Every time Shani Damron, 34, buys methamphetamines or heroin on the streets of Huntington, W.Va., she knows the risk is extreme.
"That fentanyl is no joke," Damron said, referring to the deadly synthetic opioid that now contaminates much of the illegal drug supply in the United States. "Every time we stick a needle in our arm, we're taking a 50-50 chance. We could die."
There's also a high risk of disease from contaminated needles shared by drug users. Damron's community has seen a major HIV/AIDS outbreak.
"I don't know if I have any friends that's not positive for HIV," she said. "Every one of us are. I am, too."
Harm reduction advocates say these outcomes for Americans struggling with addiction are avoidable.
Louise Vincent runs a program in Greensboro, N.C., where people can get clean needles and test street drugs for contamination. These services help keep people safer, she said, but they're banned in much of the country.
"You know I guess we have to decide, as a community and as a society, is it OK to just let people who use drugs die? Is that really something we're comfortable with?" Vincent asked.
Under the drug war model that has shaped the country's response to drug addiction since the 1970s, people who use illegal drugs are often treated as criminals.
Many of the nation's top drug addiction researchers say evidence is now clear that approach doesn't work.
"The best outcomes come when you treat the substance use disorder [as a medical condition] as opposed to criminalizing that person and putting them in jail or prison," said Dr. Nora Volkow, who has been head of the National Institute on Drug Abuse since 2003.
In parts of the world, including Australia, Canada and Portugal, communities are experimenting with public health approaches that include providing active drug users with a safe supply of their drug of choice.
Some programs also offer supervised consumption sites where the risk of overdose is reduced. Patients have access to health care providers and counselors who can guide them toward treatment.
Vincent said it's imperative now that the U.S. drug supply is so deadly that people with addiction be offered this kind of harm reduction service.
"When we don't allow anything other than black-or-white solutions, then we're not meeting the needs of our community," she said.
The U.S. saw more than 92,700 fatal overdoses in 2020, a 29% increase over the previous year, according to preliminary data from the Centers for Disease Control and Prevention released last week. If current trends continue, illicit drugs will soon kill more Americans every day than COVID-19.
But Vincent acknowledged that these programs remain controversial. In much of the U.S., addiction policy is moving in the opposite direction.
"I would be naive to say this is well-accepted," she said.
In recent months, elected officials in parts of the U.S. devastated by addiction have scaled back or eliminated harm reduction efforts.
Local leaders in Scott County, Ind., voted to shut down a needle exchange program that helped slow a major HIV outbreak among drug users.
Lawmakers in West Virginia, where the opioid epidemic remains widespread, approved a similar measure that goes into effect next month.
"New setups are going to be remarkably restricted," said Dr. Michael Kilkenny, who runs the public health department in Cabell County, W.Va.
He said the new law will dissuade towns from offering clean needles to drug users, even when there's clear evidence it would reduce the spread of disease.
"Communities that were on the fence [about harm reduction programs] have been knocked off the fence in the wrong direction," Kilkenny said.
Some forms of harm reduction are more accepted now in the United States. For example, many communities distribute naloxone among people who use drugs. The medication can reverse overdoses caused by fentanyl and other opioids.
But public health experts say much of the harm reduction happening in the U.S. occurs underground, with services — including clean needles — provided illegally by churches, nonprofits and activist groups.
Keith Humphreys, an addiction researcher at Stanford University, said it also appears many doctors are quietly keeping patients safe by prescribing opioids to those addicted to pain pills.
"There are plenty of physicians who make the decision that, 'Well, I wish this person weren't taking such very high doses, but I know that if I pull them away, they might go out and start using heroin,' " Humphreys said.
"It's not perfect, but it's better than the alternative, and that kind of thinking is really central to harm reduction."
There's also growing pressure on doctors to prescribe more buprenorphine, a medication that can reduce opioid cravings, preventing relapses and overdoses. But harm reduction advocates say most Americans don't have access to that kind of treatment or safe drug supply.
That's especially true for people who are poor and homeless. Damron said she has no choice but to go to street dealers for her heroin.
"I take my chance, with my 50-50 shot, whether it's going to kill me or not," she said.