The Struggle for Safe Supply in the Context of Harm Reduction
Donna Baines and Mohamed Ibrahim
Reprint of an entry for Christa Fouche and Liz Beddoe (eds.) Encyclopedia of Social Work. Edward Elgar, 2025.
Introduction
Initiated in 1988 in the Netherlands by people who used drugs and sought ways to reduce the transmission of HIV, harm reduction is deeply compassionate, social justice approach to reducing the negative effects of health, social and laws that criminalize and stigmatize drug use. Rather than insisting on detox and abstinence before being eligible for services, harm reduction recognises that many people may never stop using psycho-active substances. However, there are effective ways to improve health outcomes, reduce risks and fold people into productive lives, while simultaneously respecting human rights and shifting power to oppressed and vulnerabilised communities (Kerman et al., 2021).
In many cities, including Vancouver, people who use drugs and their allies have shifted the public and policy discourse on drug use from one of criminalisation and punitiveness to a view of addictions as a health issue and response to trauma requiring biomedical and community-engaged psychosocial treatments and supports. Traumas underlying addictions include: chronic pain from workplace injuries, violence in the home and the street, homophobia and transphobia, residential schools, and the ongoing violence of racism, poverty and colonialism. It is widely recognized that the longer people remain engaged with unregulated drug use, the increased exposure they have to further trauma (Norton et al., 2022). Hence, shifting even part of their lives to a safer practice tends to have benefits for many other aspects of their lives and the lives of their loved ones and communities.
Rather than a single strategy, harm reduction includes interwoven practice approaches, policies, services, and programmes. A full range of harm reduction interventions includes: the complete decriminalisation of drugs and drug use (thus ending incarceration and criminal records for possession or use); the provision of non-market, supportive housing, and a no-barrier policy framework for housing, known as housing first; health care and social supports; meeting people where they are in terms of capacity to engage in stabilization and change-oriented strategies: and the provision of a regulated, safe supply of currently illicit drugs (Csete and Elliott, 2021; Kolla et al, 2023; Orr, 2023). In large part due to these policies, many people involved in harm reduction find their lives stabilised to the point where they reduce or end their use of substances (Jannou, 2023).
Safe supply is an important plank in this group of practices and polices. It refers to innovative policy and service approach in which non-toxic, often prescription, drugs are made available to those using unregulated drugs. Though the ultimate goal of safe supply is for governments or arms-length government-regulated bodies to produce and distribute safe and regulated drugs, currently most governments do not have the capacity for production or, more importantly, the political will for this. In the few places that have adopted safe supply policies, it is undertaken largely through prescription of already legal drugs and tolerance for the distribution of other so-called clean drugs through means such as compassion clubs (voluntary groups that test illicit drugs for toxic substances and may also sell a safe supply of unregulated drugs) and other small, non-government, unregulated test and production sites (Greer, 2023).
Enacting safe supply and regulation of street drugs poses numerous challenges. When alcohol and marijuana were legalised in Canada, for example, many small-scale local producers already existed and could be regularised and regulated into small business. Currently, the production of illicit drugs globally lies with criminal gangs and overseas crime networks, and the drug supply is often laced with highly toxic substances, leading to the record high numbers of death from that toxic supply. It is in this regard that the government at provincial and federal need to invoke state of emergency to stop the unmitigated morbidities and mortalities associated with toxic drug. According to the Federal Government of Canada’s statistics, an average of 21 Canadians die daily from toxic drugs, with many more hospitalized with serious brain damage as a result of overdose (Government of Canada, 2024). Other countries, particularly in the US and Europe, face similar tragic statistics (WHO, 2023).
Unlike alcohol, marijuana or even gambling, folding existing producers into a legal, regulatory framework or replacing them is difficult and requires a comprehensive strategy to bring the production and distribution of illegal drugs into mainstream production and distribution. Nonetheless, governments have demonstrated a willingness to show leadership and undertake major interventions in the face of other public health crises, such as during the COVID-19 pandemic. A similar scale of and speed of intervention is required to address this unrelenting, major health and social crisis.
Small steps have been taken in the direction of decriminalization and harm reduction in some places. For example, in 2001, Portugal set a precedent by decriminalising the possession of heroin, cocaine and marijuana, including up to a 10-day supply for personal use (Fiaoloa and Martinez Fernandes, 2023). This legislation shifted the view of those using illegal drugs from a criminal in need of punishment to a patient in need of normalisation and supports. However, the wait time for detox and treatment remain upwards of a year, and, like the rest of the global North, the drug supply has become increasing contaminated resulting in a frightening level of toxic drug deaths. In the many states in the US, Good Samaritan laws mean that people who seek help for drug use will not face criminal charges. However, the most decisive step in the US was taken in Oregon in 2020. A state-wide referendum agreed that the possession of all nonprescribed drugs for personal use should be decriminalized, and millions of dollars should be directed to treatment, recovery services, housing, and harm reduction.
In a precedent setting example of harm reduction and safe supply, in British Columbia (BC), Canada, became the first government to legalise small supplies of some illegal drugs and then in 2022 introduced the Safer Opioid Supply policy under which people at high risk of overdose could receive pharmaceutical-grade opioids free of charge prescribed by a physician or nurse practitioner (Slaunwhite et al., 2023). The evidence confirms that people with addictions who received a safer supply of prescribed opioids were 61 per cent less likely to die than those without access to it (Slaunwhite et al., 2023). However, restricted access and other barriers also meant that the province saw a rise in the number of overdoses and opioid deaths. Facing intense criticism from right-wing political groups, in 2024, the government of BC has rolled back its commitment to safe supply as it awaits further evidence on its outcome. As in Portugal and other places pursing harm reduction policies, safe supply and harm reduction policies have triggered strong denunciations by right wing groups who argue that safe supply and harm reduction policies foster widespread drug addiction, encourage the illegal resale of safe supply, and provides massive profits for criminal gangs selling psychoactive drugs (Bailey and Woo, 2023; Fiaoloa and Martinez Fernandes, 2023).
Harm Reduction and Safe Supply Social Work Practices
Harm reduction and safe supply practices are helpful in many contexts, not just with people who use drugs. This section presents two such practice themes for social work and allied professionals.
Meeting People Where They Are and Low Barrier Services
Meeting people where they are is a practice approach that is based in the needs of the communities most affected by the drug crisis and aimed at reducing the social control of service users by being client-led, non-judgmental, and inclusive (Perera et al., 2022). This practice approach fits very well with decolonial and anti-oppressive social work approaches. The underlying principles include humanism, pragmatism, individualisation, autonomy, incrementalism, and accountability without termination (Jordan, 2023). These principles interweave tightly with low barrier approaches. Low barrier approaches seek to remove as many barriers as possible to initial and ongoing service use including the removal or reduction of criteria that service users must meet before being eligible for services (Csete and Elliott, 2021).
Humble in the Face of Lived Experience and Critical Reflexivity
This social work practice approach is built on two interwoven practices. Firstly, deep respect and compassion for the first-hand experience of those exploited and oppressed by existing structures, and as those who are the most impacted by policy and practice change. Secondly, being humble in the face of lived experience involves taking leadership from these groups in how to approach services and supports, and twinning this with a critical social analysis that fosters far reaching social change at the level of organisations and larger macro policies. Centering people with lived experience requires humility by social workers, who have generally been trained to take professional control. However, this approach involves recognizing that while theory and knowledge are essential components of critical practice, the subjective knowledge of the service user is an irreplaceable form of in situ expertise that grounds practice in an everyday integrity and commitment to those oppressed and harmed by social policies and larger social structures. Similar to meeting people where they are, remaining humble in the face of lived experience pivots on being non-judgemental, inclusive and led by service users and their communities.
Remaining open and humble also involves ongoing critical reflexivity aimed at exploring one’s own practices, values and perspectives and the structures shaping them (Morley and O’bree 2021). In an effort to connect with communities, individuals are sometimes tokenized and presented as representing an entire population of people (Voronka 2016). This reduces our capacity to maintain a critical understanding of lived experience and impedes the development of strategies to redress inequities and oppression. Critical reflexivity can help practitioners to avoid tokenizing people with lived experience and essentializing their identities by expecting that everyone with lived experience holds the same perspective or understanding, rather than respecting the diversity of lived experiences and finding ways to reflect them in emancipatory practice.
Conclusions
Harm reduction and safe supply are policy, service and practice approaches that came from the communities most harmed by existing practice. They provide a way to engage vulnerabilised and oppressed communities in approaches that will be the most helpful to them. They involve adopting a stance that is not comfortable for many professionals, namely being humble and critically reflexive in the face of lived experience in order to develop and sustain services that meet people where they are, save lives and generate a more fair and equitable society. Harm reduction is really about shifting power from the top-down professionalised system to those living with inequities and harm. It is also about shifting public discourse and tackling seemingly insurmountable policy, practice and structural issues. Fortunately, the evidence substantiates important successes. Though harm reduction originated with people who use drugs, the approach can apply to many of the wicked and intractable social problems that are the heart of anti-oppressive and critical social work practice.
References
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