Harm Reduction: A Legacy of Compassion Still Fighting for Its Place
By Leoni Descartes
In the 1980s, a quiet revolution began in response to a public health crisis that governments could no longer ignore. The world was waking up to the devastating spread of HIV/AIDS, and among those most affected were people who used drugs, particularly those who injected substances and shared needles. If you are dead, you can’t recover. From this crucible of stigma, fear, and urgent necessity, harm reduction was born - not as a radical ideology, but as a practical response to human suffering.
The Origins of Harm Reduction
The roots of harm reduction trace back to cities like Liverpool and Amsterdam, where rising HIV rates among injecting drug users pushed public health officials to rethink traditional approaches to substance misuse. The abstinence-only model, based on the idea that the only acceptable outcome was total cessation, was failing. People were dying, not just from overdose or the substances themselves, but from the ripple effects of a system that punished use instead of preventing harm.
Driven by activism and research, needle exchange programs emerged as one of the first concrete harm reduction interventions. They were controversial. Critics argued they “enabled” drug use. But the results were impossible to ignore - HIV transmission dropped, and trust between services and communities began to form. For the first time, people who used drugs were met not with handcuffs or shame, but with compassion, clean syringes, and a willingness to listen.
What Is Harm Reduction?
Harm reduction is more than just a set of interventions- it’s a philosophy. It acknowledges that drug use exists, and instead of demanding immediate abstinence, it meets people where they are. It focuses on reducing negative outcomes, such as overdose, infection, and social isolation, while respecting the autonomy and dignity of people who use drugs.
It encompasses everything from supervised consumption sites and opioid substitution therapy (OST) to naloxone distribution and peer-led outreach. But at its heart, harm reduction is about relationships, respect, and choice.
Harm minimisation is regularly practised in services to help reduce the risks associated with using substances by equipping services users with knowledge by openly discussing tolerance, Blood Borne Viruses, poly drug use, adulteration, clean works, using naloxone to reverse opiate overdoses - and empowering service users with the tools to keep themselves and their peers safer.
Fast Forward: The Persistence of Abstinence
Despite the decades of evidence and advocacy, many substance misuse services - especially in the UK- remain trapped in an abstinence-first mindset. “Recovery” is too often narrowly defined as being substance-free. People accessing services are told, explicitly or implicitly, that their progress only matters if it ends in abstinence, that they aren’t able to access certain housing or support unless they are abstinent.
The demand for abstinence is the biggest barrier to recovery.
It deters people from seeking help in the first place. It creates shame when they “relapse.” It undermines the very principles of trauma-informed care. And it ignores what people in the field - clients and practitioners alike know to be true: recovery is not linear, and it looks different for everyone. And importantly, this demand does not always make the person safer.
As someone who has worked on the frontlines in prisons, in the community, and at the intersection of gender, trauma, and substance use, I’ve seen the power of harm reduction firsthand. I’ve also seen how often people disengage from services because they feel judged, unheard, or pushed too quickly toward an ideal that isn’t realistic or safe for them at that moment.
Abstinence shouldn’t be a prerequisite for support. International models such as “Housing First” in the U.S. and Canada show that stable housing without sobriety requirements leads to better outcomes. Policies, such as requiring sobriety to access housing or support, can unintentionally exclude the very people most in need. Real-world examples, like “Housing First” have demonstrated success in reducing homelessness - harm reduction - without requiring abstinence, compared to those that reinforce stigma or delay access to care.
Data published by the Office for National Statistics on 23 October shows the number of drug-related deaths in England and Wales was higher in 2023 than in any other year since records began in 1993 with more than half of them involving opiates.
Those of us working in services see the impact, particularly as the prevalence of synthetic opioids rises and overdoses increase. We’ve seen people stop engaging after a lapse because of shame and binary models of ‘clean’ vs. ‘using’. More recently, we are seeing people present differently in withdrawal.
People use more chaotically when they’re kicked out of housing or can’t get their script on time. They disengage from services when they’re told “you don’t want recovery enough” or “you’ve missed 3 appointments,” and “you need to wait for a script with other service users and we don’t know how long it’s going to be”. The list goes on. Going to the pharmacy on a daily supervised regimen? - A trigger.
When people in recovery are released from prison with no one and nowhere to go - “it’s your choice”.
Not only this, but community substance misuse services routinely gatekeep funded rehab and detox placements. We are not meeting clients where they are at. When someone doesn’t feel safe, they don’t share openly. Especially when they haven’t been given the chance to explore and reconnect with skills to cope and communicate.
When someone doesn’t feel heard, they don’t keep trying. And when people aren’t supported, they die.
Harm Reduction Is Recovery
The truth is, harm reduction is recovery. For some, using Buvidal or methadone long-term is what keeps them housed, alive, and stable. For others, reducing use, using more safely, or simply having one consistent relationship with a non-judgmental worker is a life-changing intervention. We must broaden our definition of recovery to include these stories.
Modern harm reduction continues to evolve, embracing decriminalisation, drug checking, trauma-informed care, and culturally responsive services. But policy and commissioning structures often lag behind, demanding abstinence metrics, punishment and cost-efficiency over lived experience and sustainable change.
Speaking about rehabilitation and creating a world where spaces are truly rehabilitative is a different story.
The Way Forward
It’s time to centre harm reduction not as a peripheral service, but as the foundation of all substance use care.
This means:
Funding harm reduction services as essential health care, not optional extras
Training staff to engage without judgment, prioritising relationship over results
Involving people with lived experience in service design and delivery
Redefining recovery beyond abstinence - towards wellbeing, autonomy, and connection
Creating services where the demand for abstinence isn’t a barrier to accessing housing, programmes or a cause for recall when a person relapses.
If prisons are to be a ‘place of rehabilitation’, let’s stop punishing incarcerated people for substance use by segregating them, and instead support them through recovery ajudications, amnesty, and further support.
To ensure people are housed first, and people in prison are not released with little notice or chance for continuity of care with recovery services
Decriminalise use and possession and make better use of community support and diversion schemes.
To fund wider range of opiate substitute therapy, like the buvidal buprenorphine prolonged release injection, but also treatment for non-opiates.
Digitise OST Prescriptions so they are sent straight to the pharmacy in all services
Equip staff with more knowledge of how neurodiversity and substance use affect people and fund more practitioners to complete assessments for neurodiversity in custody and the community. At the moment, waiting lists often exceed a year for ADHD and ASD.
End the chicken and egg of demanding abstinence for those with neurodiverse conditions who are self-medicating, before they can be assessed or prescribed medication for their mental health. It’s unrealistic and dangerous.
Better and more proactive multiagency working and care coordination for service users with dual diagnoses. Often, people do not receive the support they need until they are in crisis and experience more trauma.
Peer workers (if they are paid at all) and recovery workers are overworked and underpaid, which causes a lack of employee retention, high caseloads and improper continuity of care due to a constant influx of new workers and service users having to continuously rebuild relationships with their keyworkers. Many new recovery workers, may be new to substance use field and lack knowledge, confidence in discussing harm reduction, mental health and substance use in a stretched service.
Balance listening to the science and those with lived experience, then and now. This includes the voices of people who are in active use.
More supervised consumption sites
More conversations around better integration between recovery services and primary care as opposed to fragmentation
Review care around chronic conditions, pain clinics and substance use - people in pain who self-medicate illicitly are discriminated against, often turned away from recovery services, refused prescribing, left in pain and unsafe.
Change the language we use, so we centre the person, not one facet of their experience.
Recovery has been redefined, but the message still needs to trickle to the front lines - ‘Recovery is a process of change through which people improve their health and wellness, live a self-directed life, and strive to reach their full potential’; it is not explicitly abstinence.
A nuanced understanding of addiction requires balancing the disease model with behavioural and choice-based perspectives. Recovery pathways are inherently individualised, and while 12-step fellowships such as Narcotics Anonymous (NA), Alcoholics Anonymous (AA), and Gamblers Anonymous (GA) are effective for many, reliance on a singular model overlooks the diversity of individual needs. Expanding the range of free support options is critical to providing inclusive and effective care.
The harm reduction movement began in crisis. Today, as synthetic opioids become the norm, overdoses rise and drug-related deaths reach record highs, we are again in crisis. But we are also in a moment of opportunity to build systems that are humane, evidence-based, and person-centred.
We owe it to the pioneers of the 1980s. More importantly, we owe it to the people who are still too often left behind by services that demand perfection when what’s really needed is care.
About the Author
Leoni Descartes is a Team Leader at The Forward Trust, working in a women's prison within a substance misuse service. She carries a caseload, manages a team, and leads on implementing trauma-informed and creative psychosocial interventions. Leoni has also worked for Women in Prison and Change Grow Live (CGL) as an opiate recovery worker, the former, focusing on supporting women affected by addiction and the criminal justice system.
She holds a BSc in Biology with a research focus on addiction and will begin her MSc in Addictions at King’s College London in September 2025, supported by the SSA Bursary and a KCL Scholarship. Her long-term goal is to become an international expert in addiction, to pursue a doctorate at the London School of Hygiene and Tropical Medicine, and conduct systems-based research on addiction care in the Middle East.
References
Global Commission on Drug Policy (2017) The world drug perception problem. Available at: https://www.globalcommissionondrugs.org/reports/the-world-drug-perception-problem (Accessed: 1 May 2025).
Harm Reduction International (2025) Available at: https://hri.global/what-is-harm-reduction/ (Accessed 1 May 2025)
INPUD (International Network of People who Use Drugs) (2017) What is harm reduction? Available at: https://www.inpud.net/en/what-harm-reduction (Accessed: 1 May 2025).
Marlatt, G.A. (1996) ‘Harm reduction: Come as you are’, Addictive Behaviors, 21(6), pp. 779–788. doi: 10.1016/0306-4603(96)00042-1.
National Health Care for the Homeless Council (2023) The history and foundations of harm reduction. Available at: https://nhchc.org/wp-content/uploads/2023/06/NHCH_History-Foundations-of-HR-.pdf (Accessed: 1 May 2025).
National Institute for Health and Care Excellence (NICE) (2022) Needle and syringe programmes. Available at: https://www.nice.org.uk/guidance/ng140 (Accessed: 1 May 2025).
Office for National Statistics (ONS) (2023) Deaths related to drug poisoning in England and Wales: 2023 registrations. Available at: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsrelatedtodrugpoisoninginenglandandwales/2023registrations (Accessed: 1 May 2025).
Szalavitz, M. (2021) Undoing drugs: The untold story of harm reduction and the future of addiction. New York: Hachette Go.
World Health Organization (WHO) (2004) Evidence for action: Effectiveness of community-based outreach in preventing HIV/AIDS among injecting drug users. Available at: https://www.who.int/publications/i/item/evidence-for-action (Accessed: 1 May 2025).
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