From the Editor
Jul 2024

Why Harm Reduction and Equity Are Ethical Imperatives in Opioid Use Disorder Care

Jeremy Weleff, DO
AMA J Ethics. 2024;26(7):E509-511. doi: 10.1001/amajethics.2024.509.


Evidence-based harm reduction practices for opioid use disorder (OUD)—such as syringe services programs,1 among others—hold promise to help advance approaches to thinking of comprehensive OUD care as a human right, but successful implementation of harm reduction interventions in the United States has been hampered by increasingly heated politicization of addiction care and a long history of a patchwork of federal and state laws that create gaps for many.2,3,4 From the middle of the 20th century and into America’s seemingly endless so-called War on Drugs, the addition of more regulations have increased the difficulty of accessing treatment and care for those who use opioids and other drugs. From the relegation of methadone treatment to opioid treatment programs in the 1970s5 (unlike other countries such as Canada, Australia, and the United Kingdom that allow for general prescribing or dispensing6) to the federal “crack house statute” of 1986,7 the vestiges of these laws continue to contribute to a rigid and slow response to effective implementation of best practices to reduce mortality and morbidity from opioid use. This uniquely American model of OUD care that now exists and has produced a record number of deaths as of June 20238 is the result of discriminatory laws against those who use drugs that began at the turn of the century during America’s earlier opioid epidemics.9

Given this legislative history, tertiary prevention strategies for OUD, which include naloxone distribution, syringe services programs, drug testing and checking, safe consumption sites, and safe/safer supply programs, have faced public and executive branch resistance in the United States.10,11 These harm reduction strategies, which are fundamentally situated in a perspective that upholds respect for bodily autonomy, freedom of choice, and person-centered care, continue to be included in international practice guidelines for OUD.12 These strategies have never been more needed, as recent waves of the opioid epidemic have been characterized by a rapidly changing and dangerous drug supply made up of illicitly manufactured, high-potency opioids and by supply-side drivers that contribute to an unpredictable drug supply.13

It wasn’t until the COVID-19 pandemic that the United States made some of its largest steps in decades toward more equitable and evidence-based OUD care. During the pandemic, methadone prescribing laws were loosened to allow for more take-home doses,14 laws that limited the prescribing of buprenorphine were removed,15 and the first safe consumption site opened in New York City.16,17 These steps, which should be celebrated and more closely align the United States with international and evidence-based practices, are hopefully the first of many toward advancing equity in OUD care. This issue of the AMA Journal of Ethics examines many of these advances, as well as barriers to OUD care that produce systemic inequities. In so doing, it contributes to the critical conversation on addressing the opioid epidemic earnestly and fully to ensure access to the full spectrum of evidence-based interventions for all individuals, regardless of race, ethnicity, gender, or socioeconomic status.


  1. Aspinall EJ, Nambiar D, Goldberg DJ, et al. 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;43(1):235-248.
  2. Beletsky L, Davis CS, Anderson E, Burris S. The law (and politics) of safe injection facilities in the United States. Am J Public Health. 2008;98(2):231-237.
  3. Nadelmann E, LaSalle L. Two steps forward, one step back: current harm reduction policy and politics in the United States. Harm Reduct J. 2017;14(1):37.

  4. Hollander MAG, Chang CH, Douaihy AB, Hulsey E, Donohue JM. Racial inequity in medication treatment for opioid use disorder: exploring potential facilitators and barriers to use. Drug Alcohol Depend. 2021;227:108927.

  5. US Food and Drug Administration. Methadone: listing as new drug with special requirements and opportunity for hearing. Fed Regist. 1972;37(242):26790-26807. Accessed June 18, 2024.

  6. Calcaterra SL, Bach P, Chadi A, et al. Methadone matters: what the United States can learn from the global effort to treat opioid addiction. J Gen Intern Med. 2019;34(6):1039-1042.
  7. Maintaining Drug-Involved Premises, 21 USC §856 (2024).

  8. Ahmad FB, Cisewski JA, Rossen LM, Sutton P; National Center for Health Statistics. National Vital Statistics System: provisional drug overdose death counts. Centers for Disease Control and Prevention. Updated March 13, 2024. Accessed May 22, 2024.

  9. Weleff J, Knio L, Capurso N. The opioid overdose epidemic and response. In: Reference Module in Neuroscience and Biobehavioral Psychology. Elsevier; 2023.

  10. Biddle M. South Philly residents discuss supervised injection sites at Bridging Blocks event. WHYY. November 16, 2023. Accessed February 21, 2024.

  11. Richmond LM. Justice Dept threatens action against planned safe injection sites. Psychiatric News. September 27, 2018. Accessed November 13, 2023.

  12. British Columbia Centre on Substance Use; British Columbia Ministry of Health; British Columbia Ministry of Mental Health and Addictions. A Guideline for the Clinical Management of Opioid Use Disorder. British Columbia Centre on Substance Use; 2023. Accessed February 21, 2024.

  13. Ciccarone D. The rise of illicit fentanyls, stimulants and the fourth wave of the opioid overdose crisis. Curr Opin Psychiatry. 2021;34(4):344-350.
  14. Adams Z, Krawczyk N, Simon R, Sue K, Suen L, Joudrey P. To save lives from opioid overdose deaths, bring methadone into mainstream medicine. Health Affairs Forefront. May 27, 2022. Accessed June 19, 2023.

  15. LeFevre N, St Louis J, Worringer E, Younkin M, Stahl N, Sorcinelli M. The end of the x-waiver: excitement, apprehension, and opportunity. J Am Board Fam Med. 2023;36(5):867-872.
  16. Harocopos A, Gibson BE, Saha N, et al. First 2 months of operation at first publicly recognized overdose prevention centers in US. JAMA Netw Open. 2022;5(7):e2222149.

  17. Giglio RE, Mantha S, Harocopos A, et al. The nation’s first publicly recognized overdose prevention centers: lessons learned in New York City. J Urban Health. 2023;100(2):245-254.

Editor's Note

Background image by Sara Gironi Carnevale.


AMA J Ethics. 2024;26(7):E509-511.



Conflict of Interest Disclosure

Author disclosed no conflicts of interest.

The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.