How “Just Say No” became “Just Don’t Die”

SARAH STONE KICKED HER DRUG HABIT cold turkey after spending 16 years addicted to opioids. But she takes a very different approach when it comes to helping other drug users.

Stone lives in Charleston, W.Va.—a city gutted by the opioid epidemic. In 2019, she and some of her friends decided to start helping addicts use drugs more safely by handing out clean needles and naloxone, a drug that reverses opioid overdoses.

Stone’s message to addicts is simple: Just don’t die.

It’s a philosophy known as “harm reduction,” and it’s gaining traction across the United States as drug overdose deaths continue to mount. Rather than pushing people to get clean, harm reduction assumes some people never will—and concludes the best recourse is to help them use drugs safely.

After years of opposition, harm reduction won a federal stamp of approval when President Joe Biden made it a key plank in his 2022 drug control strategy. Advocates say interventions such as syringe exchange programs, supervised injection sites, and drug checking services fight shame and save lives. But critics argue they enable addicts and hinder them from seeking recovery.

Syringe exchange programs (SEPs)—where people can get clean hypodermic needles and syringes and safely dispose of used ones—have long been controversial. They first emerged in response to the ravages of the HIV/AIDS epidemic in the 1980s as a way to stop the spread of infectious diseases.

Although the federal government declined to fund SEPs for their first decade of existence, independent organizations sponsored them, and the number of programs doubled by the turn of the 21st century. Today, the North American Syringe Exchange Network reports about 400 such programs in the United States.

Katharine Neill Harris is a drug policy fellow at the Baker Institute and a proponent of harm reduction strategies. She argues harm reduction and quitting, referred to as abstinence among addiction experts, are not opposed to one another, but rather “exist on a continuum.”

“It’s really about meeting people where they are and not turning people away who are struggling with addiction just because they cannot achieve abstinence,” Harris said. She described harm reduction as an incremental approach that allows people to focus on small gains—reducing, rather than eliminating, their substance use.

Government agencies like the U.S. Centers for Disease Control and Prevention say harm reduction strategies effectively stop the spread of infectious diseases and connect users to treatment options. And the CDC points to several scientific studies to support its claim, including one survey from 2000 that found new needle exchange users were five times more likely to seek methadone treatment than respondents who never visited an SEP.

But Stanford University psychiatry professor Keith Humphreys said it’s hard to scientifically evaluate public health interventions because so many different variables are at play. As a result, researchers haven’t done any randomized trials showing the effectiveness of harm reduction methods like SEPs.

Additionally, one recent nationwide study from the Journal of Public Economics found communities launching SEPs between 2009 and 2016 recorded increased opioid death rates—averaging about three more cases per county per year.

Keith Graves is a former narcotics officer who spent 30 years working in the San Francisco Bay area. He said harm reduction has strayed from its founding principles and turned into “this total enabling juggernaut” where people hand out “syringes and crack pipes.” He insists harm reduction advocates are “pushing a narrative” of denial.

“Harm reduction is totally enabling people to use drugs, and it’s not giving them an escape route to stop,” Graves said. In California, he argued, the approach has destroyed communities and fueled homelessness and crime. Dirty needles litter parking lots and playgrounds. “There’s a reason why people are fleeing California,” he said.

Public safety concerns in Charleston led the city to rework its code, adding a state licensing requirement and other rules for any SEP operating within city limits. Anyone handing out needles without proper authorization now faces misdemeanor charges and a $500 or $1,000 fine.

After that, Sarah Stone and the other organizers shuttered their program.

Aside from safety issues, critics say harm reduction won’t ever solve America’s drug crisis. Haley Walker, a former drug user who now directs the abstinence-based Rea of Hope program in Charleston, said she and Stone have a good working relationship and often partner to try to help addicts in need. But they have a very different perspective when it comes to harm reduction strategies like SEPs.

Walker believes the tactic dilutes a sense of personal responsibility and mitigates negative consequences that can drive people to seek recovery. “If someone would have given me an easy, free, clean place to cook meth and shoot it in my arm, I would be dead today,” she said.

The best of both worlds?

Not all addiction treatment specialists are divided over the use of medication-assisted treatment (MAT). Some Christian medical professionals and rehab programs are taking a middle path—allowing the use of certain MATs for short periods of time while still championing the complete independence that comes with quitting.

Lisa Bright and her husband Bill established Restoration Springs, a Christian residential program in Fayette, Ala., after their 25-year-old son, Will, overdosed on heroin in 2012. The Brights started the program skeptical of MAT. Suboxone didn’t save their son, who just used it as another drug and sold it to get what he wanted.

“But I did not want to be closed-minded about potentials that can help some people,” Lisa said.

Restoration Springs provides the next step for men who have completed a recovery program and need to maintain sobriety as they transition into society. Staff members prohibit anything that can be stashed on-site, but allow clients to leave campus for monthly Vivitrol injections to help reduce cravings. Vivitrol is the brand name for the long-acting form of naltrexone, an opioid antagonist in the same class of medications as naloxone.

The Brights also allow participants to receive Sublocade, a long-acting, injectable form of Suboxone. It significantly reduces the potential for diversion and misuse that accompanies frequent doses of opioid agonists Suboxone or methadone. It also helps break the daily habits of addiction.

Vivtrol Brian Snyder/Reuters/Redux

Brandon Lackey, chief program officer at the Foundry, an abstinence-­based rehab facility, also isn’t opposed to every type of addiction medication, despite his concerns that most MAT drugs boost pharmaceutical revenue at the expense of patient well-being. The Foundry allows residents to use long-acting injectable versions of MAT, such as Vivitrol and Sublocade, to help prevent daily pills from being misused or sold.

Dr. Warren Yamashita, who directs the Christian Medical & Dental Association’s Addiction Medicine Section, said pharmaceutical company profits don’t detract from the medication’s ability to help addicts. MAT companies aren’t the only ones with a profit incentive in the addiction industry, he added, noting abstinence-based residential rehabs can also come with a hefty price tag. Depending on the length of stay, the cost for inpatient rehabilitation programs ranges from $5,000 to $80,000, according to American Addiction Centers.

Yamashita routinely uses MAT drugs to treat patients battling opioid addictions in Los Angeles. He said it is not a bad thing for companies to get paid for doing good work. Medications for diabetes and cancer also turn a substantial profit.

“There’s tremendous need and people are searching for answers,” he said. “They’re willing to pay for those answers, whether it’s medication treatment, or an abstinence-based residential program.” —Addie Offereins