California Should Invest in Harm Reduction to Combat Monkeypox

Aditya Narayan; Tasnim Ahmed


October 31, 2022

Two months after California Governor Gavin Newsom declared a state of emergency over the monkeypox outbreak, the state surpassed 5000 confirmed cases of the highly transmissible infection. To make matters worse, California has a shortage of JYNNEOS, the FDA-approved vaccine for monkeypox. As public health officials urge that action be taken to mitigate monkeypox's spread, the state's government must make a concerted effort to address one group of people who are at the greatest risk of contracting the virus: people who use drugs.

They are particularly vulnerable to monkeypox because of the associated risks, such as housing insecurity, limited access to healthcare services, and needle sharing. Mitigating monkeypox spread in this group requires creative solutions, one of which may be to invest in a service that already shows promise: harm reduction.

Harm reduction services are designed to create supportive spaces for substance users without judgment or stigma. Supervised consumption sites, a key aspect of harm reduction, help to avert overdoses and adverse complications; they've been shown to reduce the risk for opioid-related morbidity and mortality without increasing crime rates in surrounding communities. Those same services could reduce monkeypox infections by minimizing the risky behaviors that are implicated in its spread, like needle sharing.

Harm reduction's most powerful tool is also its simplest: directly connecting at-risk populations with medical services. In 2019, California implemented the California Harm Reduction Initiative (CHRI), a $15.2 million pilot program that represented the state's largest-ever investment in harm reduction services. The initiative allowed 37 community-based organizations across California to hire staff, create positions dedicated to treatment navigation, and in many cases, make services accessible via telehealth. Analyses conducted by the National Harm Reduction Coalition (NHRC) — a harm reduction advocacy organization — showed that harm reduction sites that received funding from the initiative had higher rates of overdose prevention and patient entrance into treatment, according to Jenna Haywood, an associate director at the NHRC.

Yet, the California Legislature decided not to renew funding for CHRI in its draft of the state's budget, giving no official justification for ending the program. Following that decision, Governor Newsom vetoed a bill that would permit California cities to open supervised drug injection sites. Newsom's office justified the decision by pointing to the lack of infrastructure and support for these sites; he suggested that unrestricted development of new sites would have "unintended consequences." Together, these decisions could spell the end of funding for harm reduction in California.

The state legislature should reverse course before it's too late. It should revisit the opportunity to renew the CHRI and elevate it as a budget priority next year. In fact, the state should expand the initiative by increasing the number of needle exchange programs to ensure their availability in areas with rising monkeypox rates. Public health officials could even use the programs to connect with an otherwise healthcare-naive population, to promote monkeypox education campaigns and treatment referrals. Harm reduction sites could serve as hubs for other supportive services such as case management for vulnerable populations or enrollment in benefits programs.

Using harm reduction services to address infectious diseases is not a novel concept. Sterile syringe programs have helped lower the burden of bloodborne infections, such as HIV/AIDS and hepatitis C. Moreover, decades' worth of studies show that syringe service programs are a cost-saving and efficacious way to increase treatment rates and lower rates of mortality among people who use drugs.

Now is the moment when we need more harm reduction services, not fewer. Through the provision of clean needles and safe-sex supplies (such as condoms), harm reduction programs have the unique potential to minimize the chance of substance overdose and lessen the transmission of monkeypox between people who use substances together.

Some critics of harm reduction programs see it as encouraging or supporting drug use, but evidence has shown that it doesn't increase substance use rates. By accepting the reality that people who use drugs will continue to use them whether or not their drugs are accessible or legal, harm reduction programs promote responsible interventions that minimize the risks associated with drug use.

We cannot sit by and let monkeypox, fueled further by the opioid epidemic, become America's next policy and public health failure.

Aditya Narayan (@adityalearns) is an MD candidate and drug policy researcher at Stanford University School of Medicine.

Tasnim Ahmed (@TasnimMAhmed) is an MD candidate at Stanford University School of Medicine.

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