Harm reduction — an umbrella term that takes in a variety of practices intended to lessen the damaging effects of drug use — has never been an easy sell. “It’s always been kind of a political football because it’s hard to explain,” said Alonzo Plough, PhD, chief science officer at the Robert Wood Johnson Foundation in Princeton, New Jersey.

“It seems counterintuitive,” he added. “Why would you give needles to an addict? You have to take people through what that means: saving lives, offering options to get into treatment…. You have to explain that substance use disorder is like a chronic disease.”

As director of public health for Seattle and King County, Washington, in the 1990s, Plough led one of the first and largest harm reduction  initiatives in the country, a pioneering effort to prevent the transmission of HIV and hepatitis C. In the decades since, a growing body of evidence has shown the efficacy of such programs — not only syringe exchanges but also naloxone for overdose protection, medications like methadone and buprenorphine for opioid use disorder, supervised consumption sites, and test strips to make sure drugs haven’t been contaminated or adulterated.

With success stories becoming harder to dismiss, harm reduction gained traction, and the approach finally received designated federal funding in 2021 as part of the American Rescue Act. Last year overdose deaths dropped by 27%,  the largest single-year decline ever, thanks in large part to the availability of naloxone.

The current administration, however, appears unpersuaded by that statistic. In July, an executive order entitled “Ending Crime and Disorder on America’s Streets” announced that all federal funding for harm reduction would be canceled. In response, organizations involved with these programs are taking the same tack as many others facing federal cuts: They are turning to philanthropic foundations for help.

The executive order was sweeping, but it doesn’t account for all of the budget cuts in this sector. The administration has also slashed at least $345 million from programs that fund addiction treatment and overdose prevention, not to mention $588 million from related research, according to Hanna Sharif-Kazemi, MSW, federal policy manager of the New York-based advocacy group Drug Policy Alliance. On top of that, Medicaid, America’s biggest source of funding for substance use disorder treatment and prevention, is set to lose more than $1 trillion over the next decade.

“Federal funding cuts are already gutting addiction treatment,” Sharif-Kazemi said. “They’re stopping naloxone from getting into the hands of as many people as possible, medications that reduce cravings and ease withdrawal, and even drug-related research that helps us find the new, innovative solutions to the overdose crisis. All of this is just adding to longer wait times for fewer services, and [is] ultimately going to lead, I think, to the worst-case scenario — to more lives lost.”

Even when this money wasn’t earmarked specifically for harm reduction, the sudden loss of funding has a ripple effect. And since harm reduction programs tend to focus on prevention, they aren’t covered by insurance, noted Tracy Sawicki, executive director of the Peter & Elizabeth Tower Foundation in Buffalo, New York. Deep budget cuts can put an organization’s efforts into dire straits almost immediately.

Foundations Remains Committed

As a growing number of organizations in the health field seek private funding, charitable foundations are being stretched thin. But their efforts persist.

The Open Society Foundations (OSF), a grant-making network based in New York City, is a longtime proponent of harm reduction. In a recent op-ed piece, Kasia Malinowska-Sempruch, DrPh, director of advancing global drug policy reform, maintained that it’s time to double down.

“Our commitment to harm reduction continues,” Malinowska-Sempruch wrote in an email. “Billions of dollars from opioid settlement funds are now flowing into local communities, where the impact of harm reduction interventions has become increasingly visible. In many areas, these efforts have contributed to recent declines in overdose deaths, and local leaders are eager to sustain what is working for their communities. OSF remains dedicated to bringing evidence, data, and real-world success stories into these local discussions to help guide effective investment.”

The Robert Wood Johnson Foundation integrates harm reduction into its overall mission. “We’re just putting out a really large call for proposals,” Plough said, noting the importance of fostering a “better understanding of what promotes this notion of community well-being.”

Earlier this year, the Peter & Elizabeth Tower Foundation reconfigured its grantmaking process, which now focuses on general operating expenses at the organizations they work with. The foundation’s aim is to provide some breathing room, enough to keep existing programs up and running. Sawicki likens the approach to emergency home repairs.

“Sometimes you need a whole thirty-thousand-dollar roof, and you can’t do it,” she said. “But if someone gave you five thousand dollars, you could fix the hole while you’re trying to figure it out.”

Other philanthropic foundations are continuing their harm reduction programs, with some even increasing their efforts and resources to reach more communities and strengthen existing initiatives:

• The Comer Family Foundation in Chicago has been providing grants to support syringe services and community-based harm reduction programs in all 50 states, the District of Columbia, Native American Reservations/Tribal Land, and Puerto Rico since 1992. And the organization has no plan to stop: Its latest application cycle closed as recently as November 1.
• The Foundation for Opioid Response Efforts in New York City has expanded its grant program for community-based organizations working to address opioid use disorder and overdose mortality.
• Earlier this month, Chicago’s MacArthur Foundation awarded an $800,000 “genius grant” to harm reduction advocate Nabarun Dasgupta, PhD, for his work as “an epidemiologist and harm reduction advocate creating practical programs to mitigate harms from drug use, particularly opioid overdose deaths.”

Although recent government actions may suggest otherwise, executives at these and other foundations don’t view harm reduction as a partisan crusade.

“Substance use disorders affect everyone. It does not discriminate, period,” Sawicki said. “It doesn’t matter where you come from, if you’re rich or poor, Republican or Democrat. When it does hit your doorstep, we want to make sure there’s support and services to help you get back on track.”

Debbie Koenig is a health writer whose work has been published by WebMD, The New York Times, and The Washington Post.