OSCEOLA, Iowa — So many of Deborah Krauss’s friends and neighbors have died of drug overdoses during the pandemic that she said she felt as if she had been living inside of a dream. The longest she has gone without someone dying, she noted, is three weeks. Her calendar grew cluttered with funerals.
“I lost count at 40,” she recalled on a recent evening in a Des Moines office as she organized supplies to help people consume drugs more safely. “And it just keeps happening.”
The next day, Ms. Krauss was on the road, parked outside a Walmart in the small Iowa town of Osceola, her trunk brimming with boxes of syringes, fentanyl test strips and overdose-reversing medication. A former hair stylist, she recalled the stress of grooming an ex-boyfriend’s facial hair to make him presentable at his funeral after he died from an overdose in 2018.
Ms. Krauss, 38, is one of the few practitioners in Iowa of a public health strategy known as “harm reduction,” a wide-ranging set of policies that President Biden and many federal and local health officials and physicians have made central to their efforts to curtail record-breaking overdose deaths. The strategy does not seek to cut people off from drug use. Instead, it aims to give them tools to use drugs in a safer manner, like the supplies in Ms. Krauss’s trunk.
In his State of the Union address on Tuesday, Mr. Biden, the first president to endorse the strategy, highlighted the federal government’s attention to some of the core features of harm reduction work, including a provision in a recently enacted spending package that makes it easier for doctors to prescribe buprenorphine, an effective addiction medication that Ms. Krauss works to get to drug users. During his speech, Mr. Biden recognized the father of a 20-year-old from New Hampshire who died from a fentanyl overdose, citing the more than 70,000 Americans dying each year from the potent synthetic opioid.
The father’s story, he said, was “all too familiar to millions of Americans.”
But two years after Mr. Biden took office, with the nation’s drug supply increasingly complex and deadly, the practice of harm reduction remains underfunded and partially outlawed in many states. The work is often conducted by organizations that run syringe exchange programs, with workers like Ms. Krauss, a former methamphetamine user, functioning as brokers between drug users and the resources they need to manage their consumption. Those workers can face legal risk in the process.
“I have a hard time seeing the light at the end of the tunnel,” Ms. Krauss said. “We’ve been hanging by a thread.”
Ms. Krauss works for the Iowa Harm Reduction Coalition, one of the few harm reduction groups in the state. The coalition operates a syringe exchange program, which also routes drug users to medication-assisted treatment, where they receive drugs that can help manage cravings.
Researchers at RTI International, a nonprofit research institute, estimate that there are only around 1,100 full-time workers nationwide like Ms. Krauss, aided by a cast of around 600 part-time staff members and roughly 2,000 volunteers. A national survey conducted by RTI found that the median annual budget of a syringe exchange program was roughly $100,000, far less than what is needed to cover salaries, supplies and travel expenses.
The scale of the challenge facing those workers is vast: Over 100,000 Americans die each year from drug overdoses — one every five minutes, the White House estimates. Many of those who die are younger than 50.
Critics of harm reduction have argued that the strategy takes a permissive stance toward drug use, signaling acceptance of dangerous substances without the ultimate goal of sobriety. Many Republicans and some prominent Democrats have expressed discomfort with at least some of the aims of the approach. Senator Charles E. Grassley, Republican of Iowa, said at a congressional hearing last year that he “worried that making drugs more accessible is what this administration calls drug control.”
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Public health experts say that disproportionate attention to abstinence can be ineffective and punitive, leading drug users into a maze of treatment regulations and stigmatizing environments that can discourage the use of medication. They point to a body of federal and academic research that they argue has demonstrated that harm reduction saves lives, prevents dangerous disease outbreaks and leads to greater uptake of treatment.
But finding money to pay for the work is difficult. And while supplies can be cheap — $1 for a fentanyl test strip, for example — scaling the response to the magnitude of the overdose crisis in many communities is often prohibitively expensive.
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Groups like the Iowa Harm Reduction Coalition survive on a patchwork of private donations, grants, and local and state funds that come and go, causing cycles of uncertainty. Last year, the group closed a busy second office in Cedar Rapids, on the east side of the state, after grant funds ran out. Ms. Krauss said she worried that even fixing the broken toilet in the group’s Des Moines office could sacrifice other services.
While harm reduction groups can spend money from individual donors and foundations in a flexible manner, federal funds come with limits on how the money can be used. The Biden administration has established a federal grant program for harm reduction, but only 25 applicants were awarded money last year. Just 11 percent of syringe exchange programs reported receiving federal funding in the national survey conducted by RTI, said Barrot H. Lambdin, a scientist at the institute who led the study.
The kind of work that groups like the Iowa coalition undertake is expensive and time-consuming.
On a recent morning, Ms. Krauss, a single mother who often has her 2-year-old daughter in tow, drove to a public housing complex in Osceola, nearly an hour south of Des Moines, to make a single delivery. She greeted Dove Solomon, an opioid user battling immense back pain, with boxes and bags of syringes, alcohol swabs, clean smoking pipes and naloxone, the overdose-reversing medication. The night before, Ms. Krauss had called to check in on Ms. Solomon, soothing her after the death of one of her dogs.
The Iowa group’s crusading style of helping drug users is not unusual. Harm reduction workers across the country are often former or current drug users with deep ties to communities of other users and experience navigating treatment that can benefit others. Those relationships allow the workers to find vulnerable and isolated people in ways that can be challenging for outsiders.
Ms. Krauss, who makes around $55,000 a year, or roughly half the coalition’s 2022 budget, loosely oversees a network of hundreds of drug users who rely on her drop-offs, calling and texting her when they are in need. Serving as a kind of roving medical and social worker, she delivers drug use supplies around Iowa until 10 p.m. most weeknights, scrambling to counsel or intervene before an overdose.
“Even at 2 a.m.,” she said, “I will respond to a user who is worried about what they’re going to try.”
Ms. Krauss often looks for homeless residents who may need a syringe or fentanyl test strip, or parks behind a local McDonald’s in search of people who might want help. She also visits the emergency room with clients of her group, helping them navigate the stress of hospital care for an infection or overdose.
The intimacy of the work has meant that harm reduction groups prioritize funding the small staffs they already have. “I need to pay people — people who are comfortable in these communities,” said Dr. Andrea Weber, a psychiatrist at the University of Iowa who heads the Iowa Harm Reduction Coalition’s board of directors.
One recent afternoon, Ms. Krauss raced to a post office to mail supplies to Fort Dodge, a city northwest of Des Moines. She then drove to a home on the east side of Des Moines, near the state fairgrounds, to hang a plastic grocery bag of syringes and naloxone on the handle of the front door. She returned to the group’s offices to meet two clients who were supposed to pick up supplies, but they never showed. By evening, she sat anxiously in her car on the north side of town, waiting for a drug user to pick up another package of supplies.
Many of those who die from overdoses do not realize the exact contents of a drug they take. Users often consume drugs alone, without someone nearby to administer naloxone. Ms. Krauss has trained local law enforcement and county health workers to administer the medication.
With many of her deliveries, Ms. Krauss includes a brochure on seeking treatment in the state. She refers drug users to local physicians or a University of Iowa clinic that can prescribe buprenorphine or methadone, opioids that can ease cravings.
Ms. Krauss and her colleagues face legal peril in Iowa, a conservative state that has been cracking down on drug use. It is one of more than a dozen states with drug paraphernalia laws that forbid the use of fentanyl test strips, a priority of Mr. Biden’s drug control strategy. Other materials used for drug consumption, such as pipes and syringes, can also be seen as forbidden for that reason.
State and federal laws have also stifled funding for harm reduction, said Corey Davis, the director of the Harm Reduction Legal Project at the Network for Public Health Law, which advises syringe exchange programs. While the Centers for Disease Control and Prevention encourages the use of syringe exchange programs, he noted, federal funds typically cannot be used to purchase syringes for drug use. The recent spending package, which Mr. Biden signed into law in December, banned the use of federal money in purchasing pipes, Mr. Davis added.
Some harm reduction groups get creative to cover costs. Jessica Carter, who oversees a harm reduction program in Nashua, N.H., said she relied on proceeds from charity poker games to buy syringes.
As Ms. Krauss waited for people to pick up supplies at the Des Moines office one recent evening, she reflected on the relentlessness of fatal overdoses in Iowa, something that she said many Americans might not easily associate with states like her own.
“It makes sense in New York; it makes sense in San Francisco,” she said. “Why would it make sense in Pella, Iowa?”