What does it mean to do harm reduction work? An interview with Nik Carverhill

Nik Carverhill is a Canadian harm reduction worker and researcher. He works in supervised consumption sites, has done outreach and organising in homeless encampments, and conducts research on embedded harm reduction services in homeless shelters.

When we first talked I was really interested in about the work he was doing in Canada, which is experiencing an overdose crisis. I wanted to find out how people are reacting to this; are there calls for more policing or a war on drugs? Is there support for harm reduction? What sort of harm reduction services are available? There's so much we could talk about but I didn't want to overwhelm with a really chunky issue of the newsletter, so tried my best to keep the interview short!

How would you explain harm reduction to someone who has never encountered the term or concept before?

Harm reduction is a philosophy to inform the way we approach building relationships of care and support with others—especially people who use drugs or whose activities are otherwise marginalised or criminalised (e.g. sex work). It instructs us to meet others 'where they are at' with non-judgement, compassionate curiosity and an understanding that people make choices for reasons that are often adaptive to their circumstances. That is, drug use often serves an important purpose for people.

Harm reduction is also a set of practical strategies about how to reduce the potentially negative or harmful consequences of certain behaviours. In relation to drug use, this includes distributing clean equipment to reduce the transmission of disease, education about proper injection technique to avoid infection, and offering people who use drugs a 'safe supply' of pharmaceutical-grade drugs to separate them from the toxic illicit supply that kills so many. In everyday life, harm reduction also looks like wearing a bike helmet, using a condom or drinking water while consuming alcohol.

What drew you to do harm reduction work?

There is a widespread overdose crisis in Canada and I was compelled to begin doing harm reduction work because I could see it was one of the most effective ways of supporting people. I am first and foremost motivated by work that involves relationship-building, and that is what is at the heart of harm reduction. I care about people who use drugs—they are my friends, my neighbours—and want to do work that supports them.

What sorts of harm reduction services (in relation to drug use) are there in Canada?

In big cities, there is typically a combination of harm reduction services that include clean equipment exchanges (needles, pipes, etc.), supervised consumption sites (spaces where people can bring their drugs and be supervised while using in case they overdose), and Naloxone kit distribution (Naloxone is a drug that can reverse an opioid overdose). These services are offered by a combination of health centres and other medical providers, as well as by community members who self-organise to keep their loved ones safe. There are also limited 'safe supply' and medication-assisted programs that help reduce people's reliance on the illicit drug supply. In rural areas, there are often very limited harm reduction services.

British Columbia has decriminalised personal possession of small amounts of certain illicit drugs on a pilot project basis, and other jurisdictions have applied to do the same. Efforts to decriminalise drugs are widely endorsed by advocacy groups, police associations, city councils and more.

What does the harm reduction work that you do entail?

I primarily work in supervised consumption sites (SCS) that are housed within community health centres. The most important aspect of this work is building trusting relationships with clients who use the site. I support people by doing education around safer use (e.g. how to inject in a way that reduces likelihood of an abscess), responding to overdoses as they happen and connecting clients with other services (e.g. nursing, wound-care, mental health resources, housing). The SCS is often the entry point for people to access other services, including drug treatment if that is something they are ready for and wanting.

What does the research and data say about the effectiveness of such harm reduction strategies in Canada?

The evidence base for harm reduction is consistently growing and overwhelmingly demonstrates its effectiveness in improving health and social outcomes. For decades, needle exchange and other clean equipment distribution has been shown to decrease rates of HIV, Hepatitis C and other transmissible diseases. 'Safe supply' also has a decades-long track-record of improving clients' lives—from reducing illicit substance use to improving mental health, stabilising housing, reducing reliance on crime and other social and health indicators.

Conversely, the evidence is equally as strong that prohibition does not reduce drug use, but rather increases the harms associated with it by incentivising the production of more potent substances.

What is public opinion like in Canada with regard to drug use? Is there a call for more policing and punishment, or are people aware of harm reduction and supportive of such an approach?

Public opinion on harm reduction in Canada is generally split. Many folks support harm reduction services, but there is also a strong reactionary 'tough on crime' backlash washing across the country. The Federal Conservative party is using the issue as a wedge issue for a possible election in 2024/25. Public opinion polls indicate that about half of Canadians support the decriminalisation of all illicit drugs, for example. Given that harm reduction in Canada is a patchwork of services that do not address the underlying root causes of the overdose crisis (i.e. that the supply is toxic and needs to be regulated) or addiction (e.g. poverty, intergenerational trauma, housing crisis), it has been easy for communities to oppose harm reduction on the basis that it threatens 'regular' citizens with disorder and violence.

Do you feel like harm reduction services might come across as enabling or encouraging people to use drugs? It’s one of the concerns present in Singapore when we talk about moving away from punishment.

People always have, and always will, use drugs for a variety of reasons. These include using opioids to manage chronic pain and disability, as well as the psychic wounds of trauma; using stimulants to have enough energy to work a 16-hour shift to make ends meet; using psychedelics to explore the nature of our own personhood. These reasons for drug use remain the same whether harm reduction is available or not. Whether the government or health agencies offer harm reduction services will not change the fact that people who use drugs are the ones who are most concerned with their own well-being.

To me, the real underlying issue with this concern is a stigmatisation of drug use itself that is often rooted in a lack of information (drug use is not inherently dangerous, it is often dangerous because it is criminalised). The evidence is clear—coercing people into drug treatment often increases the risk of overdose and death and is not an effective approach to improving a person's health.