Ryan Marino, MD, is a triple-board-certified physician practicing emergency medicine, medical toxicology and addiction medicine. He is an Associate Professor at Case Western Reserve University School of Medicine in Cleveland, Ohio, and shares his opinion on whether giving out "crack pipes" is truly harmful.
In June, New York City debuted the first of multiple planned public health vending machines, stocked with a variety of health supplies including personal hygiene items, safer sex supplies, and Narcan (naloxone) and fentanyl test strips. The latter harm reduction items have received the most attention, particularly the safer smoking kits, which include lip balm, mouthpieces and clean stems (often referred to as “crack pipes”).
While the practice of harm reduction as public health is neither remotely new nor limited to drug topics, and has extensive scientific backing, this has sparked quite a bit of controversy.
The idea of giving people supplies for drug use, often referred to as 'paraphernalia,' has received a significant amount of backlash since then in popular media, mainly focused on the smoking supplies — the 'crack pipes.'
It is easy to make such a concept sound ridiculous to the general public by implying that government agencies are just passing out items that allow for drug use, even if that’s not really the truth.
Similar narratives have been presented before to oppose even things like naloxone, a literal lifesaving antidote for opioid overdose, by falsely implying that saving the life of someone experiencing is enabling use and even unsafe use, both of which are false. Because of our deep-rooted societal stigma towards certain drugs (and the people who use them) it is unsurprising that anything that can possibly be seen as enabling such drug use will draw outrage. And in today’s popular media cycle, outrage seems to get the most attention.
A useful counterpoint is alcohol. Alcohol is a drug; it causes significant health consequences and is actually a leading cause of death. But most people don’t think of alcohol as a drug (the U.S. Food and Drug Administration even classifies it as a food), and even if they do, they do not think of it as being bad or harmful like other drugs even though it objectively is. Cannabis, too, has benefited from similar double standards. Both alcohol and cannabis users benefit from significant harm reduction strategies from the government. But there is little attention paid to these drugs or the steps that have been taken to make it safer for the people who use them simply because they are more socially acceptable.
How harm reduction benefits public health
It is important to note that access to clean paraphernalia, or even any paraphernalia, does not stop anyone from using drugs. What we can do is reduce the risks of things like death, and reduce the societal costs from unsafe drug use. The primary goals of distributing these safer smoking supplies is to reduce transmission of infectious diseases that can occur from reusing or sharing pipes, and also to prevent overdoses since smoking is a safer alternative to using by injection (another risk for infectious disease as well) and snorting.
The safe smoking supplies are not specific for crack cocaine only, and can be used in the same way as a harm reduction tool for numerous other substances, including fentanyl.
The kits also prevent cuts and burns, which is still another risk for infections and transmission of infections.
These are all good things. Overdoses and deaths from overdose continue to increase in the U.S. and elsewhere. Rates of communicable diseases like HIV, hepatitis C, and hospitalizations for other problematic infections like MRSA and difficult-to-treat conditions like endocarditis (an infection of the valves inside the heart) and osteomyelitis (an infection in the bones), remain high enough to still be a public health concern.
Another goal of both these kits and the vending machines in general — as well as the practice of harm reduction for substance use — is to increase engagement between people who use drugs and public and community health. Because they are criminalized and stigmatized, people who use illicit drugs are less likely to have positive interactions with healthcare, or even to interact at all. This leads to additional preventable problems, and is a major barrier for people to access recovery services, meaning that our policies are actually even preventing people who use drugs from successfully stopping.
Harm reduction benefits everyone
In addition to their health and safety benefits for individuals who use drugs, distributing these supplies also benefit the community at large. Most importantly to remember for people who oppose harm reduction on moral grounds or just oppose drug use in general, these strategies and resources are proven to increase rates of people who enter treatment and achieve recovery.
Beyond just reducing infection rates and the burden of preventable diseases, reductions in disease can help with current issues like hospital overcrowding and medication shortages, which don’t seem to be going away any time soon.
Reducing the burden of disease and subsequent disability also reduces overall costs and provides downstream economic benefits. More people are able to work, more people are able to spend time with their families, and people are more able to function.
While estimates vary, even just preventing one overdose death is estimated to save hundreds of thousands to millions of dollars in societal costs, not to mention reducing the significant costs associated with nonfatal overdose and other complications. Compared to the $11,000 price tag for these machines, and items that can be restocked for dirt cheap, the math speaks for itself.
Not only are such public health — and specifically harm reduction — vending machines a new concept, New York City is not alone in installing them. There are large, successful programs that have been in other U.S. states for years, and in other countries around the world. Similar harm reduction practices are more widespread outside the U.S. but are also expanding in many areas inside the U.S. as well.
Years of study has proven their benefits. Harm reduction services, including providing clean supplies like safe smoking kits, do not increase drug use and do not increase crime. They actually have the opposite effects and even can reduce other problems like discarded needles and syringes in public spaces. The fact is that these are good for everyone. There is no factual or evidence-based argument against this, and the opposition is only based in unfounded fears, biases and ignorance.
But we continue to see opposition directed at this sound public health not just in New York City, but recently in places like Oregon and even at the level of the U.S. federal government. With so many dying and being harmed by our ongoing drug crisis, and no end in sight, there is no justifiable excuse to let uninformed feelings stand in the way of real solutions to save lives.