“Harm reduction programming and harm reduction research share two critical values: identifying what is pragmatically effective and respecting the human rights of persons who use drugs.”
Harm reduction in the USA: the research perspective and an archive to David Purchase
Behaviors that carry risk exist. Harm reduction works to reduce the social, physical, and legal harms of a behavior, like drug use. Additionally, harm reduction fights the harm caused by dangerous policies and laws governing a behavior. Harm reduction is cost-effective, evidence-based, and lifesaving.
Harm reduction programs support people without judgement, coercion, discrimination, or requiring that someone stops using drugs to get support. People who use drugs are agents of change and leaders of the movement. Harm reduction is grounded in justice and human rights.
A common misconception about harm reduction is that it is in opposition to abstinence. This is false. Harm reduction meets people where they are at and serves each person with specific tools to help them reach their own goals. If an individual’s goal is to abstain from drug use, harm reduction programs provide that person with services and supports for that goal.
It is important to differentiate between a person’s own goal of abstinence and abstinence as a requirement to access services, even services unrelated to substance use like housing or healthcare. Harm reduction recognizes abstinence is not the only positive path forward and mandating abstinence for everyone harms people who use drugs.
“[Harm reduction] accepts, for better or worse, that licit and illicit drug use is part of our world and chooses to work to minimize its harmful effects rather than simply ignore or condemn them.”
Principles of Harm Reduction, National Harm Reduction Coalition
Decades of quantitative and qualitative research have proven that harm reduction is the evidence-based, most effective way to reduce overdoses, harmful drug use, and save lives. The following is a snapshot of some of the many peer-reviewed studies supporting harm reduction practices, broken into sections by practice.
Naloxone (brand name “Narcan”) is a life-saving medication used to reverse an opioid overdose. Overdose education and community-based naloxone distribution significantly reduce overdoses and overdose deaths [1][2]. Focusing demand-based distribution on people who use drugs leads to the best outcomes, averting an estimated mean of 25.3% of overdoses annually [3]. Due to increased naloxone access, from 2020 to 2022, layperson administration of naloxone to reverse an overdose increased by 43%, with laypersons administering naloxone on average 5 minutes before EMS arrival in 59% of overdoses [4].
Medication-Assisted Treatment (MAT) is the use of medications like methadone and buprenorphine, in combination with counseling and other therapies, to help treat people who use drugs. MAT prevents withdrawals, cravings, and helps stabilize people who are trying to stop or change their use [5]. MAT significantly reduces the risk of overdose death [6], reduces opioid use, and crime [7].
Safer Use Supplies are sterile equipment like syringes, pipes, water, tourniquets, test strips [8], straws, and mouthpieces. When people need to share and reuse equipment, it puts people at risk of HIV or Hepatitis transmission, overdoses, injuries like cuts and burns [9], and respiratory sickness like tuberculosis [10]. The legality of these supplies varies by state and county. It is critically important supply distribution is accompanied by safer use guides for different equipment and substances.
Safer Use Guide Library
| Title |
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Syringe Service Programs [11] are community-based programs providing free access to sterile injection supplies, syringe disposal, HIV testing, linkage to care or treatment, and other prevention services. Syringe Service Programs reduce HIV and Hepatitis C by 50% [12][13][14][15], and are participants are significantly more likely [16] to stop or change their drug use [17]. Syringe Service Programs do not increase crime [18] [19]and have been found in some studies to decrease crime [20].
Drug Checking, sometimes called “Drug Testing”, allows people who use drugs to make informed choices [21], identify trends, reduce harmful substance use [22], and prevent overdoses [23]. Different programs analyze drug samples at home, on outreach, or in a site-based lab with supplies like fentanyl test strips [24] or FTIR spectrometers [25] to identify the substance, additives, or impurities.
Safer Consumption Sites reduce the risks of drug use by offering sterile, medically supervised places for people to use their own drugs. At these sites, people who use drugs are monitored for overdoses, get first aid, access safer use supplies, and receive additional resources like case management, treatment connection, and help with housing and basic needs. Safer Consumption Sites save lives [26]–worldwide at Safer Consumption Sites there has never been a reported fatal overdose [27].
Safer Consumption Sites do not increase crime [28] or drug use [29] and reduce syringe litter [30]. They may also be called “Overdose Prevention Centers” or “Safe Recovery Sites”. Learn more here.
Safer Supply Services offer prescribed medications as a safer alternative [31] to drugs bought on the street to people who already use drugs. Programs like heroin buyer’s clubs and Drug User Liberation Front [32] have shown the effective and life-saving power of these programs. Safer supply services help prevent overdoses and reduce legal involvement in the lives of people who use drugs [33].
“Decades of punitive, ‘war on drugs’ strategies had failed to prevent an increasing range and quantity of substances from being produced and consumed.”
Office of the United Nations High Commissioner for Human Rights, August 2023 [34]
Punitive measures and the harsh criminalization of drugs in the attempt to address substance use and overdose deaths have failed. While US overdose deaths decreased in 2024 for the first time since 2020 this year, 100,000 people still die of a drug overdose a year. From 2022-2023, despite opioid overdose deaths reducing by 3%, psychostimulant overdoses increased by 2% and cocaine overdoses increased by 5% [35].
Starting in the 1970s, the US Government’s policies of the “War on Drugs” worsened punishments for the use, sale, or possession of drugs through prohibition, increased policing, incarceration, militarization, and policy. Since 1971, an estimated $1 trillion dollars have been spent by the federal government on “War on Drugs” policies, and tens of millions have been arrested. Aggressive approaches to addressing drug use—such as imprisoning drug offenders—have no effect on rates of drug use [36][37].
Instead, harsh criminalization has driven rapid changes in the drug supply and dangerous, unpredictable spikes in potency. “The Iron Law of Prohibition” is a theory demonstrating that as illegality and law enforcement increase, so does drug potency [38]. For example, crackdowns on fentanyl have led to the rise in fentanyl analogs, xylazine, and medetomidine in the drug supply [39][40]. The rapid spread of these adulterants leads to overdose spikes, with public health professionals struggling to keep up [41].
Additionally, intense curtailing of necessary opioid prescription has left many people suffering with life-altering pain [42]. Disabled people and people living with chronic pain have an increasingly difficult time accessing medically necessary drugs. Numerous efforts targeting the legal prescription of opioids persist, for example, the Drug Enforcement Administration mandated cutbacks in the pharmaceutical production of opioids, leading to a 53% decrease from 2016 to 2020 [43]. State prescription drug monitoring efforts have “were not associated with reductions in drug overdose mortality rates and may be related to increased mortality from illicit drugs and other, unspecified drugs. [44]” The narrative that the opioid crisis is an issue between doctors and patients is decades old, and no longer representative of our current crisis.
Harm reduction as a practice isn’t just for substance use—though substance use is often the focus.
Sex work
Sex work [45] is the exchange of sexual services or performance for compensation. Sex work is a broad label referring to things like stripping, escort services, “full-service” sex work, porn, and more. Sex work is widely criminalized, stigmatized, and vilified; sex work is also heavily conflated with human trafficking or non-consensual exploitation.
“The decision to earn income through sex work is made along a spectrum of options, regardless of a person’s age. Some people’s spectrums are more limited than others and youth, like others, confront numerous systemic factors or personal circumstances including poverty, homelessness, drug use and mental health…there is a difference between youth who exercise agency to earn income through sex work and the commercial sexual exploitation of youth.”
LANGUAGE MATTERS, Global Network of Sex Work Projects
Policies aimed at combatting sex trafficking often result in both sex workers and trafficking victims being harassed, arrested, and deported [46] [47]. Asymmetrical criminalization or “end demand” models are a major barrier for the safety of anyone engaging in sex work or a survivor of sex trafficking [48]. It’s been shown to increase physical and sexual violence against people engaging in sex work, primarily because it drives negotiations to be rushed and secretive. No country has ever shown an “end demand” model reduces adult trafficking.
The criminalization of sex work prevents people from reporting assault, receiving health services, and reduces autonomy [49]. Harm reduction for sex work should always be sex worker led, and center around justice and destigmatization [50].
Harm reduction for sex workers includes [51][52][53][54]:
• Safer sex materials [55] and education
• Work in community, with a buddy, or a safety pod
• Work indoors, when possible, as high visibility increases risk
• Wear shoes you can run in, and avoid loose clothes or jewelry
• If you are going to use drugs, use your own drugs
• Stick to your prices and your limits
“Bad date” lists are reporting options for sex workers to anonymously submit the description of a client who was violent, dangerous, or didn’t pay [56]. Due to heavy criminalization, sex workers can no longer post these online as a personal safety issue, which is why it’s important third parties provide them as a service for sex workers. It is also important for people to have access to “Know Your Rights” trainings.
Gambling
For people experiencing problematic gambling or gambling-related harms, harm reduction strategies can differ for land-based gambling and online gambling. Programs like GameSense in Massachusetts are casino-based harm reduction programs providing money and gambling literacy education, as well as installing tools that allow players to set personal limits and notifies them when they have reached their own set limit [57]. Voluntary self-exclusion lists allow people to add themselves to a “ban” list and be prevented from entering a casino for anywhere between 6 months and a lifetime [58].
Online gambling and sports betting are getting more and more popular and increase many of the potential harms of gambling. Mobile apps and social media sites are utilizing targeted ads and data tracking to increase advertising toward people who are experiencing gambling-related harms [59]. Online gambling also increases availability, provides cash incentives to encourage gambling, increases intensity, and often lacks age verification. Harm reduction strategies include individually set cash-limits with pop-ups and reminders of those limits, destigmatizing public health messaging, and making it easier for people to close accounts [60].
On a broader level, policies need to be in place to shift the blame of “problem gambling” from the consumer onto the companies and regulators [61].
Check out our Resource Directory: Youth-Centered Harm Reduction Resources – StreetWorks Outreach Collaborative | Minneapolis St. Paul
Book recommendations:
References
[1] Walley A Y, Xuan Z, Hackman H H, Quinn E, Doe-Simkins M, Sorensen-Alawad A et al. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis BMJ 2013; 346 :f174 doi:10.1136/bmj.f174
[2] Coffin PO, Sullivan SD. Cost-effectiveness of distributing naloxone to heroin users for lay overdose reversal. Ann Intern Med. 2013 Jan 1;158(1):1-9. doi: 10.7326/0003-4819-158-1-201301010-00003. Erratum in: Ann Intern Med. 2017 May 2;166(9):687. doi: 10.7326/M17-0652. PMID: 23277895.
[3] Zang X, Bessey SE, Krieger MS, Hallowell BD, Koziol JA, Nolen S, Behrends CN, Murphy SM, Walley AY, Linas BP, Schackman BR, Marshall BDL. Comparing Projected Fatal Overdose Outcomes and Costs of Strategies to Expand Community-Based Distribution of Naloxone in Rhode Island. JAMA Netw Open. 2022 Nov 1;5(11):e2241174. doi: 10.1001/jamanetworkopen.2022.41174. PMID: 36350649; PMCID: PMC9647481.
[4] Gage CB, Powell JR, Ulintz A, et al. Layperson-Administered Naloxone Trends Reported in Emergency Medical Service Activations, 2020-2022. JAMA Netw Open. 2024;7(10):e2439427. doi:10.1001/jamanetworkopen.2024.39427
[5] Clinical Guidelines for Withdrawal Management and Treatment of Drug Dependence in Closed Settings. Geneva: World Health Organization; 2009. 4, Withdrawal Management. Available from: https://www.ncbi.nlm.nih.gov/books/NBK310652/
[6] Sordo L, Barrio G, Bravo M J, Indave B I, Degenhardt L, Wiessing L et al. Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies BMJ 2017; 357 :j1550 doi:10.1136/bmj.j1550
[7] NIDA. 2018, June 1. How effective are medications to treat opioid use disorder?. Retrieved from https://nida.nih.gov/publications/research-reports/medications-to-treat-opioid-addiction/efficacy-medications-opioid-use-disorder#:~:text=A%20comprehensive%20Cochrane%20review%20in,of%20infectious%20disease%2C%20and%20crime.on 2024, November 19
[8] Park JN, Frankel S, Morris M, Dieni O, Fahey-Morrison L, Luta M, Hunt D, Long J, Sherman SG. Evaluation of fentanyl test strip distribution in two Mid-Atlantic syringe services programs. Int J Drug Policy. 2021 Aug;94:103196. doi: 10.1016/j.drugpo.2021.103196. Epub 2021 Mar 10. PMID: 33713964.
[9] Hunter, C., Strike, C., Barnaby, L. et al. Reducing widespread pipe sharing and risky sex among crystal methamphetamine smokers in Toronto: do safer smoking kits have a potential role to play?. Harm Reduct J 9, 9 (2012). https://doi.org/10.1186/1477-7517-9-9
[10] Gardy JL, Johnston JC, Ho Sui SJ, Cook VJ, Shah L, Brodkin E, Rempel S, Moore R, Zhao Y, Holt R, Varhol R, Birol I, Lem M, Sharma MK, Elwood K, Jones SJ, Brinkman FS, Brunham RC, Tang P. Whole-genome sequencing and social-network analysis of a tuberculosis outbreak. N Engl J Med. 2011 Feb 24;364(8):730-9. doi: 10.1056/NEJMoa1003176. Erratum in: N Engl J Med. 2011 Jun 2;364(22):2174. PMID: 21345102.
[11] NIDA. 2021, June 7. Syringe Services Programs. Retrieved from https://nida.nih.gov/research-topics/syringe-services-programs on 2024, November 20.
[12] Centers for Disease Control and Prevention. (n.d.). Syringe Services Programs. Centers for Disease Control and Prevention. https://www.cdc.gov/syringe-services-programs/php/index.html?CDC_AAref_Val=https%3A%2F%2Fwww.cdc.gov%2Fssp%2Fsyringe-services-programs-factsheet.html
[13] Syringe Services Programs’ Role in Ending the HIV Epidemic in the U.S.: Why We Cannot Do It Without Them. Broz, Dita et al.American Journal of Preventive Medicine, Volume 61, Issue 5, S118 – S129
[14] Aspinall EJ, Nambiar D, Goldberg DJ, Hickman M, Weir A, Van Velzen E, Palmateer N, Doyle JS, Hellard ME, Hutchinson SJ. Are needle and syringe programmes associated with a reduction in HIV transmission among people who inject drugs: a systematic review and meta-analysis. Int J Epidemiol. 2014 Feb;43(1):235-48. doi: 10.1093/ije/dyt243. Epub 2013 Dec 27. PMID: 24374889.
[15] van Santen DK, Lodi S, Dietze P, van den Boom W, Hayashi K, Dong H, Cui Z, Maher L, Hickman M, Boyd A, Prins M. Comprehensive needle and syringe program and opioid agonist therapy reduce HIV and hepatitis c virus acquisition among people who inject drugs in different settings: A pooled analysis of emulated trials. Addiction. 2023 Jun;118(6):1116-1126. doi: 10.1111/add.16147. Epub 2023 Feb 13. PMID: 36710474; PMCID: PMC10175130.
[16] Surratt HL, Otachi JK, Williams T, Gulley J, Lockard AS, Rains R. Motivation to Change and Treatment Participation Among Syringe Service Program Utilizers in Rural Kentucky. J Rural Health. 2020 Mar;36(2):224-233. doi: 10.1111/jrh.12388. Epub 2019 Aug 15. PMID: 31415716; PMCID: PMC7021582.
[17] Hagan H, McGough JP, Thiede H, Hopkins S, Duchin J, Alexander ER. Reduced injection frequency and increased entry and retention in drug treatment associated with needle-exchange participation in Seattle drug injectors. J Subst Abuse Treat. 2000 Oct;19(3):247-52. doi: 10.1016/s0740-5472(00)00104-5. PMID: 11027894.
[18] Marx MA, Crape B, Brookmeyer RS, Junge B, Latkin C, Vlahov D, Strathdee SA. Trends in crime and the introduction of a needle exchange program. Am J Public Health. 2000 Dec;90(12):1933-6. doi: 10.2105/ajph.90.12.1933. PMID: 11111271; PMCID: PMC1446444.
[19] Galea S, Ahern J, Fuller C, Freudenberg N, Vlahov D. Needle exchange programs and experience of violence in an inner city neighborhood. J Acquir Immune Defic Syndr. 2001 Nov 1;28(3):282-8. doi: 10.1097/00042560-200111010-00014. PMID: 11694838.
[20] Davidson PJ, Lambdin BH, Browne EN, Wenger LD, Kral AH. Impact of an unsanctioned safe consumption site on criminal activity, 2010-2019. Drug Alcohol Depend. 2021 Mar 1;220:108521. doi: 10.1016/j.drugalcdep.2021.108521. Epub 2021 Jan 11. PMID: 33485010.
[21] Peiper NC, Clarke SD, Vincent LB, Ciccarone D, Kral AH, Zibbell JE. Fentanyl test strips as an opioid overdose prevention strategy: Findings from a syringe services program in the Southeastern United States. Int J Drug Policy. 2019 Jan;63:122-128. doi: 10.1016/j.drugpo.2018.08.007. Epub 2018 Oct 3. PMID: 30292493.
[22] Pu, J., Ajisope, T., & Earlywine, J. (2021, September 17). Drug Checking Programs in the United States and Internationally: Environmental Scan Summary. https://aspe.hhs.gov/sites/default/files/documents/79e1975d5921d309ed924148ef019417/drug-checking-programs.pdf
[23] Moran, L., Ondocsin, J., Outram, S. et al. How do we understand the value of drug checking as a component of harm reduction services? A qualitative exploration of client and provider perspectives. Harm Reduct J 21, 92 (2024). https://doi.org/10.1186/s12954-024-01014-w
[24] Goldman JE, Waye KM, Periera KA, Krieger MS, Yedinak JL, Marshall BDL. Perspectives on rapid fentanyl test strips as a harm reduction practice among young adults who use drugs: a qualitative study. Harm Reduct J. 2019 Jan 8;16(1):3. doi: 10.1186/s12954-018-0276-0. PMID: 30621699; PMCID: PMC6325714.
[25] Saving lives via drug checking by FT-IR spectrochemical analysis, Bruker
[26] Reduction in overdose mortality after the opening of North America’s first medically supervised safer injecting facility: a retrospective population-based study – The Lancet, Marshall, Brandon DL et al., The Lancet, Volume 377, Issue 9775, 1429 – 1437
[27] Henry, T. A. (2020a, December 15). Will the U.S. get its first supervised drug consumption site?. American Medical Association. https://www.ama-assn.org/delivering-care/overdose-epidemic/will-us-get-its-first-supervised-drug-consumption-site
[28] Levengood TW, Yoon GH, Davoust MJ, Ogden SN, Marshall BDL, Cahill SR, Bazzi AR. Supervised Injection Facilities as Harm Reduction: A Systematic Review. Am J Prev Med. 2021 Nov;61(5):738-749. doi: 10.1016/j.amepre.2021.04.017. Epub 2021 Jul 1. PMID: 34218964; PMCID: PMC8541900.
[29] Potier C, Laprévote V, Dubois-Arber F, Cottencin O, Rolland B. Supervised injection services: what has been demonstrated? A systematic literature review. Drug Alcohol Depend. 2014 Dec 1;145:48-68. doi: 10.1016/j.drugalcdep.2014.10.012. Epub 2014 Oct 23. PMID: 25456324.
[30] Ibid 20
[31] Canadian Drug Policy Coalition. (2023, June). Imagine safer supply: Envisioning an Ideal Safe Supply Program, from available substances to the staff and setting. https://drugpolicy.ca/imagine-safer-supply-envisioning-an-ideal-safe-supply-program/.
[32] Jeremy Kalicum, Eris Nyx, Mary Clare Kennedy, Thomas Kerr, The impact of an unsanctioned compassion club on non-fatal overdose, International Journal of Drug Policy, Volume 131, 2024, 104330, ISSN 0955-3959, https://doi.org/10.1016/j.drugpo.2024.104330.
[33] Ryan McNeil, Taylor Fleming, Samara Mayer, Allison Barker, Manal Mansoor, Alex Betsos, Tamar Austin, Sylvia Parusel, Andrew Ivsins, and Jade Boyd, 2022: Implementation of Safe Supply Alternatives During Intersecting COVID-19 and Overdose Health Emergencies in British Columbia, Canada, 2021 American Journal of Public Health 112, S151_S158, https://doi.org/10.2105/AJPH.2021.306692
[34] Office of the United Nations High Commissioner for Human Rights. (2023, August 15). Human rights challenges in addressing and countering all aspects of the world drug problem. United Nations. https://www.ohchr.org/sites/default/files/documents/hrbodies/hrcouncil/sessions-regular/session56/A-HRC-54-53-summary.pdf
[35] Centers for Disease Control and Prevention. (2024b, May 15). U.S. overdose deaths decrease in 2023, first time since 2018. Centers for Disease Control and Prevention. https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2024/20240515.htm
[36] National Research Council, The Growth of Incarceration in the United States: Exploring Causes and Consequences (Washington, D.C.: The National Academies Press, 2014), 347.
[37] The Pew Charitable Trusts. (2018, March 8). More imprisonment does not reduce state drug problems. The Pew Charitable Trusts. https://www.pewtrusts.org/en/research-and-analysis/issue-briefs/2018/03/more-imprisonment-does-not-reduce-state-drug-problems
[38] Beletsky L, Davis CS. Today’s fentanyl crisis: Prohibition’s Iron Law, revisited. Int J Drug Policy. 2017 Aug;46:156-159. doi: 10.1016/j.drugpo.2017.05.050. Epub 2017 Jul 18. PMID: 28735773.
[39] Daniel Ciccarone, The triple wave epidemic: Supply and demand drivers of the US opioid overdose crisis, International Journal of Drug Policy, Volume 71, 2019, Pages 183-188, ISSN 0955-3959, https://doi.org/10.1016/j.drugpo.2019.01.010.
[40] Why Fentanyl is Suddenly Everywhere with Dr. Nabarun Dasgupta. (2024). Youtube. Retrieved 2024, from https://www.youtube.com/watch?v=hXP0IZYE6aA.
[41] Medetomidine rapidly proliferating across USA – implicated in recreational opioid drug supply & causing overdose outbreaks. The Center for Forensic Science Research & Education. (2024, May 20). https://www.cfsre.org/nps-discovery/public-alerts/medetomidine-rapidly-proliferating-across-usa-implicated-in-recreational-opioid-drug-supply-causing-overdose-outbreaks
[42] Goldstone, B. (2021, June 18). The pain refugees: the forgotten victims of America’s opioid crisis. Harper’s Magazine. https://harpers.org/archive/2018/04/the-pain-refugees/
[43] The U.S. Drug Enforcement Administration. (2019, September 11). DEA proposes to reduce the amount of five opioids manufactured in 2020, marijuana quota for research increases by almost a third. The U.S. Drug Enforcement Administration. Retrieved 2024, from https://www.dea.gov/press-releases/2019/09/11/dea-proposes-reduce-amount-five-opioids-manufactured-2020-marijuana-quota
[44] Nam YH, Shea DG, Shi Y, Moran JR. State prescription drug monitoring programs and fatal drug overdoses. Am J Manag Care. 2017 May;23(5):297-303. PMID: 28738683.
[45] Carol Leigh, “Inventing Sex Work” in Whores and Other Feminists, New York: Routledge Press), 1997
[46] Thukral, J. (2010). Sex Work and Human Rights. https://sexworkersproject.org/media-toolkit/downloads/SexWorkAndHumanRightsMediaToolkit.pdf
[47] Human Trafficking and Sex Worker Rights. Freedom Network USA. (2015, April). https://freedomnetworkusa.org/app/uploads/2016/12/HT-and-Sex-Workers-Rights.pdf
[48] Positive Women’s Network. (n.d.). Harm reduction factsheet. https://www.pwn-usa.org/wp-content/uploads/2019/01/harm-reduction-factsheet-final.pdf
[49] Fitzgerald, E., Elspeth, S., & Hickey, D. (2015c, December). Meaningful work: TRANSGENDER EXPERIENCES IN THE SEX TRADE. Red Umbrella Project, Best Practices Project. https://transequality.org/sites/default/files/Meaningful%20Work-Full%20Report_FINAL_3.pdf
[50] Centering Sex Workers in harm reduction programming. National Alliance of State & Territorial AIDS Directors. https://nastad.org/sites/default/files/2021-11/PDF-Centering-Sex-Workers-Harm-Reduction.pdf
[51] Luitjens, S. Male Sexwork Handbook. Harm Reduction Coalition. https://harmreduction.org/wp-content/uploads/2020/08/Resource-SexWork-MaleSexWorkHandbook.pdf
[52] Sex work & harm reduction. National Harm Reduction Coalition. (2020b, October 2). https://harmreduction.org/issues/sex-work/harm-reduction-facts/
[53] Safer sex work. NC Harm Reduction Coalition. (2023, January 19). https://www.nchrc.org/about-2/harm-reduction/safer-sex-work/
[54] Stern, L. S. (n.d.). Tricks of the trade. Berkeley NEED. https://www.berkeleyneed.org/resources/tricksmanual.pdf
[55] Safer sex tips. Options for Sexual Health. (2019, April 4). https://www.optionsforsexualhealth.org/facts/sti/safer-sex-tips/
[56] Bowen, R. (2007, August). Protection for All: Bad Date Reporting and Response Strategies. BC Coalition of Experiential Women and Communities. https://www.pace-society.org/library/protection-for-all-bad-date-reporting-and-response-strategies.pdf
[57] Brown, K. (2023, November 8). Tackling problem gambling from inside the casino. Harvard Public Health Magazine. https://harvardpublichealth.org/policy-practice/using-harm-reduction-to-curb-problem-gambling/
[58] Yakovenko I, Hodgins DC. Effectiveness of a voluntary casino self-exclusion online self-management program. Internet Interv. 2020 Dec 1;23:100354. doi: 10.1016/j.invent.2020.100354. PMID: 33425687; PMCID: PMC7779774.
[59] University of Queensland. (2024, November 14). Research reveals facebook, alcohol and gambling companies target ads at Australians most at risk of harm. ADM+S Centre. https://www.admscentre.org.au/research-reveals-facebook-alcohol-and-gambling-companies-target-ads-at-australians-most-at-risk-of-harm/#:~:text=Findings%20from%20the%20report%20How,many%20individuals%20actively%20trying%20to
[60] House of Representatives Standing Committee on Social Policy and Legal Affairs. (2023) You win some, you lose more. Online gambling and its impacts on those experiencing gambling harm. Canbarra: Parliament of Australia.
[61] Marionneau, V., Ruohio, H. & Karlsson, N. Gambling harm prevention and harm reduction in online environments: a call for action. Harm Reduct J 20, 92 (2023). https://harmreductionjournal.biomedcentral.com/articles/10.1186/s12954-023-00828-4