Earlier this year, Stephanie Vaughn entered her daughter Sienna’s bedroom to find the 16-year-old cheerleader blue-lipped and unconscious on her bed. The teen and a friend had taken counterfeit pills that were later found to be laced with fentanyl. Sienna was taken to a hospital, where she was pronounced dead—one of the nearly 300 tragic overdose fatalities that occur across the United States each day, roughly 1% of whom are adolescents.
This persistent crush of overdose deaths is driving a newfound prioritization of substance use disorder (SUD) treatment in the United States. In 2021, only 6% of an estimated 46.3 million people living with a SUD received appropriate care. In 2023, in an effort to make medication for opioid use disorder (MOUD) more available and accessible, new policies and guidelines relaxed restrictions on buprenorphine and methadone. Such moves are an essential part of curbing the overdose crisis, as evidence-based treatment saves lives. For example, MOUD has been shown to reduce overdose mortality by up to nearly 60%.
But treatment alone will not halt overdoses, in large part because the majority of people who use drugs do not have a SUD. Nor do most continue using if the negative consequences begin to outweigh the drug’s benefits, a pattern sometimes referred to as “problematic” or “chaotic” use. Yet regardless of whether a person uses compulsively, occasionally or is experimenting for the first time, drugs—especially those purchased on the unregulated illicit market—come with risks. So if we want to save lives right now, we must look beyond treatment and embrace harm reduction.
Not All Drug Users Are Addicted
It’s impossible to know, in retrospect, if Sienna Vaughn was struggling with substance dependence or “problematic” drug use. After all, people use both legal and illegal drugs for a wide array of reasons, from recreation to coping with the struggles of daily life. And while the National Survey on Drug Use and Health finds that roughly half of respondents age 12 and older report ever having used an illicit drug, only around 14% have done so in the past month. This suggests that for most people, such drug use tends to be episodic and temporary.
Furthermore, only a minority of those who use drugs—even on a regular basis—meet the criteria for a SUD. Worldwide, only about 12% of people who use alcohol, tobacco or other drugs would be considered to be engaging in problematic use, although the exact proportions do differ by drug. Studies in the United States, conducted decades apart, draw similar conclusions, even as the breadth of available substances has expanded.
For example, research shows that only about 5% of people who use psychedelics develop a SUD, while about a third of those who use tobacco can be considered dependent. Opioids and cocaine have problematic use rates around 23%-30% and 15%-20%, respectively, while up to 1 in 10 stimulant users struggle with compulsive or problematic use.
The odds, therefore, are that Sienna Vaughn was not struggling with a substance use disorder. Rather, she was most likely doing what teens do: experimenting. Or perhaps she just used drugs casually and occasionally. Unfortunately, all substance use comes with health risks. And if we focus on treatment alone, we will miss an opportunity to empower the majority of people who use drugs to protect their health and their lives—including those who use functionally, casually or experimentally, as well as individuals living with a SUD who are unwilling, unable or just not ready to quit.
What Makes Drug Use Risky?
For some people, engaging in problematic drug use may increase the risk of overdose and other health consequences. Individuals living with substance use disorders are more likely to act impulsively or demonstrate impaired decision-making. Chronic, heavy use of a range of drugs, from methamphetamine to tobacco, is a contributing factor in organ damage and disease. And for individuals who are physically dependent on alcohol or opioids, acute withdrawal is not just unpleasant, but it can also be dangerous.
As with almost everything in life, substance use comes with some inherent risks, even for those who are using casually, periodically or experimentally. Some of these potential harms are based simply on the ways that particular drugs operate. Opioids, for example, depress the respiratory system, and the potential for harm will be dependent on factors such as dose, potency, individual tolerance and whether multiple drugs were used. People who inject drugs are at risk for HIV and other infectious diseases if they share needles, syringes and injection-related equipment.
In addition to the risks associated with specific substances, the unstable and unregulated illicit market brings unique dangers of its own. People do not know exactly what is in their supply and cannot depend on consistent potency. In fact, recent research has found that in the weeks following drug bust-related market disruptions—when people have the least certainty about their supply—overdoses increase.
This is why some people have adopted the term “fentanyl poisoning” when discussing youth deaths. According to her family and friends, Sienna Vaughn believed she was taking Percocet, not fentanyl. But it applies to anybody who purchases drugs on the illicit market. When fentanyl—a synthetic opioid that is roughly 50 times as potent as heroin—began surging across the United States, longtime heroin users no longer knew how to measure a safe dose. And just as people have begun adapting to fentanyl’s ubiquity, the rise of the veterinary tranquilizer xylazine is shaking things up once again.
Harm Reduction Saves Lives
Fortunately, no matter whether a person is living with a SUD or taking a pill for the first time, many of the risks associated with substance use can be managed via an approach known as harm reduction. Acknowledging that abstinence is not a realistic goal for everybody, and may not even be desirable (or necessary) for many, harm reduction meets people where they are and supports any positive, health-protective actions. Both philosophy and toolkit, the approach empowers people who use drugs and their families “with the choice to live healthy, self-directed, and purpose-filled lives.”
Although we don’t talk about it as such, many of us engage in personal harm reduction when we consume legal substances. For instance, bar-goers might designate a driver or use public transit to avoid the potential for an automobile accident after a night of drinking. Someone new to cannabis may control their dose by cutting an edible into smaller pieces, whereas those who are sensitive to THC’s unwanted side effects can still enjoy the experience by choosing products with a higher ratio of CBD. Meanwhile, people who are nicotine-dependent can reduce the health dangers of smoking by switching to reduced-risk products.
But when it comes to illegal substances, such as those that are driving the overdose crisis in the United States, many of the same issues of criminalization that make use risky also make it harder for individuals to manage those risks. For example, use of drug-checking equipment such as fentanyl test strips, which can identify fentanyl’s presence in street drugs, has been shown to encourage safer injection practices because such equipment helps users to have a better sense of whether their supply has been tainted.
But if people like Sienna Vaughn don’t realize their supply could be contaminated, they have no reason to take extra precautions. And even among individuals who are familiar with and want to practice harm reduction, the threat of punishment—often in the form of paraphernalia laws—can be a deterrent. Research shows that people are less likely to carry multiple clean needles or the overdose reversal medication naloxone if they’re worried that police or prosecutors will use these tools against them. Furthermore, the threat of incarceration reduces people’s willingness to call emergency medical services during an overdose.
Community-based harm reduction organizations work to support and protect individuals who engage in harm reduction practices. They provide people who use drugs with the knowledge and resources to protect their health, and they have been doing so for decades. They are extremely cost-effective, and they work. Syringe service programs reduce HIV and hepatitis C by as much as 50%. Overdose education programs, coupled with distribution of naloxone, can reduce overdose fatalities by more than 20%. In addition to preventing deaths, overdose prevention centers are associated with reductions in public drug use, litter and crime in the neighborhoods where they’re located.
Unlike treatment, harm reduction is relevant for every person who uses drugs. Yet nonetheless, harm reduction organizations are chronically underfunded, and their work is often hindered by restrictive policies and the continuation of the drug war. As of June 2022, only 38 states and Washington, D.C., authorized syringe services programs, despite the fact that these organizations are a primary distributor of life-saving naloxone. And while many states are moving to decriminalize fentanyl test strips, some—including Vaughn’s home state of Texas—continue to resist the effort despite spikes in fentanyl-involved overdose deaths within their borders.
Since 1999, more than a million people have died of a drug overdose in the United States. It is too late to save their lives, but it is not too late to prevent more deaths. Improving and expanding treatment is one part of the solution, but if we truly hope to end the overdose crisis, we need to put the same gusto into harm reduction. More than that, we need to back it up with policy that is both empathetic and pragmatic—policy that recognizes that drug use isn’t the same for all users.