What Those in Power Are Missing About the Opioid Epidemic

“This is what happens when public health fails.”

About the author: Jack Shuler is a professor of English at Denison University. He is the author of This Is Ohio: The Overdose Crisis and the Front Lines of a New America.

Patricia Perry
Trish Perry organizes weekly outreach for homeless populations in Newark, Ohio. (William Widmer / Redux)

Updated at 10 a.m. ET on July 25, 2021.

On a street corner in Newark, Ohio, every Saturday, rain or shine, Trish Perry distributes harm-reduction supplies—syringes, Neosporin, saline, and the overdose-reversal drug naloxone—to people who use drugs. She also provides food, clothing, tents, and blankets to the more than 75 people who stop by each week. Set up in a grassy lot shaded by a scrawny hackberry and a silver maple, her outreach efforts are funded purely by donations. Sometimes health-care workers will check wounds; sometimes a stylist will offer free haircuts. The people who come here for aid know that Perry isn’t going to ask them for personal information or expect anything in return.

Perry’s efforts aren’t supported by the local board of health. In fact, two years ago, it voted unanimously against establishing a syringe-service program. Perry, the mother of a son with substance-use disorder, decided to continue getting lifesaving supplies directly into the hands of the people who need them most.

People who use drugs and those who love them have helped reverse thousands of overdoses in the United States, saving friends, family members, and strangers. They’ve done this work without recognition, without fanfare, and sometimes at great risk to themselves. They know firsthand the benefits of access to sterile syringes, naloxone, and drug-testing strips, which detect the presence of fentanyl in a particular drug. But few in power listen to their advice. Some state and local governments actively ignore them. If local governments want to tackle the opioid crisis, they need to listen more to harm-reduction advocates, especially those in hard-hit communities.

The CDC estimates that more than 93,000 Americans died from drug overdoses in 2020, up 29 percent from the year before. And since 1999, more than 840,000 Americans have died from overdoses. In recent years, the overwhelming majority died from using the synthetic opioid fentanyl, which is used on its own or found in other drugs, resulting in people taking it unintentionally.

Overdose-death rates are especially high in West Virginia and Ohio, where I live. In the years that I’ve reported on this crisis, I’ve seen local-government officials act ineffectively, sometimes in direct contradiction to the recommendations of experts. Even today, with a supportive federal government, I’ve seen pushback against the kinds of harm-reduction efforts that research shows can save lives and prevent disease.

Critics argue that syringe-service programs create needle litter and crime, and enable drug use. The evidence, though, does not support these concerns. According to the CDC, “New users of SSPs are five times more likely to enter drug treatment and three times more likely to stop using drugs than those who don’t use the programs.” Syringe-service programs, which provide sterile syringes in exchange for used ones, also help reduce transmission of blood-borne infections and other risks of intravenous drug use.

Still, in rural Scott County, Indiana, where the biggest U.S. HIV outbreak in recent history occurred in 2015, county commissioners voted to shut down a local syringe-service program. In the past year, lawmakers have also sought to restrict syringe services throughout North Carolina, and last week the city council in Atlantic City, New Jersey, shut down a program. West Virginia Governor Jim Justice and local city-council leaders have rolled back syringe programs and signed into law measures that further restrict access to syringes and free health care. West Virginians are already seeing the repercussions. Amid a rise in intravenous drug use, Kanawha County, the home of West Virginia’s capital, Charleston, is experiencing an uptick in HIV cases that the CDC has called the “most concerning in the United States.”

These laws complicate the efforts of grassroots harm-reduction advocates and, in some cases, could make their work illegal. Yet with few resources and, typically, no pay, volunteers push on. These advocates believe in meeting people who use where they’re at—both physically and emotionally—and in respecting them as humans. People who use drugs, for example, can face judgment, mistreatment, or even arrest when they seek resources at traditional health-care facilities, which makes them reluctant to go. The harm-reduction community knows that people feel this stigma, so the advocates have learned how to reduce the physical harms, including hepatitis C, HIV, abscesses, and overdoses, that can come with drug use. They see the benefits of incremental improvements—a sterile syringe is better than a used one; a naloxone-reversed overdose is better than death. The advocates I know go out day after day, night after night, meeting people in drug houses, on corners, in their homes, and under bridges. In Columbus, Ohio, for example, the Columbus Kappa Foundation—an alumni organization for members of Kappa Alpha Psi, a Black fraternity—distributes naloxone in churches and barber shops. Sometimes they knock on doors.

Fentanyl testing strips
Perry distributes fentanyl testing strips at no cost. (William Widmer / Redux)

“We didn’t invent grassroots harm reduction,” Brooke Parker told me. She helps run a street-outreach harm-reduction organization called SOAR in Charleston. “This is what happens when public health fails. Communities step up, especially in Appalachia.” For Parker, the work is about much more than giving people harm-reduction supplies; it’s about building trust and connection. But, she said, people view her willingness to help people who use drugs—to give them what they need to stay healthy without judgment or questions—as naive or even radical.

The pushback against SOAR has been aggressive, and the organization has stopped handing out syringes. Parker said that ostracizing people who use drugs has become so normalized that some people no longer see them as humans. Her empathy comes from personal experience—she’s in recovery herself—as well as from her upbringing. “I remember my dad telling me when I was younger, ‘Love people through hard things.’ That’s the whole idea behind agape, love. It’s unending … There’s no other way; people just end up alone. And if you’re alone, you don’t get anything. You don’t get anything done. We’re meant to be in community. We’re meant to take care of each other.”

Grassroots harm-reduction advocates’ organizing principle is love. This kind of love is not admonishing people to pull themselves up by their bootstraps. And it’s not the showy, egocentric do-goodism primed for viral videos. Radical love is unconditional, and so is evidence-based harm reduction, which asks nothing from the people being helped, not even a tinge of reciprocity. As the preacher, writer, and harm-reduction advocate Blyth Barnow told me: “Radical love is incredibly ordinary. It’s just … of course this is how you act.” But it’s also visionary—a way of seeing what is possible for the person in front of you.

Joe Biden’s platform for ending the opioid crisis supports important interventions, including expanded access to treatment, harm reduction, and health care. But he has spoken in favor of measures such as mandatory treatment for substance use, which takes away a person's agency and is not proven to be effective, and drug courts, in which a judge essentially supervises treatment. The people most harmed by the structural violence of these policies, and by a lack of adequate health care, are poor, and many of them are people of color. Combatting the overdose crisis by punishing people who use drugs through the criminal-justice system will not work.

Federal, state, and local governments should heed the advice of harm-reduction advocates. Because the drug supply is full of fentanyl, people need more fentanyl-testing strips, safe consumption spaces, and access to regulated medication. Allowing harm-reduction programs to use federal dollars to purchase syringes, which is currently prohibited, would be an important policy change. Funding to fight the opioid epidemic, as well as the opioid settlement money from lawsuits against pharmaceutical companies, needs to reach grassroots programs in order to help them become more sustainable.

Finally, more official harm-reduction work should move out of health departments and into the streets. Syringe-service programs can be gateways to better health and, if folks are ready, to treatment. They are a place for people to experience radical love and potentially build connections—to nonjudgmental health care and to a supportive community.

Harm reduction doesn’t have to be fancy; it just has to meet people where they’re at. I’ve seen successful harm reduction carried out in storefronts, in vans, and, in Perry’s case, at some card tables in a grassy lot. On summer days in Newark, after getting a hot dog and some harm-reduction supplies, folks head for the shade of the hackberry and maple. They talk and rest in this cool refuge. This is their safe space, and they are loved.


Due to an editing error, an earlier version of this essay misstated what testing strips are measuring. It's the presence of fentanyl, not the amount.