How Harm Reduction Saves Lives: Dr. Tom Reach on Reducing Stigma in the Treatment of Substance Use Disorders

The first goal of harm reduction is simple: keep people alive.

That may sound obvious, but in addiction medicine it has to be said plainly. A person who is actively using drugs is not going to get clean and sober, repair his family, find meaningful work, return to church, enter treatment, work the 12 steps, or build a new life if he is dead. If we lose him to overdose, infection, or brain injury, then all of our higher hopes for him are gone.

This is not a small problem affecting a handful of people somewhere else. In 2023, SAMHSA estimated that 48.5 million Americans aged 12 or older had a substance use disorder in the past year. The CDC reported that 79,384 people died from drug overdoses in the United States in 2024. That number was lower than the year before, which is encouraging, but it is still a staggering loss of human life. Behind every number is a son, daughter, father, mother, friend, or neighbor. 

So when I talk about harm reduction, I am not talking about some abstract political slogan. I am talking about keeping Narcan available. I am talking about teaching people never to use alone. I am talking about encouraging a test dose. I am talking about sterile supplies, proper needle disposal, HIV and hepatitis C testing, and helping people stay connected to medical care instead of leaving them out on the street until something terrible happens.

And the evidence matters here. The CDC has reported that syringe services programs are associated with about a 50% reduction in HIV and hepatitis C incidence, and that decades of research show comprehensive programs are safe, effective, and cost-saving. The CDC also notes that these programs do not increase illegal drug use or crime. That last point matters because one of the oldest objections to harm reduction is the claim that it makes the problem worse. The evidence does not support that claim. 

Harm reduction also reduces catastrophic medical consequences. If we can keep contaminated needles out of people’s arms, we can reduce the risk of bacterial endocarditis, hepatitis C, HIV, abscesses, sepsis, overdose, permanent brain injury, and prolonged hospitalization. That is not sentimentalism. That is basic public health.

It is also basic arithmetic. Treating HIV is expensive. Treating hepatitis C is expensive. Open-heart surgery for bacterial endocarditis is extraordinarily expensive. Long-term care for someone who survives an overdose with permanent brain damage can continue for years. Much of that cost eventually falls on hospitals, emergency services, Medicaid, local governments, law enforcement, jails, and taxpayers.

So even for the person who is not moved by the moral argument, there is a practical argument that should be impossible to ignore. Harm reduction saves lives, and it also reduces the burden on the healthcare system and public services. The most cost-effective long-term answer is to treat substance use disorders with appropriate medical care, including medications when indicated. But while we are trying to get people into treatment, we should not allow them to die from preventable causes.

That is why I have changed my mind on this issue over the years. Fifteen years ago, I would not have advocated for all of these measures. But after seeing the destruction caused by outdated thinking, stigma, and a failure to treat addiction like the disease that it is, I have changed my tune. Harm reduction is not giving up on people. It is refusing to give up on them before they have a chance to recover.