Injection drug use is associated with significant societal costs, and both opiate use and related deaths are increasing nationwide . Although harm reduction strategies, such as needle and syringe programs (NSPs) and safe injection facilities (SIFs), have been shown to be effective at reducing negative consequences of drug use [23, 41, 42], these strategies are not currently part of federal drug control policy in the U.S., likely due to political, legal, and moral objections [1, 35], as well as stigma, and perception of drug use as a criminal behavior, rather than a health problem . Still, a number of U.S. states provide funding for some form of harm reduction interventions, and there is renewed debate about the most effective strategies to address the burden of opiate addiction, and injection drug use . Given the significant impact of public opinion on policy decisions , it is crucial to gain a better understanding of attitudes toward harm reduction policies held by the individuals in the U.S. While previous public opinion polls have contributed to our knowledge, they have tended to look at attitudes on average, rather than considering individual differences in support for harm reduction strategies . Thus, the goal of the current study was to evaluate several demographic factors and individual differences in beliefs that might differentially predict support for NSPs and SIFs.
We selected NSPs due to their controversial status in the U.S. in spite of data supporting their efficacy in reducing harm among PWID [41, 42]. Our interest in SIFs was motivated by two reasons. First, there is accumulating research support for their efficacy in reducing high risk behaviors while increasing healthcare participation among PWID [24, 43, 44]. Second, to our knowledge, U.S. adults’ support for SIFs has not been evaluated. NSPs refer to the provision of sterile injection equipment to PWID to reduce transmission of infectious disease [18, 20], whereas SIFs refer to locales where PWID can more safely (i.e., supervised by a nurse or social worker) consume drugs. There is robust support for NSPs efficacy in reducing the transmission of HIV without increasing drug use [35, 41, 42]. While NSPs have a longer history and more scientific scrutiny, SIFs have received increased attention from researchers in recent years. SIFs were established to reduce risk of overdose, infectious disease transmission, and negative impact on public order [2, 17]. A growing body of research indicates that SIFs reduce high-risk behaviors among PWID, such as syringe sharing [16, 21, 22, 24, 44], while facilitating provision of health care and addiction treatment [14, 38] without increasing drug use or injecting behavior [23, 25, 43].
In contrast to the lack of data about SIFs in the U.S., there are some data describing support towards NSPs. Specifically, a systematic analysis of national public opinion polls evaluating support towards NSPs indicated that, depending on the poll, between 29 and 66 % of individuals endorsed favorable views . These statistics represent quite a wide range of support, and the authors suggested several reasons for the variability . First, it might be partially due to how the survey questions are worded, such as the use of loaded terms like “drug addicts’ or “junkies,” that could contribute to more bias-driven responses. In fact, the authors documented that simply replacing “those addicted to illegal drugs” with “drug addicts” was related to a 9 % drop in support towards NSPs. Hence, the authors recommended avoiding pejorative terms in survey questions. Second, they identified the beliefs and/or bias of an organization as a potential explanatory factor. Given that polls sponsored by more liberal organizations reported more support towards NSPs than those sponsored by more conservative organizations, the authors recommended that polls should be sponsored by organizations without a public position on the issue. Third, the lack of knowledge about the scientific evidence supporting efficacy of these strategies in reducing HIV infection may be another reason for the inconsistent findings and low support. Last, the authors noted the importance of evaluating factors that might influence public support toward harm reduction strategies; the focus of the current study.
We are not aware of any published research that directly assesses predictors of public support for harm reduction services in the US. When considering plausible candidates, U.S. and international research related to other drug policies is informative. First, stigma toward individuals coping with substance abuse is one possible factor; here, we focus on public stigma, which is the endorsement of negative stereotypes by society at large, which can then lead to negative emotional reactions (e.g., anger, fear) and discrimination toward individuals belonging to the stigmatized group . Given stigma relates to a preference for more punitive, rather than help-related, responses to individuals with substance abuse [26, 28, 33], it is expected that greater stigma will predict rejection of harm reduction approaches in the current study.
Second, findings from two studies conducted in Canada assessing participants’ views about harm reduction programs indicated that several factors were associated with greater support: higher income and education [13, 39], younger age , personal use of cocaine or marijuana in the past year , favorable view of marijuana decriminalization , and perception of individuals with substance abuse as ill people . Gender, however, was not a significant predictor in one study  while another reported that women were more supportive . Also, a study evaluating U.S. public support for increased government spending for “dealing with drug addiction” found that while all demographic groups were generally supportive of increased spending, after controlling for general domestic spending, men (vs. women), conservatives (vs. liberals), older (vs. younger) individuals, and residents of the South (vs. North) were more supportive of spending . These surprising results were speculated to stem from participants’ assuming that drug-problem spending would be more punitive/criminal justice-based, rather than public health-oriented. Interestingly, race/ethnicity was not a significant predictor. Because these data were either from Canada [13, 39] or are dated , we evaluated predictors of current support toward harm reduction services in a large U.S. sample.
We sought to add to the literature in the following ways. First, evidence suggests that even after accounting for other factors such as the influence of interest groups, public opinion has a significant impact on public policy . Hence, by evaluating public views towards provision of federal funding for harm reduction strategies, we increase our knowledge about a potential source of the current U.S. federal ban on support for harm reduction strategies. Second, we addressed some of the criticisms of the extant literature  by avoiding use of prejudicial terms in our survey, framing questions neutrally, describing PWID in behavioral terms, and linking the use of harm reduction strategies to scientific evidence. Third, given the dearth of research looking at correlates of U.S. public opinion toward government funding for harm reduction services, we also assessed whether public stigma toward PWID and a series of demographic factors were related to the extent of support. Note, we are not attempting to conduct an epidemiological study among a representative sample; rather, to identify promising predictors. We used a sample that was relatively diverse and large enough to enable analyses of various individual differences, but we make no claims that the sample is representative. Finally, we are the first to assess support toward SIFs among U.S. adults.
Our aims, therefore, were to: (1) assess participants’ opinions about providing government funding for SIFs and NSPs, and (2) evaluate several demographic and individual difference factors (age, gender, race, education, political ideology, religiosity, and public stigma towards PWID) that might relate to support for these strategies.