​Expert insights on the challenges and promise of implementing harm reduction strategies

Focusing on the array of harm reduction strategies currently used in various jurisdictions in the United States, Vera researchers interviewed 14 stakeholders in law enforcement, courts, corrections, drug policy, and the community about how they are responding to opioid-related issues in their communities and about how receptive their agencies and jurisdictions are to harm reduction strategies. For New Mexico, New York, and West Virginia, Vera interviewed stakeholders at both the city and county level: respectively, Albuquerque in Bernalillo County, Ithaca in Tompkins County, and Huntington in Cabell County. For North Carolina, Vera focused on statewide initiatives; interviewees included stakeholders who work across the state and one city-level official.


The analysis, observations, and recommendations in this report are based on Vera researchers’ review of the literature in the criminal justice, substance use treatment, and harm reduction fields, as well as on interviews with 14 local criminal justice stakeholders from New Mexico, New York, North Carolina, and West Virginia. Vera researchers identified jurisdictions for participation in these interviews based on a combination of the magnitude of the overdose epidemic in the jurisdiction and/or the presence of promising or novel harm reduction initiatives underway in those locations. 

At the time of the interviews, West Virginia and New Mexico had the two highest rates of drug overdose mortality in the United States. (Age-adjusted rates of overdose deaths were 35.5/100,000 and 27.3/100,000 respectively). They now rank first and eighth according to the most recent data published by the Centers for Disease Control and Prevention (with age-adjusted rates of overdose deaths at 41.5/100,000 and 25.3/100,000). While New York and North Carolina both have comparatively lower overdose rates (13.6/100,000 and 15.8/100,000), they rank fifth and tenth nationally in the total number of overdose deaths.a Both states also have notable initiatives underway. In New York, the city of Ithaca recently released a groundbreaking plan to create a comprehensive health-based approach to drug policy and the state is expanding overdose prevention within its correctional facilities. In North Carolina, the North Carolina Harm Reduction Coalition has become a national leader in expanding access to naloxone among law enforcement and has a strong record of legislative advocacy for supporting harm reduction approaches.

Once jurisdictions were identified, researchers contacted individuals in those jurisdictions who work in law enforcement agencies, the court system, corrections agencies, drug policy, or the community, and invited them to participate in telephone interviews focused on how their jurisdiction and sector is responding to the opioid epidemic. Researchers contacted 30 individuals and 14 responded and agreed to participate. One or two Vera researchers conducted interviews by telephone with those individuals between February and April 2016. Participants included stakeholders from a range of sectors: five from law enforcement; three from the court system; one from corrections; two who are leading the development of drug policy strategy for their jurisdictions (within a Mayor’s Office of Drug Control Policy and a countywide Opioid Abuse Accountability Initiative, respectively); and three who work in the community (one parent advocate and two harm reduction experts).

a. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention, “Injury Prevention & Control: Opioid Overdose State Data,” February 22, 2017, https://www.cdc.gov/drugoverdose/data/statedeaths.html.

Of those interviewed, most people discussed wanting to shift from a punishment-oriented model to a treatment-oriented model in their jurisdictions’ response to people who use drugs; many also reported that they had considered implementing some type of harm reduction practice in their jurisdiction, such as the ones discussed above. Collectively, the interviews revealed four key challenges to integrating harm reduction practices:

  • defining and understanding what harm reduction means;
  • assessing support for a range of harm reduction strategies;
  • changing long-ingrained attitudes about crime and addiction; and
  • conceptualizing how big or small a role the criminal justice system should have in the lives of people who use drugs. 

Defining and understanding harm reduction

When asked to define harm reduction, stakeholders presented a wide range of answers. Some interviewees mentioned its core principle—reducing the negative effects of drug use—though most did not, and several cited the importance of minimizing disease transmission. Other respondents were quite broad in their definitions, describing harm reduction as a way to save lives or using the phrase “harm reduction” to signal approaching drug use as a public health issue rather than a criminal justice issue.

Respondents lacked clarity about the spectrum of strategies that could fall under the umbrella of “harm reduction.” Only three of the 14 people with whom Vera spoke were able to describe a full range of harm reduction techniques for drug use—from LEAD, to MAT, to naloxone distribution, to SEPs, and supervised injection facilities. Others were unaware of the range of options or admitted they were not familiar enough with the evidence base to support currently using a particular technique.

Assessing support for different harm reduction strategies

When Vera researchers asked stakeholders more specifically about harm reduction strategies currently being used within the justice system, it became clear that there is a continuum of comfort with different harm reduction techniques. The use of naloxone and MAT are illustrative examples. All jurisdictions discussed in this brief have state laws that provide civil and/or criminal immunity to licensed healthcare professionals for the administration of naloxone.24 Almost all interviewees supported community-based naloxone distribution, often described as an inevitable response to the worsening opioid overdose epidemic or as a technique for which there is mounting peer pressure to endorse. 

However, several interviewees reported lingering resistance to law enforcement carrying or administering the antidote in the jurisdictions where they are based. Interviewees described a lack of resources or bandwidth for police departments to take on added responsibilities, a feeling that the service may not be necessary if fire departments and EMTs were already carrying naloxone, and a continuing concern about liability since police officers are not medical professionals.25 In terms of distribution in jail or prison, Ray Bunce, captain of the Corrections Division in the Tompkins County Sheriff’s Office, recognized the importance of providing overdose education and facilitating access to treatment for people who used drugs, but opposed the practice of naloxone distribution upon release from jail. He cited what some research shows to be a commonly shared misconception—that equipping drug users with naloxone incentivizes riskier using behavior.26 He also noted the challenge of distribution in jail settings, since delivering effective behavioral health services requires rapport between providers and patients, which is inherently challenging in a transient environment. Moreover, many jails lack the staffing and resource capacity to adopt new programs, and have organizational cultures resistant to harm reduction approaches.27 Even with these barriers, there are examples of jail-based MAT programs nationwide, including a program that has been in operation in the New York City jail since 1987.28 

The use of MAT in drug courts and in correctional facilities was much rarer in Vera’s sample, often due to legal, logistical, or capacity issues. Even as laws change to expand the use of MAT in drug court and federal funding for drug court becomes contingent on allowing access to MAT, wide-scale implementation and accessibility of such programs is dependent on a host of factors. Indeed, courts must address practical and cultural barriers to using MAT by adapting supervision and monitoring practices, developing relationships with treatment programs and prescribing physicians, ensuring that decisions about access to medication are solely the responsibility of trained clinicians, and educating drug court staff about the use and efficacy of MAT.

Voices from the Field: On harm reduction, naloxone distribution, and MAT

“We approach it as a public health issue and not a [criminal justice] issue… To put it in a nutshell, the stance I take is that it’s got to be as easy to get into treatment as it is into jail.” – Gwen Wilkinson, former district attorney (Tompkins County, New York)

“Naloxone distribution has a little bit of a domino effect. As an agency, we have initiated the use of naloxone statewide to multiple law enforcement jurisdictions. The agencies that are currently not using naloxone are falling like dominos because the heroin and opioid problem is so severe that there is little choice but to approach this epidemic differently… Do you really want your municipality to be the last domino to fall to make a progressive change that could prevent people from dying from overdoses in your community?” – Ronald Martin, harm reduction policing advocate (North Carolina)

“We’re getting all these front-running therapy services [services given to people in drug court], helping you get a job, get connected with your family, helping you get an education, helping you get housing. How do we know that you’re learning any of these things to move forward? Really how we can make sure we can keep them drug free?” – Patricia Keller, judge (Cabell County, West Virginia)

Changing attitudes about crime and addiction

Although leaders in the criminal justice field increasingly are recognizing the limitations of traditional criminal justice approaches to drug use, interviewees admitted they face challenges when it comes to changing attitudes and implementing practical change. They commonly described how their own attitudes toward drug use and addiction have evolved because of their increasing proximity or even personal connection to people confronting the opioid epidemic. Indeed, the rising numbers of people dying from drug overdoses and the fact that drug arrests continue to be the leading cause of arrest in the United States has changed attitudes and perhaps even diminished stigma around people with substance use disorders.29 Robert Childs, a harm reduction expert in North Carolina, observed what he called a “sea change” in law enforcement due to the fact that most everyone now knows someone who has been affected by the opioid epidemic. The result is that there is more support—at least theoretically—for treatment-oriented solutions.

However, even as interviewees acknowledged that broad attitudes are changing and softening, they also noted that there remains resistance to changing practice on the ground. For example, Joseph Ciccarelli, the police chief of Huntington, West Virginia, described how some police officers can be resistant to LEAD programs because they perceive them as “feel good kind of programs” (see below for “Voices from the Field: On treatment, new models, and old policing methods”). For North Carolina, Mr. Childs cited how some communities are hesitant to implement LEAD because they fear they won’t look tough on crime if they divert people to services rather than arrest them. But other interviewees spoke about confronting more deep-seated beliefs about drug use and addiction. Nan Nash, chief judge in New Mexico’s 2nd District Court, explained that allowing MAT in drug courts would appear to be a “very radical approach” to some people, even if they can articulate the theory that addiction is a disease, because of deeply ingrained beliefs that anyone can stop using drugs if they just work hard or have enough will power. Thus, despite evidence showing that MAT can aid in recovery, giving people drugs to treat drug addiction may fly in the face of the abstinence-only model on which drug courts traditionally have been based; it asks people to reframe what addiction means and how it can be managed. 

Many of the people in Vera’s sample asserted that, despite increasingly progressive attitudes, change would have to be incremental in their agency or jurisdiction and should be approached cautiously. Interviewees discussed the importance of knowing their audience when advocating for the use of new approaches. Whether people are moved by the human cost of overdose, the financial cost of drug addiction and incarceration, or the framing of substance use as a public safety or public health problem, stakeholders stressed that there is something in this for everybody—that the current system is so broken that there is inevitably some common goal despite different justifications for it. In the words of harm reduction policing advocate Ronald Martin, “Anything you can do to change the temperature one degree is like a win for your organization.” Such comments suggest there is a very pragmatic aspect to the work of changing justice system responses to drug use. Even without broad agreement on the nature of addiction, justice stakeholders may agree on the viability of trying harm reduction approaches.30

Voices from the Field: On personal connections and changing beliefs

“Even though it is fairly well-established that drug abuse—and alcoholism for that matter—are diseases, there is still a notion, just a sort of deep-seated subconscious feeling, that you can get a hold of it if you’re really dedicated to getting a hold of it. There isn’t a person who doesn’t know somebody who has become sober—you know, conquered their addiction—so there’s this belief that, well, if one person can do it, anyone can do it… So, I think that there is your rational mind and then there’s this nagging subconscious [feeling] that if you really wanted to do it, you would do it, so why are you giving folks an out? Why are we making it easy for them not to do it? It just in some ways goes against the grain of our model, which is a model that expects people to change their behavior.” – Nan Nash, chief judge (2nd District Court, New Mexico)

 “I think, as a law enforcement agency, we’re here to serve a community and the national motto of protect and serve. I think protection means more than arrest, means more than deterring crime; we’re a community partner and this is a social issue that affects many families for many years. I know of families that are dealing with multiple addictions within the home, and they’ve had 10 to 15 years of waiting for the phone call that their child has OD-ed on a drug.” – Brad Shirley, police chief (Boiling Spring Lakes, North Carolina)

 “Now all of a sudden, when the opiates came in, that wasn’t just ‘that part of society’; that was your family; that was your neighborhood. Everybody knows somebody that’s been touched by it…You have to understand that it’s not a moral decision they’re making. It’s in your family; it’s in your neighborhood…It’s in your home now; it’s in your church; it’s in your office.” – Jim Johnson, director, Mayor’s Office of Drug Control Policy (Huntington, West Virginia)

 “We had a few people who were like, ‘Why are we bringing them back? That’s natural selection’s way of getting rid of these problems. Let them die.’ But it didn’t take long for them to realize that this could be your kid; this could be your neighbor; this is happening to the lawyers; it’s happening to professionals; it’s happening to everyone in your community.” – Patricia Keller, judge (Cabell County, West Virginia)

Right-sizing the criminal justice response

While there is growing recognition that harm reduction principles are an essential component of any community’s response to drug use, there are still a range of questions about the appropriate role for the criminal justice system in responding to drug use. For example, if the current or old model is broken, what should the new model look like? Even if there is increasing momentum for adopting harm reduction approaches in the justice system and even if more people agree that the standards of care in the justice system should match those of community care, when is it appropriate for the criminal justice system to be the pathway to treatment, and when is it more appropriate to keep people out of the criminal justice system altogether? What role can criminal justice leaders play in advocating for increased resources for a stronger public health infrastructure to respond to issues rooted in addiction and poverty, and a smaller role for law enforcement, courts, and corrections?

Interviewees were especially reflective in describing the traditional roles their agencies have played in relation to drug use as well as their ambivalence about what a new approach could look like. Court system actors described increasing recognition of the limits of a model that places more emphasis on punishment but were unsure of what a better model would look like. For example, Gwen Wilkinson, the former district attorney in Tompkins County, New York, acknowledged that while her office is mandated to prosecute crime, she sought to integrate harm reduction approaches when applying the law. Judge Nash of New Mexico described how judges easily recognize the need for additional, non-punitive approaches, but also admitted that many lack knowledge about the efficacy of alternatives, especially those that are not abstinence-based.

Police were equally open about the limitations of their traditional approach to drug use and addiction, but all echoed the sentiment that there is no simple solution to confronting the drug epidemic in their communities, short of re-envisioning the role of police. This is not an easy task given the hard work of changing attitudes described above and the reality that different criminal justice stakeholders will invariably be driven by competing priorities or incentives and may operate with varying degrees of knowledge of, or enthusiasm for, alternatives. But the very fact that leaders in law enforcement are starting to articulate questions about the appropriate role of their agency in responding to drug use indicates there are opportunities for conversation about how to define the potential new roles of the various criminal justice actors who find themselves responding to a worsening drug epidemic.

 Notably, a wider role for the police, prosecutors, or judges in responding to drug use—even through the adoption of innovative treatment alternatives and harm reduction approaches—may reinforce the idea that people must enter the criminal justice system in order to get needed health treatment, particularly in places where there is an absence of community-based treatment or services, therefore increasing the number of people who get arrested. For example, Huntington, West Virginia police chief Ciccarelli described having more success with post-arrest diversion than pre-arrest diversion, in part because he believes that the mechanism of arrest often serves as the necessary entrée to recovery for many people—a “wake-up call” of sorts—and keeps officers from feeling that they’re enabling immoral activity. (See below for “Voices from the Field: On treatment, new models, and old policing methods.”)

Several interviewees said they wanted to provide interventions for people struggling with drug addiction outside the criminal justice system, but were unable to do so because pre-arrest or community care options are limited or nonexistent. In Huntington, West Virginia, for example, the Women’s Empowerment and Addiction Recovery Program is a vital pathway to treatment for women who engage in sex work and have a substance use disorder, but it is only open to women arrested on felony charges. Access to treatment is thus dependent on deep criminal justice involvement, which brings a host of long-term collateral consequences such as limited access to employment, public benefits, or participation in civic life. 

Voices from the Field: On treatment, new models, and old policing methods

“I can inform my approach to prosecutions and investigations with an eye to having the best public safety outcome I can—and that is legitimately a decline in the numbers of addicted people—by putting them in touch with treatment.” – Gwen Wilkinson, former district attorney (Tompkins County, New York)

“The criminal justice system has embraced this model… the carrot [and] stick model and we understand that model because we understand being a stick, but ok, that helps some people, but what else is out there? What else can and should we do?… I need to have more information about the efficacy of [harm reduction] programs but from what I understand… those programs offer a potential avenue that the system has to consider.”  – Nan Nash, chief judge (2nd District Court, New Mexico)

“I think that all of these ‘feel good’ kind of programs will always…raise concerns…We can keep doing what we’ve been doing for the last 50 years that hasn’t worked or we can do something different. Quite frankly, [police] are paying the consequences of criminal activity. So, I think from that standpoint it’s a little more powerful to the average policeman on the street to say, ‘If they have a needle on them, I don’t care if they got it from the health department harm reduction program; if they’re shooting heroin, you charge them with it. You let the judge worry about what’s going to happen and that’s when you get them into diversion and into the treatment program.’ To some degree the policeman contents himself that he’s not enabling anybody. That he’s doing his job. Those arrests are halfway to recovery for some people. Those citations are a mechanism for a wake-up call.” – Joseph Ciccarelli, police chief (Huntington, West Virginia)