“Only the people can save the people”: As Trump guts harm reduction programs, activists fight back

Susan Ousterman remembers her son Tyler as quiet, curious and “with a smile that lit up the room.” He loved nature, skateboarding and was a talented percussionist. He also struggled with an opioid dependency, and by October 2020 was sleeping in his car.

“My son wanted more than anything to break free from his addiction, but we had no resources — none,” she told Salon. “He had just been robbed while sleeping in his car in Kensington [Philadelphia], and without a phone, he never got my message telling him to come home. Thankfully, he came anyway.”

On October 5, the pair shared a pizza in the yard, and promised to make a plan to put his life back together.

“It was one of the best conversations we ever had,” Ousterman, the executive director of the non-profit Vilomah Foundation, recalled.

Tyler then left for the corner store to buy cigarettes. After twenty minutes had gone by, Susan went to look for him, only to find him lifeless on the bathroom floor of a nearby gas station, having taken a cocktail of drugs including fentanyl. He was 24-years old.

After years of a seemingly unstoppable overdose onslaught, the tide finally seems to be turning in the opioid crisis: the Centers for Disease Control and Prevention reported drug fatalities plunged by a quarter between January and December 2024. While still leaving 80,000 people dead, it’s a remarkable improvement compared to the peak of two years ago when 114,000 Americans lost their lives.

It's not clear yet exactly why this trend has started to reverse. Perhaps law enforcement pressure diluted the potency of fentanyl, replaced by less-lethal (though still dangerous) concoctions such as xylazine, an animal tranquilizer. Or perhaps youngsters are shunning opioid intoxication while the most vulnerable demographics are already dead.

But for harm reductionists like Chelsea Mudalagi, coordinator at the AmeriCorps Community Training for Overdose Rescue (ACT) program in Michigan, the reason is clear: the proliferation of the lifesaving antidote naloxone, which works by blocking the effects of heroin, fentanyl and other opioids.

“We get really excited when we hear things like in Michigan, the overdose death rate has decreased five times faster than that of the rest of the country,” she told Salon.

“I think the fact that we carpeted Metro Detroit in Narcan [naloxone] has helped quite a bit. We always like to compare Narcan to fire extinguishers: everyone should have a fire extinguisher in their house. If you're out in public, you know where the fire extinguisher is, or if you needed one, someone else could get it for you. And I think that more people are willing to think about that if they're encountering an emergency; they might say to themselves, ‘oh, this might be an overdose.’”

But now, that progress may be coming undone by the Trump administration, which is reinvigorating the war on drugs while cutting back public services faster than you can say DEI.

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“Arresting people for their suffering is not just ineffective, it’s inhumane,” Susan stated. “Cutting health care while doubling down on punishment only deepens the crisis, especially for families like mine. We’ve already seen where that approach leads: more deaths, more stigma, and more people abandoned by the very systems meant to protect them.”

Harm reduction is the pragmatic principle that recognizes, whether we like it or not, human beings will engage in dangerous behavior. Rather than trying to force them into stopping, an often-futile exercise (especially if we haven’t addressed why they do what they do), we should minimize the potential damage this might cause. A great example would be designated drivers: getting you home safely without keeping you from your Bud Light.

It's a principle Susan supports.

“I had not known the term while Tyler was alive, but we practiced it at times,” she reflected. “It meant loving Tyler where he was, without shame, without ultimatums. It gave us tools to keep him safe, and it affirmed that his life was worth protecting regardless of his decisions. Harm reduction isn’t the absence of care — it’s what love looks like in the face of an unjust system.”

But there are those who cry that by removing the consequences, you encourage more of this "bad" (from their point-of-view) behavior to occur.

“Dead people can't recover, and overwhelmingly the research shows that there's no opposition between harm reduction and abstinence goals, because when you look at what happens if people participate in harm reduction, they are more likely to participate in other forms of recovery, not less,” said Maia Szalavitz, author of “Undoing Drugs: The Untold Story of Harm Reduction."

“So for example, somebody who participates regularly in syringe exchange is more likely to enter treatment than someone who does not,” Szalavitz said. “And given that relapse is common in abstinence, you need harm reduction along with it.”

The term “harm reduction” was first coined in 1980s Liverpool, England, to describe the needle exchanges there, which themselves were based on a Dutch program. The idea was to contain HIV infections among heroin users sharing syringes.

The harm reduction movement also evolved out of the AIDS movement, which itself evolved out of the patients’ rights movement that began in the ‘70s. Although gay men were at the forefront of the AIDS movement, injecting drug users were fighting for their lives as well. In the 1980s Jon Parker, a former heroin user from Boston, founded the National AIDS Brigade and began distributing needles across the East Coast, earning him the nickname the “Johnny Appleseed of needles.” At the time, handing out syringes was banned, so Parker and his comrades risked their freedom as a public act of civil disobedience, inviting both the press and police, who arrested everyone involved. In 1991, at the Trial of the Needle Eight, a judge ruled that the AIDS emergency was grave enough to justify breaking the law to save lives. But a 1988 federal ban on funding syringe swaps remained in place for decades.

At first, naloxone was only available in hospitals and ambulances because of the usual panic around “enabling druggies.” But in the early 2000s, harm reduction pioneer Dan Bigg of Chicago persuaded physicians to prescribe it to him and his pals to start making it widely available on the street. It was thanks to Bigg’s efforts that naloxone became accepted nationwide. A big man, true to his name, dog lover, and a heroin user himself, Bigg sadly passed away in his apartment in 2018 from a cocktail of drugs including fentanyl.

Meanwhile, underground syringe exchanges and shooting galleries spawned across the country, with sterile needles, Narcan, wipes and bins at hand, all in violation of the 1986 “crackhouse statute” which outlaws premises used for illicit drug-taking. (It was Joe Biden, then a U.S. senator, who crafted this law.) Nevertheless, in New York these interventions became gradually accepted by the state health department, which issued guidelines.

This eventually led to the opening of OnPoint, America’s first official supervised consumption facilities in two Manhattan neighborhoods, Harlem and Washington Heights, in 2021. Another idea adopted from European drug policy, supervised consumption sites allow people to use drugs under medical supervision. It can be incredibly dangerous taking drugs alone, with no one to help if something goes wrong, but at OnPoint anyone can be instantly revived. As of January, OnPoint has reversed over 1,700 overdoses as well as connecting clients with other health care and housing services. A similar facility recently opened on Rhode Island.

In 2021, President Biden appointed Dr. Rahul Gupta as drug czar, signaling a shift towards embracing harm reduction by promoting naloxone, sterile syringes and fentanyl test strips. Naloxone became so mainstream that in certain areas you could find vending machines dispensing it for free.

But for some, it was too little, too late. The pivot to harm reduction also sparked alarm in conservative circles, exemplified in a row about tax dollars being purportedly spent on “crack pipes.”

“Harm reduction has pretty radical roots, and there’s always a tension when something on the fringe moves to the mainstream,” Szalavitz noted. “You're not an activist because you want things to stay the same; you want your ideas to influence the mainstream. But surely in going from people who are actually breaking the law to save lives to just civil servants or nonprofit employees doing their job, you will often end up with a loss of a radical spirit … It was great to see the Biden administration recognize that this is a critical aspect of public health … but they certainly didn't take the larger steps that people in the movement would have liked to see them do.”

Then in February, an executive order from Trump tasked DOGE, the Department of Government Efficiency, with “eliminating waste, bloat and insularity” in federal agencies. As the head of DOGE, which is not an official government department, billionaire oligarch Elon Musk (together with his teenage assistants with usernames like “Big Balls”) then set about taking a sledgehammer to the U.S. government, with seemingly little idea of what government actually does.

In March, the U.S. Department of Health and Human Services withdrew over $11 billion from the CDC, leaving many state and local level health initiatives without funding, effective immediately. Another $1 billion was slashed from the Substance Abuse and Mental Health Services Administration, a key agency in tackling the overdose crisis.

Critics argued that SAMHSA failed in its mission and was overly enamoured with progressive causes. Indeed, some of SAMHSA’s cutbacks explicitly leaned into conservative criticisms, including scrapping harm reduction efforts referred to in one document as the “Biden crack pipe.”

The impact was felt almost immediately. For instance, the Pennsylvania nonprofit Unity Recovery, which distributed 30,000 doses of naloxone last year, lost $1.2 million in federal grants, forcing them to shutter their site in Philadelphia and halve their working hours in Pittsburgh.

While some of the cutbacks are being held up in court as dozens of states sue the federal government for imperiling their constituents’ health, a climate of uncertainty prevails and the Philly site has not reopened.

Also affected was ACT in Michigan, which dispatched AmeriCorps members to train communities – for example, at churches, businesses and mosques – how to use naloxone, as well as distributing it through various channels. Mudalagi estimates over the past five years, ACT has trained 5,000 individuals what to do in case of an overdose emergency.

But when DOGE cut AmeriCorps in April, laying off most of its staff and canceling its grants, ACT lost a central pillar of support.

“Thankfully, our program leadership had a really a really good defensive funding strategy and we've been able to cover this current [AmeriCorps cohort] through the end of July with other funds,” Mudalagi explained. “But moving forward, what my program is losing is that education component: teaching people what to do in those moments. And that's essentially lost because of this funding.”

Instead ACT, now rebranded Strategies and Tools for Overdose Prevention, will focus on restocking naloxone distribution points.

While the White House’s official drug strategy is to expand access to naloxone and fentanyl test strips, the administration’s own cutbacks undermine those very goals. A leaked budget proposal reveals plans to cut the First Responders-Comprehensive Addiction and Recovery Act program, which operates on a $56 million SAMHSA grant. In 2023, it distributed more than 101,000 overdose reversal kits. This proved vital in rural areas like Oklahoma’s Cherokee Nation Reservation, where local emergency services would not have been able to afford the lifesaving antidote.

Meanwhile, the feds have axed the National Survey on Drug Use and Health, the nation’s sole drug use survey, abruptly laying off all seventeen researchers on April 1. The survey tracked drug consumption, addiction and mental health among Americans aged twelve and over. It’s not clear how the data, essential for policymaking decisions, will be gathered now, if at all.

The impact of the cutbacks has been felt far overseas as well. The United States Agency for International Development is responsible for the American government’s foreign aid. Musk has bragged about “feeding USAID into the wood chipper.” While USAID has sometimes questionably been used to meddle in other countries’ affairs (for instance, attempting to foment discord via social media in Cuba), it’s also one of the largest humanitarian organizations on the globe. In March, 83% of USAID operations were canceled or drastically-scaled back, including HIV testing and treatment programs in Africa, where the virus spreads through injecting drugs and sex work. The U.N. and WHO warn that suspending these programs could be catastrophic, undoing two decades of progress and creating thousands of new infections each day.

Other dangers are looming. Republicans seem determined to slash hundreds of billions from Medicaid, which covers nearly 90% of opioid addiction treatment nationwide. The operator of an overdose prevention hotline told Salon, off-the-record, that the bulk of their funding comes through Medicaid, “which seems like a pretty major threat.”

Meanwhile OnPoint has been accused of being a magnet for crime and antisocial behavior. This is debatable: a 2023 study found no accompanying rise in complaints in the vicinity of OnPoint’s facilities, although the NYPD has since claimed otherwise. In any case, Congresswoman Nicole Malliotakis (R-NY), a Trump supporter, is calling on the state attorney general to shut OnPoint down.

The opening of another safe consumption site in Minnesota, the third state to follow New York and Rhode Island, has been stalled by local officials fearing further cutbacks and the unpredictable political climate.

So with all this happening, what’s the future of harm reduction? Could it return to its underground roots?

“I don't think it ever left that,” Szalavitz observed. “If you talk to anybody who does harm reduction in the South, it is basically under the same conditions that those of us in the North and the West were facing in the 1980s. We are seemingly as a country trying to go back to that law enforcement-heavy approach and more intense drug war. But to be fair, the drug war has never gone away.”

Meanwhile, harm reductionists pledge to continue even with dwindling resources.

Tamara Oyola-Santiago is the co-founder of Bronx Móvil, a mobile harm reduction and needle swap service.

“As a mutual aid collective that started with no funding but plenty of love and solidarity, we are committed to do this work regardless of funding streams,” she told Salon. “Harm reduction started by people who use and inject drugs, many of whom were people living with and/or impacted by HIV/AIDS. The same is true for us. There is a saying in Puerto Rico that reflects our commitment to this life work: ‘solo el pueblo salva al pueblo’ – only the people can save the people.’”

“We found a way to survive the cuts. Even if we're not happy about everything that we lost, we're going to keep going,” added Mudalagi. “Like I told my AmeriCorps members, we're going to be out here giving out Narcan and trying to make a difference until they literally lock us out of the building!”