Jessica Bellwoar

Implementing Harm Reduction Policy into the U.S. Healthcare System

Jessica Bellwoar

May 7, 2015

Illicit drugs, such as marijuana, opium, coca, and psychedelics have been used for thousands of years for both medical and spiritual purposes. The United States history with drugs is complicated and often linked to politics and misinformation. The United State’s War on Drugs started in the 1970s under Rickard Nixon. Under Nixon’s presidency federal drug control agencies gained power and legitimacy whiling pushing through strict drug control policy. The U.S. created a strict zero tolerance policies with society’s support – deeming the subject taboo and unethical, drugs as evil, and addicts as “bad” people. Today, this mentality is surrounded in controversy from drug-control policy and recreational drug use to treatment of addicts and rising healthcare costs. The traditional, outdated, and ineffective laws and mentality are creating more harm than good. As the number of illicit drug users in the U.S. increases, society needs to take a different approach towards the drug community.

Harm reduction is range of public health practices designed to reduce the negatives consequences associated with various human behaviors, both legal and illegal. The philosophy focuses on the prevention of harm and increased drug education, rather than the prevention of drug use itself. Many individuals do not understand that addiction is a biological disorder and that addicts have no control over their addictive tendencies. Harm reduction recognizes that addicts are sick individuals and deserve the same respect and access to medical resources as others in society. From this sense, Harm reduction is a social justice movement built on the belief that drug users have the same rights as others. Advocates claim harm reduction saves lives, reconnects marginalized drug addicts with the community, has financial benefits to healthcare costs, and is overall beneficial to society. Critiques, however, argue harm reduction practices encourage drug users, perpetuate a problem, and give the “green light” on illicit drug use. Yet, there is no evidence that harm reduction encourages drug use, increases drug use, or sends a larger signal to society.

Regardless of successful harm reductions programs in Europe and Australia since the early 1990s, operational programs are limited in North America. The only operational supervised injection site in North America is in Canada. INSITE is a legal, supervised injection site offering a safe environment to use illicit drugs and to connect with healthcare services. The facility allows drug users to shoot-up safely without fear of arrest and with on-site medical assistant. There is sufficient evidence that INSITE has public health benefits by lowering HIV and AIDS rates, but the model has not been widely adopted because it is still controversial and political.

The United States has several harm reduction programs, but outright lacks federal support. Despite President Obama and other politicians advocating for reforms – such as reducing the crack/powder sentencing disparity and ending the ban on federal funding for syringe access programs – a change has yet to happen in drug control funding and harm reduction implementation. By eliminating the federal funding ban on syringe and needle exchange program and diverting 10% of funding spent on drug reinforcement towards harm reduction programs, the United States government would save millions of dollars annually in the healthcare system. Though implementing these changes into American culture will be a tedious process, the timing is ideal with structural changes occurring in the healthcare system and the results being economically, emotionally, culturally beneficial for our society.

Table of Contents
Title Page ……1

Executive Summary ……2

Table of Contents ……3

Illicit Drug Use in United States & Government Response ……4

Harm Reduction & HIV Infections ……7

INSITE ……8

U.S. Harm Reduction Programs ……10

DanceSafe ……11

Appendix ……18

Today society often associates illicit drugs with danger and illegality, when in reality the term is more inclusive. The United States government defines illicit drugs as narcotics (opiates), stimulants, depressants, hallucinogens, and cannabis. These categories include natural, semi-synthetic, and synthetic drugs with varying degrees of legality; illicit drugs can be legally produced and prescribed drugs as well as illegally produced drugs sold outside of medical channels. It is important to understand this definition when discussing the implementation of harm reduction policy as dichotomy is important.

The United States has a complicated history with dangerous drugs, promoting or banning them for political or economic reasons. Tobacco was economically intertwined with slavery as the foundation of our country. In 1884, the medical community embraced cocaine as miracle cure for all, including alcohol and morphine (Shmoop University, 2015). Coco-Cola’s original formula had cocaine as an ingredient. Heroin was sold as a medicine in the early 20^th century. During the 1960s, recreational illicit drug use – marijuana, heroin, LSD, opiates, and cocaine –grew exponentially among the middle class and young people. As anti-drug laws were created, they sought to target minority groups or immigrants: the first anti-opium laws in the 1870s were directed at Chinese immigrants; the first anti-cocaine laws in the early 1900s were directed at Southern black men; the first anti-marijuana laws in the early 20^th century were directed at Mexican migrants and Mexican Americans in the Mid and Southwest (Drug Policy Alliance, 2015). The “War on Drugs” began in June 1971 where Richard Nixon declared, “[drugs are the] public enemy number one in the United States... If we cannot destroy the drug menace, then it will destroy us.” Nixon’s time in office dramatically increased the size and presence of federal drug control agencies whiling pushing through austerity measures such as mandatory sentencing and no-knock warrants for police.

During the 1980s, anti-drug campaigns targeted youths with First Lady Nancy Reagan’s “Just Say No” campaign and the DARE education program, which was quickly adopted nationwide despite the lack of evidence of its effectiveness. The increasingly harsh drug policies of the late 20^th century caused the number of people behind bars for nonviolent drug law offenses to increase from 50,000 in 1980 to over 400,000 by 1997 (Drug Alliance Policy, 2015). It also blocked the expansion of syringe access programs, as federal funding ban was placed on those programs, and other harm reduction policies that could have stopped the rapid spread of HIV and AIDS. As the 21^st century began with the era of George W. Bush, drug testing of marijuana was promoted in high schools while overdose rates rose across the country. The Bush administration also escalated the militarization of domestic drug law enforcement; roughly 40,000 paramilitary-style SWAT raids occur on Americans every year for mostly nonviolent drug law offenses, often misdemeanors (Drug Alliance Policy, 2015).

Today, there are over 23.9 million illicit drug users in America (Figure 1). The United States is the world's largest consumer of cocaine, heroin, and marijuana. The U.S. is a major consumer of ecstasy and Mexican methamphetamine. The U.S. produces vast amounts of illicit cannabis, depressants, stimulants, hallucinogens, and methamphetamine (Central Intelligence Agency, 2015). As the U.S. government seeks to control this illicit drug use and activity, our country climbs steeper into debt while spending roughly $51 billion annually on the War on Drugs. We have the highest incarceration rate in the world with 1 in every 110 Americans being in jail, and over 40,000 U.S. citizens accidentally overdosing each year. Despite President Obama and other major politicians advocating for drug policy reform, this unsustainable war continues. Some reformers believe harm reduction policies and practices are the answer to financial, societal, and healthcare burdens.
Harm Reduction Philosophy

Harm reduction, or harm minimization, is range of public health strategies designed to reduce the harmful consequences associated with various human behaviors, both legal and illegal. The concept focuses on the prevention of harm, rather than the prevention of drug use itself. Though it has no globally accepted definition, harm reduction refers to “policies, programs and practices that aim to reduce the harms associated with the use of psychoactive drugs in people unable or unwilling to stop” (Harm Reduction International, 2015). Harm reduction policies can be used to manage recreational drug use, addicted drug use, or sexual activity in numerous settings from services to geographical regions. Harm reduction programs include but are not limited to: needle and syringe exchange programs, opioid replacement therapy (ORT), heroin maintenance programs, Naloxone treatment, safe injection sites, designated driving programs (to protect against drunk driving), sex education programs, giving out free condoms, and the legalization of prostitution. Though this paper focuses on harm reduction regarding drug-use, harm reduction practices have been growing across different forms of public healthcare in the last several decades.

Many advocates argue that prohibitionist laws criminalize people for suffering from a disease, and addiction is a disease. Much of society does not understand that addition is a complex, biological disease. According to the National Institute of Drug Abuse, “addiction is a chronic, often relapsing brain disease that causes compulsive drug seeking and use (2012).” The brain changes over time challenging an addict’s self-control and hampering his or her ability to resist intense impulses to take drugs. Nobody chooses to be an addict, and society shuns them. Intravenous drug users are the most reviled by society and other non-intravenous users. Isolation is a large factor of addition and illicit drug users tend to be isolated from their communities. Society needs to take the stigma out of addition and see addicts as human beings with enormous burdens. Harm reduction programs help fight this stigma.

Many activists see harm reduction as a social justice movement built on the belief and respect for the rights of people who use drugs. For many intravenous drug users social inequality and injustice amplify drug-related harm and limit the voice of the drug user. Harm Reduction Coalition states three gained values associated with harm reduction: drug user health in access to clean medical equipment and reliable information; drug user dignity in anti-stigma mentality and increased culture competency; and community impact through program development and sustainability, organizational development, and community mobilization (Harm Reduction Coalition, 2015).

With nearly 16 millions people using intravenous drug worldwide, 3 million have HIV infections. In the U.S. 1.2 million people are living with HIV, and almost 14% are unaware of their infection (U.S. Department of Health and Human Services, 2015). The U.S. has seen an increase over the last decade of the number of people living with HIV infections. Though the annual percent of new HIV infections remains relatively stable, new infections continue to be a major healthcare problem for our society. On average, one out of every ten new HIV infection is caused by injecting drugs with dirty equipment such as needles. Sharing needles and using dirty needs increases hepatitis and AIDS among the general population. Rising HIV rates are a public health issue that can be combatted through harm reduction programs, such as needle and syringe exchange programs. These programs would be especially effective in impoverished, dejected neighborhoods with high crime and drug rates. Advocates claim society would benefit more than the addicted because HIV rates would be lower and addicts are back in contact with their medical professionals.

Harm Reduction programs have been around for several decades, most notably needle exchange programs and as safe injection sites in Europe. Needle exchange programs began informally in the 1970s and were formally adopted by European government to fight the growing Hepatitis B outbreak and AIDS epidemic. The world’s first supervised injection site opened in 1986 in Switzerland; founder Jakob Huber states “this was at that time revolutionary for drug policy globally.” Historically, these programs operate largely in legal gray areas – funded by local health authorities and ignored by police. They have traditionally lacked outright legal approval. Starting in 2000, countries including Germany, Luxemburg, Switzerland, Norway, and Spain have granted full legal sanctions to safe injection sites. Today, there are roughly 90 such facilities in Europe and Australia (Holeywell, 2013). Though the U.S. has several needle and syringe exchange program, there are currently no supervised injection sites in the U.S. The only supervised injection site in North America is INSITE located in Vancouver, Canada.

INSITE opened its doors in 2003 as a three-year trial period for scientific research on reducing HIV levels in Downtown Eastside Vancouver, which had rates similar to developing countries (Figure 2 and 3). During the 1990s, disease and overdose rates skyrocketed. Out of the 16,000 population in Downtown East, approximately one-third of them were drug users (CNN International, 2013). In 1997, 19% of injection drug users were infected with HIV, the highest annual rate ever recorded in the developed world (National Geographic, 2010). Approximately, one overdose occurred daily in the region. The open-air drug market was coupled with increasing poverty, violence, homelessness, and crime. Doctors Julio Montaner and Thomas Kerr of the BC Centre for Excellence in HIV/AIDS organized the harm reduction program, INSITE, and pushed for changes in the impoverished community. The supervised injection site is exempt from Section 56 of the Controlled Drugs and Substances Act and allows drug users to safely shoot-up without fear of arrest or police harassment. It is funded by the British Columbia Ministry of Health and run by Vancouver Coastal Health (regional health authority) in conjunction with the Portland Hotel Society (nonprofit serving mental health and addiction issues). INSITE has 12 injection rooms with on-call nurses, clean needles, filters, clean water, and alcohol swabs. They only thing not provided are the drugs. Nearly 800 people use those booths every day. INSITE clients are 70% less likely to share needles than other addicts in Vancouver. One INSITE client states “there's typically a line to get in before the site opens its doors at 10 a.m.”

INSITE not only reduces the negative consequences of intravenous drug use but also connects addicts, who are sick human beings, with health care professionals. The facility offers professional healthcare services such as counseling, housing assistance, addiction services and mental health treatment. The three-story building is divided between INSITE located on the first floor, and ONSITE located on the two floors above. ONSITE is a detox and rehab facility where no drugs are allowed. When clients are ready to get clean they are referred upstairs where they are offered therapy, yoga, and housing services; the detox process is entirely up to the addict. It is estimated since INSITE started the number of users entering detox has increased by 30%, and 40% of people who enter ONSITE detox make it through the program, a relatively high number compared to other recovery programs (National Geographic, 2010). In addition to the supervised injection facility and detox center, INSITE also has a mobile needle exchange program. INSITE staff members drive around Vancouver in search of addicts to provide clean equipment and safe injection kits. These kits can include mouthpieces, glass pipe, alcohol swabs, band-aids, lighters, gauze, and clean needles. The van operates over 20 hours a day with INSITE staff having 150 to 200 contacts per day. “Giving out the tools of addiction is extreme but essential for staying safe and saving lives,” states an INSITE employee, especially when more than half of INSITE users are homeless, living in shelters, or have untreated mental issues. INSITE can help get addicts off the street, away from isolation, and in contact with treatment if desired (Figure 4 and 5). Additionally, there has been no clear evidence on increasing drug usage in Downtown East surrounding INSITE. Most clients describe the facility as their safe haven and absolutely necessary to prevent overdose. Since opening its doors, INSITE has had 1,000 overdoses but not a single death. In addition, the healthcare services and anti-stigma atmosphere INSITE provides directly benefit INSITE clients. One must also consider that not all addicts use INSITE. Yet, these non-INSITE clients still reap benefits in the addition community. Needle sharing and infection rates are lower within their community.

INSITE has strong support from the local Vancouver community at 76% approval rating (National Geographic, 2010). Support is lowest among the regions conservatives, including Prime Minister Stephen Harper who outwardly criticizes the facility and has attempted to close INSITE on multiple occasions. INSITE’s legal battle to remain open has been long and bitter. After 10 years and finally appearing before the Supreme Court, INSITE received full approval in May 2011. The facility has been the focus of over 30 studies since opening. One four-year study on the effects of opening supervised injection sites in Toronto and Ontario had astounding results. The results showed over 9,000 people in Toronto use illicit drugs and more than 75% would use supervised injection sites (CNN International, 2013). This would change user needle habits with injection sites, and large number of hepatitis c infections could be avoided. The study also found public support for supervised injection sites is over 50%. Yet the 4-year study on facility expansion was shut down within an hour by all levels of municipal government. Experts say there is only one reason the INSITE model hasn’t been adopted anywhere else in North America – because it is politically controversial.

The early 1990s marked the beginning of needle and syringe exchange programs in the U.S. Between 1991 and 1997 the U.S. government funded seven clean needle experimental programs. The findings were unanimous – clean needle programs reduce HIV transmission, and none found that clean needle programs caused rates of drug use to increase. Rapid growth occurred in the number of syringe and needle exchange programs (SNEP) in the early 2000s followed by more incremental growth through 2008. In 2009, 184 SNEPs existed operating in 98 cities in 36 states, the District of Columbia, and Puerto Rico. These 123 SNEPs reported “exchanging 29.1 million syringes and had budgets totaling $21.3 million, of which 79% came from state and local governments” (Atlanta Center for Disease Control, 2010). In addition to clean medical equipment, most of the SNEPs also offered preventive health and clinical services, while some offered HIV and Hepatitis C counseling and testing, sexually transmitted disease screening, and referrals to substance abuse treatment. Today, there are over 194 operational needle and exchange programs in the U.S. (Figure 6, 7, and 8). Most are legally authorized to operate, while local health authorities manage 38.2% compared to state authorities management.

Though there is ample evidence that harm reduction programs, such as SNEPs, help lower HIV infection rates policy has not been widely adopted. In 2011 – the same year Congress elected to continue the federal funding ban on syringe and needle programs, the U.S. Surgeon General determined “a demonstration needle exchange program would be effective in reducing drug abuse and risk of infections.” In order to effectively combat rising HIV rates, rising drug overdoses, and growing healthcare costs, the U.S. government should consider lifting this ban and implementing harm reduction on a national scale. There is a real need for harm reduction practices in American society that extends beyond syringe and needle exchange programs. Safe injections sites, like INSITE, should be seriously considered in addition to underserved drug users. Non-profit organizations, like DanceSafe for example, have sought to fill this gap and address recreational drug users.
DanceSafe

The non-governmental organization, DanceSafe, focuses on making the electronic music community healthier and safer. The organization is known for drug screening on-sight at music concerts, raves and to the nightlife community. Their two core values are harm reduction and peer-based education, which seek to educate youth on drug-misinformation. DanceSafe is unbiased, neither condoning nor promoting drug use. Their motto “test it before you ingest it” is prominently displayed on their website. They offer pill testing, drug checking, and “unbiased educational literature describing the effects and risks associated with the use of various drugs”. All of this is offered in safe, judgment free spaces at concerts where recreational drug users can engage in conversation about health, drug use, and personal safety. DanceSafe also provides other safety equipment including: free water and electrolytes to prevent dehydration and heatstroke, free condoms to protect against unwanted pregnancies and the spread of STDs, and free ear plugs to prevent hearing loss. DanceSafe seeks to work with local stakeholders to advocate for safety-first approaches. Any individuals requesting medical or detox treatment can also be referred by DanceSafe staff. Lastly, they offer the only publicly accessible laboratory analysis program for ecstasy in the United States.

Their information and services are primarily targeting recreational, non-addicted drug users. The organization claims this is a vastly underserved population in the harm reduction movement and the gap needs to be filled for education and safety purposes, especially considering the rise in MDMA and cocaine use among youth. This organization differs from most harm reduction organization in that it targets non-addicted individuals who are experimenting with dangerous and illicit drugs. Their website offers tips and tricks to stay safe and healthy while using physically harmful drugs. The 12-chapter organization, located in 10 cities across the America, has made arguments that they can prevent deaths at music festivals and concerts. By offering on-site drug testing and information, users are better informed. All of these innovative services focus on harm reduction practices, not drug prevention. It offers interesting insight into the changing mentality of drugs and harm reduction regarding recreational drug use in American society. Though this change may be insignificant to the majority of the population, harsh criticism of harm reduction practices still exists.
Critiques of Harm Reduction

Critics of harm reduction state harm reduction sets a precedent that drug use is acceptable in society. Tolerating risky or illegal behavior sends a message to the community that such behavior is conventional. It creates the perception, especially among youth, that drug-using behavior is safe. “We oppose so-called 'harm reduction' strategies as endpoints that promote the false notion that there are safe or responsible ways to use drugs,” states the network group International Task Force on Strategic Drug Policy. Many critics are concerned with the unseen “ripple effects” caused by harm reduction programs. Yet, there is also no substantial evidence that harm reduction programs give the “green-light” on illicit drug use; some evidence suggests harm reduction practices actually reduce illicit drugs use.

Other critical organizations have compared harm reduction programs as “harm promotion” and tactics to normalize drug use. “Harm reduction is too often another word for drug legalization or other inappropriate relaxation efforts,” states Drug Free America Foundation.

Harm reduction activists, especially regarding safe injections sites, must acknowledge the action of giving users legal places to inject drugs or drug equipment. Is this the best way to help addicts? What type of message does this send to users? What type of message does this send to future generations? Some critics also argue harm reduction does not reduce harm over the long term, but hinder then drug users chance of getting clean. Drug addiction counselor Berner argues harm reduction programs “ignore completely the mechanics of addition.” Addicts want more and more of their chosen substance until they “keel over.” His answer to conquering addition is getting people into treatment and therapy. The “best harm reduction is abstinence” and getting users engaged with human contact. The “notion of INSITE [and other harm reduction programs] is distinguishing,” declares Berner and “it is not even a band aid. It's a totally waste of time.” The problem with a total abstinence solution is not all addicts are willing to accept sobriety or able to achieve this for themselves. The reality is that addicts will continue to use. Does this mean the best overall outcome for addicts refusing to get treatment is to shun and ignore them until they desire sobriety? Harm Reduction International vehemently states, “people who use drugs do not forfeit their human rights, including the right to the highest attainable standard of health, to social services, to work, and freedom from cruel inhuman and degrading treatment (2015).” This includes a lack of clean needles, medical supplies, and long-standing negative stigma by society.

There are clear, tangible financial benefits of harm reduction programs. With societies rising healthcare costs, rationing taxpayers’ dollars becomes more important. In the United States alone it is estimated the total overall costs of substance abuse – including productivity and health- and crime-related costs – exceeds $600 billion annually; approximately $193 billion goes toward illicit drugs (Figure 9). These numbers do not account for the emotional and human turmoil that are associated with the costs of substance abuse. Addicts who become sick or infected require enormous amounts of taxpayers’ dollars. Emergency ambulances for overdoses cost 1,000 per trip on average, regardless if the overdosed person is uninsured. It costs approximately $380,000 to $619,000 to treat a single person with an HIV infection over a lifetime (National Institute of Drug Abuse, 2012). The daily cost for HIV medication is roughly $36 per person, whereas the cost of a needle for a needle exchange program is $0.97. This is almost 50 times more cost effective daily. As of 2011, Center for Disease Control estimated that every HIV infection prevented through a needle exchange program saves an estimated $178,000 (Atlanta Centers for Disease Control, 2012). Failure of federal government to implement widespread needle exchange program has cost approximately $244 to $538 million in HIV treatment from 1987 to1995 (Lurie, 1997).

Harm reduction is grossly underfunded when ten of billions of dollars are spent on the War on Drugs. For every dollar spent on drug enforcement, 10 cents would cover annual HIV and Hepatitis C prevention for people who inject drugs globally (Harm Reduction International, 2015). Harm reduction philosophy seeks to invest in health and human rights through alternative measures. For example, the Canadian government saves the healthcare system four dollars for every dollar spent at the supervised injection site, INSITE. Critics argue that the three million dollars INSITE receives from taxpayers is far too much (CNN International, 2013). Addition counselor, David Berner states addicts in recovery save the community thousands because they don’t use INSITE, doctors, psychiatrists, ambulances, police, and courts. He poses the argument that taxpayers should not have to bear the costs of irresponsible people, or addicts. The reality is that taxpayers have been bearing this responsibility for decades and the problem is not diminishing. Harm reduction is practical, feasible, effective, safe and cost-effective.
Implementing Harm Reduction Policy

The federal and state governments have poured over $1 trillion into the War on Drugs, relying on taxpayers’ dollars the last four decades. This wasted effort has led caused the U.S. to be the world’s largest jailer, drugs remain widely available, and treatment resources are scarce. Money, going towards drug enforcement, has been funneled away from important services such as essential education, health, social services and public safety. The U.S. government needs to shift its funding away from failed and outdated policies towards effective drug treatment and education programs via harm reduction programs. This would cut economic costs, increase health benefits for multiple stakeholders, and reconnect marginalized drug communities. Though the U.S. has several hundred harm reduction programs across the country, harm reduction is still relatively unheard of and resources are difficult to acquire for drug users. Most addicts seeking treatment cannot afford the costs and healthcare insurance companies are little to no help; “many people who seek help for their problematic drug use are unable to access treatment, encountering insurance barriers, months-long wait lists, or programs that don't meet their needs” (Drug Alliance Policy, 2015). Far too many drug users are only able to access drug treatment as a result of an arrest or criminal conviction. Drug policies should not be based off a utopian society and belief that citizens will not use illicit or non-medical drugs. Drug policies need to be pragmatic, not based off of right, wrong, or mixed messages that could potentially influence American society. Drug users are a large part of our society and our laws need to stop isolating and neglecting their rights as citizens. The United States government needs to offer cheaper, more tangible, and more effective services to people using drugs. With massive changes in the U.S. healthcare system occurring, now is the ideal time to implement harm reduction programs and synchronize with the shift in healthcare policy.

In 2008, Obama signed the Mental Health Parity and Addiction Equity Act making healthcare more accessible for the average America. It mandated that insurance companies now have to cover mental health and addiction treatment that was on par with the medical side of the healthcare industry, including outpatient services and hospitalizations (U.S. Department of Labor, 2010). Though the “Parity Act” made it easier for individuals to get healthcare treatment, there are many loopholes for businesses to bypass the law and rising copays and deductibles for individuals. Many individuals choose not to pay the out-of-pocket expenses because of high deductibles and copays, in favor of saving their deductibles for major expenses. Though this poses current and future problem for the changing healthcare industry and American society, Obamacare has made healthcare more affordable and tangible for the average American.

Two major harm reduction initiatives should be implemented into U.S. policy. Firstly, U.S. congress needs to lift the ban on federal funding for syringe and needle exchange programs. This would allow for better funding towards these programs and give harm reduction policy legitimacy. Second, 10% of all funding spent on drug enforcement should be redirected to harm reduction practices, including but not limited to: syringe and needle exchange programs, naloxone programs, opening two supervised injection sites, hospitals partnering with organization, and strengthening service network for drug users. Syringe and needle exchange programs would prevent HIV and Hepatitis C infections. Implementing Naloxone programs would prevent thousands of overdoses each year to counter heroin and other illicit drugs; police officers and mobile needle programs should carry this life-saving drug. The opening of two supervised injection sites, modeled after INSITE, would allow for government authorities to study the outcomes of each site and make adjustments as needed. It is recommended that these sites be opened in New York City and Miami as they present the highest HIV infections rates in metropolitan areas in the U.S. (Reynolds, 2014). Hospitals should seek to partner with local organization – local healthcare authorities, harm reduction organizations, and mission-driven non-profits – on harm reduction programs. This would allow for service networks to be formed, strengthened, and become more visible as drug users seek treatment or services. All of these policy changes and implementations would help create awareness about harm reduction, reduce the stigma faced by drug users as a marginalized population, and lead to more visible campaign strategies for better drug education, information dissemination, alliance and coalition building, policy analysis, and direct advocacy with policy makers.

Since the start of Nixon’s War on Drugs in the 1970s, American society has shifted its mentality towards drugs and drug users. Society has become disconnected from the reality of drugs as mythical, utopic society was created regarding drugs. We must accept that individuals will use drugs for recreational use and some addicts will refuse to be sober. This system is outdated and unsustainable as our spending increases annually for drug enforcement, number of jailed individuals over minor, non-violent drug offense increases, and the drug community continues to suffer from unequal human rights.

Harm reduction in the United States is not a new philosophy. Yet, it is not widely accepted or recognized as a solution to the United States drug problem. Having spent over $1 trillion on the War on Drugs and with our problems only worsening, American society needs to shift its focus towards modern, feasible, effective and cost-conscious solutions. The U.S. government should intertwine harm reduction policy into the changing healthcare industry. By implementing changes in current healthcare policy and laws, our society will be more open about discussing the reality of drug use be more effective in handling the drug crisis. In lifting the ban on federal funding for syringe and needle exchange programs and redirecting 10% of all funding to harm reduction practices, American society will have created real health benefits, reconnected a marginalized population, and saved billions within the healthcare systems.

Appendix
Figure 1 Number of Illicit Drug Users aged 12 or older in America in 2012 (National Institute of Drug Abuse, 2012)



Figure 2 Patterns of injection-related HIV risk behavior among people who use illicit drugs in Vancouver, 1996-2011 (Urban Health Research Initiative of the British Columbia Center for Excellence in HIV/AIDS)


Figure 3 Incidence of HIV and HCV infections among people who use illicit drugs in Vancouver, 1996-2011 (Urban Health Research Initiative of the British Columbia Center for Excellence in HIV/AIDS)




Figure 4 Percentage of street-involved youth reporting homelessness in Vancouver, 2005-2011

(Urban Health Research Initiative of the British Columbia Center for Excellence in HIV/AIDS)

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