sheila Vakharia says compassion, not stigma and criminalization, is needed to save lives.
Vakharia, who last month debuted her first book, “The Harm Reduction Gap,” recently spoke to The Long Haul at length about the importance of harm reduction practices as more than 100,000 Americans die of drug overdoses each year.
“I felt like we needed a kind of harm reduction 101 book, not only for folks who are coming up in the health professions or drug policy, but also for community members, family members of people who use drugs, people who identify as in recovery and people who are seeing what’s happening in the community around them and have a lot of questions about, 'Are we doing the best we can to help save lives?” Vakharia said.
Harm reduction has been described as a more compassionate, nuanced practice that aims to meet drug users where they are.
Rather than criminalize drug users or require abstinence, harm reductionists work to ensure that, if those using substances are not ready to get clean, they can use drugs safely and be treated with dignity.
Harm reduction initiatives include the distribution of sterile injection and smoking equipment, decriminalization and increased access to health care and social services.
With a background in social work, Vakharia began her work in treatment at a traditional, abstinence-based facility, she said.
As an intake coordinator and group facilitator, she was required to report to probation officers and child protective services — making her partially responsible for the livelihoods and freedom of clients.
“It flew in the face of so much of what I had been taught in social work school, where we were taught to support self-determination, be client-centered and have unconditional positive regard. There was a degree of animosity and distrust of our clients.
“While I was there, I was taking it all in, and I really loved working with people who used drugs, but there was so much wrong with how we were providing services. I didn’t deserve my clients’ trust. I hadn’t given them a reason to tell me the truth because the truth can lead to some really tough consequences,” she said.
Vakharia later took a job at a syringe service program, or SSP, which offered services such as sterile syringes for injection drug users.
She now works as the deputy director of the Department of Research and Academic Engagement at the Drug Policy Alliance, a New York-based nonprofit that works to fight the more than 50-year-old war on drugs and advocate for policies to help those who use drugs.
Vakharia and the organization’s work comes as fentanyl in particular contributes to an alarming number of overdose deaths, many of which harm reductionists view as entirely preventable.
Baltimore has become the epicenter of the crisis, cementing its role as the city with the highest overdose death rate in the nation.
The city’s death toll comprises more than 41% of overdose fatalities in Maryland, yet it accounts for only 9.5% of its population.
Baltimore had 182.3 deaths per 100,000 people — more than 1,000 overdose deaths — in the 12-month period ending October 2023, according to the most recent data from Maryland’s Office of Overdose Response.
To see more local and national overdose death data, take a look at The Long Haul’s Overdose Death Data Dashboard here.
All the while, U.S. drug policy has been fueled by harmful stigmas and defined by criminalization and a general sense of apathy.
That is not to say cities haven’t implemented harm reduction policies. The proliferation of access to naloxone is one indicator that the country is increasingly willing to embrace a more compassionate approach to treatment, Vakharia said.
“I will say that I’ve never heard or seen as many people saying ‘harm reduction’ and talking about harm reduction,” she said. “More and more people are becoming aware of harm reduction, largely through our interventions and tools.”
The Baltimore City Health Department, for example, already runs a mobile SSP. The department provides its services at 17 locations in the city, also offering HIV testing, overdose response training, counseling and resources to link people to treatment facilities.
“The biggest message I want people to get from reading the book is that it’s not an anti-treatment book, it’s not an anti-prevention book. Instead, it’s like, ‘Let’s look at our continuum of care critically and how can we ensure there is a touchpoint along our continuum of care so everyone can get the help and support they need.’
“With people dying at unprecedented rates, something needs to change,” Vakharia said.
There are also 10 other SSPs in the city with varying services, according to a map on the Maryland Department of Health’s website.
In addition, Baltimore has a relatively large amount of treatment facilities, with 112 drug and alcohol abuse programs within city limits, according to a national directory maintained by the U.S. Substance Abuse and Mental Health Services Administration.
But it’s not as simple as just having the programs, Vakharia said.
There are many other variables, such as what neighborhoods the services are located in, the hours and days they are open and whether they have mobile outreach or mail delivery of sterile equipment.
As for treatment facilities, it also is important to have adequate access to all levels of care, not just services such as detoxification, she said.
And Vakharia warned that, despite these programs, the opposition to harm reduction efforts is alive and well.
“We cannot get complacent and comfortable that any program is safe, or that any program we’re doing is mainstream enough not to be challenged or threatened,” Vakharia said. “A lot of this has to do with us emerging from post-COVID, after lockdowns were lifted and all those temporary supports that were offered to people who were struggling were no longer offered.”
Most recently, West Virginia — the state hardest hit by the overdose crisis — has left many without access to treatment because lawmakers are refusing to restore pandemic-era Medicaid policies that helped residents keep their insurance policies.
Philadelphia and Boise, Idaho, have also made headlines, with local harm reduction initiatives under fire.
Last month, the Philadelphia-based harm reduction organization Savage Sisters announced its landlord refused to renew its lease, threatening its services in the high-risk neighborhood of Kensington.
In Boise, the Idaho Harm Reduction Project had two of its locations raided by police, forcing it to shutter its offices.
Pushback to these programs can partially be attributed to the stigma that harm reduction enables drug users. And the stigma also manifests in how politicians approach the issue, Vakharia said.
“It does take a lot of fortitude and courage,” Vakharia said. “And in this very polarized and political moment, both sides of the aisle are very reluctant to take major steps that may feel in any way politically risky. I think we’re seeing that when it comes to a lot of social issues.”
Drug decriminalization, which is often mistakenly conflated with legalization, is a prime example.
With Oregon recently reversing course on Measure 110, the state law decriminalizing drugs, no states have implemented widespread decriminalization— despite the fact incarceration and the transition out of incarceration have been proven to increase the likelihood of fatal overdoses.
Baltimore at one time had implemented de facto decriminalization of small quantities of drugs under former State’s Attorney Marilyn Mosby, who Vakharia praised as “incredibly courageous,” but prosecution has resumed under Ivan Bates.
Overdose prevention centers, or OTCs, are also viewed as a gold standard of harm reduction. The facilities allow drug users to bring pre-obtained drugs to use onsite.
There are trained staff to supply proper supplies, respond to overdoses and provide other services. Studies have shown they reduce the transmission of HIV and hepatitis, prevent overdose deaths and reduce public use.
Yet only two exist in the country, both of which operate in New York City — although legislation permitting them to open has also been approved in Rhode Island.
OPCs are not legal in Maryland, and bills to permit the creation of up to six facilities have failed to ever make it to floor votes in the General Assembly despite vocal support from Mayor Brandon Scott and some state lawmakers.
Even so, that is not to say there is no appetite for the sites.
A 2022 study focusing on Baltimore found that 65% of business owners supported having the sites in their neighborhood, and 47% had witnessed an overdose near their place of work.
Nationally, studies have shown as much as 64% of American voters support the sites — roughly the same percentage of people who support decriminalization.
Vakharia acknowledged there is a long way to go in transforming drug policy and making harm reduction approaches the norm in helping those struggling with addiction.
But a growing dialogue about the approach brings some optimism.
And spreading the word about the importance of how compassion, rather than criminalization and stigma, is an imperative part of the process, Vakharia said.
“The biggest message I want people to get from reading the book is that it’s not an anti-treatment book, it’s not an anti-prevention book. Instead, it’s like, ‘Let’s look at our continuum of care critically and how can we ensure there is a touchpoint along our continuum of care so everyone can get the help and support they need.’
“With people dying at unprecedented rates, something needs to change,” she said.
Disclaimer: The Long Haul was provided a free copy of “The Harm Reduction Gap” prior to this article. The book can be purchased on Amazon and the publisher’s website.
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