Interviewees included eight females and seven males, all with professional roles advocating for harm reduction policies (Table 1). Eight interviewees were advocates in harm reduction-focused agencies and coalitions, including two members of a coalition of people who use drugs and/or have been impacted by the war on drugs, and seven interviewees were advocates in organizations conducting advocacy around harm reduction in addition to other issues (e.g., an organization focused on drug policy or viral hepatitis). Interviewees reported professional experiences including harm reduction advocacy directed to policymakers at the federal, state, and local levels (e.g., legislative testimony); advocacy activities directed to the public (e.g., opinion editorials and social media campaigns); and community-focused advocacy efforts (e.g., advocacy at a town hall meeting in support of a community’s proposed adoption of a harm reduction program). Multiple interviewees played dual roles as advocates and direct harm reduction service providers.
Interviewees agreed that messages about the scientific evidence demonstrating the effectiveness of harm reduction approaches are important but inadequate, on their own, to persuade U.S. audiences on the value of harm reduction. Interviewees identified two overarching messaging strategies they perceived as persuasive: using messages about harm reduction that align with audience-specific values; and positioning harm reduction as part of the comprehensive solution to current issues audiences are facing related to drug use and overdose in their community. Interviewees stressed that these values and issues vary by audience and that messages need to be tailored accordingly:
One messaging system is not going to work with certain types of folks, but another messaging system will work with– say, from my own local organizing, like in the city limits, very Democratic, Black-led. The organizing there is night and day from outside of [City Area Code]. Our perimeter is really two different messaging systems. I mean, that's the truth. And what works inside of [City Area Code] doesn't really work outside of it and vice versa. And maybe hopefully one day it will. But as a realistic kind of like, okay, ‘what's really going to work to get this law passed,’ you have to be like, ‘okay, do what you need to do. Talk in the way you need to talk. Do the dress in the way you need to dress.’ But on the inside of [City Area Code], where it's Black-led, I mean, that's where [State]’s harm reduction started.
Aligning Messages on Harm Reduction with Audience Values
Four groups were consistently highlighted across interviewees as key audiences to tailor messaging strategies towards: policymakers, law enforcement, religious groups, and the family and friends of people who use, or have used, drugs. For policymakers, interviewees noted that arguments on the cost-effectiveness of harm reduction interventions, or a “value-for-money” framing, were sometimes useful. However, interviewees also reported that these messages should be paired with meaningful stories from constituents and messages emphasizing harm reduction’s role in promoting their community’s goals:
So for policymakers, I think that efficacy in terms of reduction of infection, not encouraging drug use, all of the standard talking points about why harm reduction is good policy. Cost savings compared to the cost of HIV infections averted, those kinds of things. Very useful. That's one audience. I think that those arguments are pretty well developed. And I can think of a lot of papers that make the case, but, that that has not been incredibly compelling to, for example, even policymakers who might be charged with health allocation but don't want the moral risk of seeming to support something that goes against community values.
For law enforcement, interviewees recommended framing harm reduction as a set of interventions that contribute to public safety, including the safety of both communities and officers. Interviewees’ examples included messages about how overdose prevention centers can decrease public drug use and its impact on officers and communities, and messages about how syringe service programs can decrease officers’ (and communities’) contact with used syringes:
We're doing work with law enforcement to implement a needle-stick prevention law that was passed in the state several years ago… So, the law that said that if somebody discloses they have a syringe prior to being searched, then that syringe is exempted from charge -- at least they can't incur a paraphernalia charge from it… The side effect of that, though, is that if somebody is going to ask, "Do you have a syringe on you?" and then they actually don't charge the person for it after discovering it, you build some bridges in some unlikely places and you build support in unlikely places… So, the cop doesn't have to like the person that has syringes in their pocket. But they also don't need to go jamming their fingers into their pockets without asking. There's something that they gain from the behavior, whether they feel good about it or not.
Notably, interviewees recognized concerns among harm reduction advocates, organizers, and service delivery providers about whether and how to involve law enforcement in advocacy and implementation efforts:
So, it's like the harm reduction movement is splintered because some people feel like it's good to work with law enforcement and some people feel like law enforcement has only ever harmed communities of people who use drugs or engage in sex work.
While these tensions were recognized, interviewees mostly agreed that engaging with law enforcement about harm reduction program implementation was critical because advocacy efforts to policymakers and local communities would often fail without law enforcement support:
You can have everybody on the same page. But if prosecutor or somebody from law enforcement community walks in and says, ‘Our communities will be less safe because of this,’ everybody falls in line with that. Literally. ‘This will make us less safe,’ and everybody’s like, ‘Well, we’d love to talk about it, but it can’t be less safe.’
For religious groups, interviewees recommended tailoring messages towards the compassionate values of that religion. Interviewees primarily discussed strategies for U.S. Christian audiences and framing harm reduction as aligning with Christian values around redemption. Interviewees highlighted international examples of faith leaders championing harm reduction programs, as well as domestic examples like Project Lazarus and GLIDE.22,23 However, interviewees also recognized that harm reduction efforts have historically been less accepted by U.S. individuals who identify as religious conservatives. Advocates expressed a particular need for individuals trusted by this audience, like religious leaders, to deliver authentic messages that resonate with their values:
This is not messages that we employ as an organization, but it is messages that it's like, we will work with allies on the ground who come from those communities, or are part of those constituencies that then put it into their own words to kind of appeal to people's more compassionate nature through their church. Or through their faith. In terms of just what would you– how would you want this person to be treated, right? As opposed to really a lot of talk about the interventions themselves, it's really about how would you want this person to be treated? What would it look like to treat this person with dignity and compassion?
For family and friends of people who use drugs, interviewees reported framing harm reduction as an approach that values the life of their loved one:
Family members definitely need their pain and challenges acknowledged. And their fears acknowledged. I think a lot of family members have a lot of fears. And so really grounding how you talk about harm reduction in terms of these are the people who will stay connected with them. These are the people who won't leave your loved one behind because they dropped out of treatment, right? I feel like so many family members want to get their loved one into treatment because that seems like the safest place for their loved ones to go. And then what happens is, oftentimes, their loved one is one of the 60% of people who started a treatment episode and didn't finish it. Then their loved one is left floating. So, if you want to talk about harm reduction with loved ones and even maybe with community members, it's this idea that it's still a touchpoint. It's still a place where they're going to get their needs met. They're going to be connected with someone, someone's keeping an eye on them, giving them connections to other resources.
Interviewees noted that they often encounter, and must attempt to counter, oppositional messages that drug use devalues a person’s life. These oppositional messages may have previously resonated with the family and friends of people who use drugs; so, an additional strategy noted by interviewees as helpful for loved ones was utilizing stories of “changed minds” – peers in similar family situations that changed their minds about the value that harm reduction could provide to their loved one and their family:
I do think the personal stories can also be useful there, particularly from family members or parents who had a change of heart. Who said ‘yeah, I did tough love for like 10 years and it didn't change a thing;’ ‘I ostracized the person from my family. I wouldn't let them come to Christmas. I tried to force them into treatment, and none of it worked. Ultimately what's most important to me now is that my son, or daughter, or brother, or sister, or uncle, or whoever is safe and is in a position if and when they're ready to try to abstain or to enter long-term recovery but they're able to do that and that harm reduction provides them this opportunity. It provides them opportunity for eventual recovery if that's what they want.’
While interviewees emphasized this message in the context of family and friends of people who use drugs, they also noted that messages emphasizing the value of life were persuasive across many audiences:
Preventing deaths, saving lives has to be the North Star. Harm reduction does that. We have to keep– number one, first and foremost above everything else, is keeping people alive. Harm reduction does that more effectively than anything else we have.
Framing Harm Reduction as Part of Comprehensive Solution to Audience Concerns
Another communication strategy interviewees perceived as persuasive was positioning harm reduction as part of the comprehensive solution needed to address audiences’ specific concerns related to drug use and overdose in their community. Interviewees noted that audiences’ concerns were often influenced by personal and anecdotal experiences, and that persuasive messaging strategies addressed the concerns raised by those experiences. For example, the advocates interviewed reported using messages emphasizing how harm reduction interventions like naloxone distribution can decrease overdose deaths in communities that are heavily impacted by rising deaths. When audience concerns focused on enabling drug use, interviewees described contextualizing how harm reduction does not encourage new users and offers needed, immediate, and integrated support to people in their community. As a cautionary note, many interviewees reported hearing audience concerns about community-level harms that they had data to refute; however, they stressed that arguing on technicalities is not persuasive and noted that they work to avoid dismissing an individual’s concerns.
When communicating about harm reduction with representatives of organizations in the community, for example health systems or major employers within a community, the advocates interviewed suggested tailoring messages to emphasize how harm reduction can address specific burdens faced by that organization:
Highlighting how harm reduction will benefit the institution or organization I'm talking to has also been very, very good for messaging. So, explaining that by decreasing HIV, we're going to save X amount of dollars financially at a county level. Right? That's a big benefit there. If we tell a sheriff that you're not going to have people puking and dying in your jail if people get the medication [for opioid use disorder], that's a huge pain point for them and a benefit for them. So, tying the harm reduction interventions to why that's beneficial to somebody else is always good for messaging… Law enforcement, specifically the medical community, specifically legislators, policymakers, municipality leaders, they need to see an overall picture of the cost of SUD on their workforce, on their emergency departments, on their jails, and they need to be highlighted how the cost savings related to syringe service predications, medications, naloxone, how it will help the cost in their emergency departments, how it will reduce recidivism in their jails, all these public health– the way these public health interventions will help.
When discussing persuasive messaging strategies for communities considering harm reduction interventions, interviewees reported using messages that highlight the community-level wellness that harm reduction can promote. Additionally, messages need to recognize the harms from drug use, overdose, and the criminalization of drug use that the community has experienced. For some audiences, interviewees posited that harm reduction should be framed as improving community wellness by addressing harms like overdose deaths and syringe litter:
I mean when I'm talking about the people who are afraid, those folks think you’re going to take their property values down; or you have parents who have lost kids, and, well, you come into their community, and they see you as killing more kids. Part of the [harm reduction] campaign, really, is actually listening to what they have to say and being smart enough to be able to respond to what they have to say. Which I don’t think the feds are in a position to do yet – they don’t have the language. So, there's the gentle piece of it where you talk about the life-saving things, you talk about the amount of people who enter drug treatment, you talk about how many people got cured of hepatitis C, those kind of things.
For audiences from minority communities, particularly Black communities, interviewees noted that it was critical to frame harm reduction as alleviating community-level harms from the historic and continued discriminatory criminalization of drug use in the U.S:
Many poor, historically African American neighborhoods in [Interviewee’s community] would be opposed to an overdose prevention center. Why is that? Is it because their other needs aren't being met? Because they feel ignored? Because they feel discriminated against? Because they feel they've been historically criminalized and stigmatized for substance use and incarcerated? Depicted in the media as less-than-human? Or all of these other things, right? - Not worthy of treatment, worthy of prison, jail? … I always say we need to go back to the 1980s, 1990s crack epidemic, so to speak, because people, in their communities, have lived experiences and have been historically and structurally traumatized by our collective responses to substance use. And a lot of people that carry those [stigmatizing] beliefs have come from communities that may have been harmed.