Of Condoms and Crack Pipes: A Lesson in Harm Reduction

A Lesson in Harm Reduction

In early 2014, I began volunteering at a drop-in centre for homeless youth in Boston. At the time, I had never met anyone who used drugs, nor had I any prior knowledge of harm reduction. In other words, I was utterly unprepared for what I was about to encounter.

On the first day of orientation, I was shown the various facilities available to clients, including the treasure trove of vital supplies offered by the centre. Among these were expected provisions such as hot food, clothing, sleeping bags, toiletries, and first-aid materials.

There were also some more surprising items to be found; in the common area sat a cheerful shelf of multi-coloured condoms, strawberry-flavoured dental dams, and bright pink packets of lube. Right below was a more sinister-looking shelf, holding Ziploc bags of drug paraphernalia such as alcohol swabs, syringes, and hypodermic needles. These were drug kits for people who used crack and heroin, containing everything needed to consume the drug, save for the drug itself. 

I still remember the shock I felt when I first saw these drug kits. I was completely baffled. Why, I thought, should we give out drug paraphernalia to known addicts? Why should we be indulging people’s self-destructive behaviour?

I soon realised that I had been entirely misguided in my judgement.

The reality was that many of our clients engaged in sex work and drug use to cope with the hardships of poverty, homelessness, and past trauma. By providing sterile tools for drug use, alongside condoms, the centre was reducing the transmission of viruses such as HIV and hepatitis C. The drug kits were literally life-savers.

Clients told me that they found the centre’s approach to be a welcome change to the abstinence-focused approach of many so-called rehabilitation institutions. Such a method, they felt, had been a source of further disempowerment, as it made them feel like they had less control. Clients preferred our non-coercive form of support that showed them respect and tolerance.

I came to greatly respect the centre’s principles of harm reduction – to reduce the adverse consequences of potentially high-risk behaviour while affirming the agency and dignity of those unable or uninterested in stopping their drug use.

The centre encouraged open and receptive communication between staff and clients, and this allowed the latter to have a real voice in the programmes designed to serve them, thereby allowing for a more effective delivery of service.

For example, a client once asked staff to provide disposable straws in the medicine cabinet. When we questioned this, he told us that the straws would function as useful tools for snorting drugs, reducing the risk of infection from using or sharing banknotes. The client was able to draw on his own experience and effectively guide staff as to where the service was lacking.

Our clients also helped us reconsider some basic assumptions we had about best harm reduction practices.

We had traditionally provided bleach in our drug kits so that clients could sterilise used needles before reusing them, as bleach can eradicate blood-borne viruses from syringes. Despite this, clients told us that they found the process of bleaching to be too time-consuming and conspicuous when they sought a quick and discreet hit. Out of haste, clients were rarely cleaning their needles properly. In response to this reality, we abandoned the distribution of bleach kits, and focused on promoting our long-running needle exchange programme instead.

During my work within the centre, I gradually began dispelling the doubt I had initially felt about providing drug kits. Rather than actively encouraging drug use, the centre provided a safe and secure space in which clients were supported in managing their own drug use with life-saving tools and information.

I grew to understand the importance of the centre’s harm reduction philosophy, and I realised how problematic drug use and addiction are often symptoms of other deep-rooted problems, including systemic marginalisation and abuse. For those already in a broken state, the centre was thus a place to find acceptance, to gain the strength and readiness to pursue rehabilitation.

The centre’s culture of harm reduction gave me a more nuanced understanding of drug use, and it changed my own perspective of our clients – these individuals were not simply “addicts”, they were people.

Returning to the centre’s collection of condoms and crack pipes, it now makes sense to me why such ostensibly jarring items were kept side by side. Ultimately, both are important life-saving prophylactics; both are tools of harm reduction targeted at people engaging in activities that have potential health risks. It is, therefore, vital to have open and objective discussions about how to use drugs safely.