Going Dutch: Harm reduction is embraced in the Netherlands but struggles in the US

Cornelissen is presenting a safe-injection training to his staff at Mainline, a harm reduction organization in the Netherlands. It’s one he gives to people who use drugs in safe consumption rooms across Amsterdam — places where people can use drugs under medical supervision.

The Mainline staff sits around the conference table of the sunlit office in the center of Amsterdam, surrounded by green plants and cases of drug paraphernalia used as part of a “History of Drugs” exhibition the group puts on at local museums. A cat makes its way from lap to lap while they learn how to correctly prepare and inject opioids like heroin and fentanyl.

Cornelissen goes over the proper techniques, passes around little baggies of “fake heroin” and supplies like syringes, Mainline-branded lighters and cookers — small metal spoons used to heat and dissolve opioids before injection. He walks around the room, going from person to person, inspecting their work as he would a science experiment in a classroom.

“So you see, there are little crumbs,” he says, pointing to a cooker with flecks of powder in the water, “You don’t want that in your needlework.”

The purpose of the training isn’t to promote drug use. It’s to reduce the harm of using drugs — to teach safer practices and prevent overdoses, infections, and injuries.

“It comes with serious risks,” Cornelissen says about using opioids. “And the overdose is that your heart stops beating. And death is the next step, which happens a lot in the United States of America. That’s where the harm reduction comes in place.”

The Netherlands averages around 300 overdose deaths per year. There were more than 80,000 in the U.S. last year — a decrease of nearly 27% compared to the year before. That drop in deaths is due, in part, to harm reduction strategies, including increasing the availability of naloxone, or Narcan, to reverse opioid overdoses.

Still, harm reduction faces a lot of pushback in the U.S., where it consistently bucks up against the false, but persistent view that it promotes and encourages drug use.

In the Gulf South, there are few, if any, official syringe exchange programs and no safe consumption rooms, sometimes called overdose prevention or safe injection sites. And DOGE cutsunder President Donald Trump’s administration threaten what little harm reduction there is.

In the Netherlands, there’s nothing controversial about the practice.

Mainline offers services like syringe exchange and drug checking, where people bring their drugs to have them tested to find out what’s in them before they use them. The organization is funded by both city and national funding — harm reduction is integrated into the country's health and social care system.

Cornelissen said the Dutch don’t embrace these harm reduction strategies because they’re more tolerant or open to drug use. It’s because they work. Harm reduction is often cited for its role in solving the country's heroin crisis in the 1970s, ‘80s and ‘90s.

For the former physics teacher, harm reduction is as fundamental as a law of nature.

“Do you believe in gravity?” he asks. “Well we wouldn’t be sitting here without it. [It] is a hilarious question for that reason. The same goes for harm reduction. It has been proven so many times, so how can you doubt it?”

Part of Mainline’s mission is to connect with people who use drugs. To go out to where they are, meet with them, and find out what they need, how they can help and what drugs they’re using. Knowing what’s on the market helps them adapt and tailor their services.

“The most thing I think they need is someone to listen to them,” Sultan Baghdadi, an outreach worker at Mainline who bikes across the city to meet with people who use drugs, said outside of a safe consumption room in Amsterdam.

Inside the safe consumption room are a handful of people scattered around tables. It looks like an ordinary health clinic. A smiling nurse looks on from behind a window. Some people in the room are using cocaine. Others, like Lucas, are preparing and injecting heroin.

Lucas explains how it all works.

“You register downstairs, come up, and sit down to use,” he said. “They’ve got everything — needles, a safe place. It’s cool, man. You don’t have to use in the bushes or in the toilets. You don’t leave needles somewhere in the park.”

Everyone is happy to see someone from Mainline. They all trust the organization. Baghdadi checks in with people and hands out brochures about the risks of synthetic opioids like fentanyl, which haven’t yet appeared in the country’s illegal drug supply in a major way or caused the caused the devastation they have in the U.S.

Mostly, Baghdadi just sits with people and talks with them without any judgment. If anybody wants help, whether it’s housing, food, laundry, or treatment, he can connect them to the right places.

Research has long shown that harm reduction helps prevent people who use drugs from getting sick, injured or dying, including research from Dr. Wim van den Brink, professor of addiction psychiatry at the University of Amsterdam.

Van den Brink says harm reduction shouldn’t be a political issue — it’s health care. He presents it as a “medical model” whenever he encounters resistance to the idea.

“I don’t need the words ‘harm reduction,’ because they hate harm reduction. It's woke,” van den Brink said. “But they know terms like crisis treatment, they know cure, and they know care. This is in medical terms.

“Care is what we do the most in medicine, like people with rheumatoid arthritis, people with diabetes. We cannot cure them, but we can take care of them so they can live a normal life with normal lifetime expectancy, with decent quality of life, sometimes actually with an ongoing job.”

Van den Brink is also chairman of the board of Mainline, which is facing budget cuts next year. These cuts are “salami cuts” that all agencies, including the country’s health departments, have to make. They aren’t driven by ideology or targeted toward harm reduction services.

“It wasn’t a politically-driven cut,” van den Brink said, “It’s just the cuts that go out. It’s an unfortunate reality, I think.”

Addiction and harm reduction resources are facing similar budget cuts in the U.S. But here, they’re done in accordance with the Trump administration’s political priorities.

Regions where harm reduction faces a lot of resistance — like the Gulf South — could see even fewer resources available. Syringe exchange programs aren’t legal in Alabama or Mississippi, and basic harm reduction tools, like fentanyl test strips, were considered illegal paraphernalia until 2022 in Alabama and 2023 in Mississippi.

In Louisiana, there are only a few official syringe exchanges. One is the New Orleans Syringe Access Program, or NOSAP.

NOSAP’s drop-in area is reminiscent of similar harm reduction facilities in the Netherlands. People sign in and wait for supplies like syringes, drug testing strips, naloxone and wound care. Xylazine, a tranquilizer sometimes mixed with fentanyl that can cause necrotic ulcers, has been in the local drug market lately, causing severe injuries.

“What we try to do is decrease as many barriers as possible, and to keep all of our harm reduction services as low threshold as possible,” said Caitlin Boyle, NOSAP’s prevention manager.

NOSAP is part of a Federally Qualified Health Center called CrescentCare. Boyle said the designation gives them an “institutional shield,” which is helpful, because harm reduction isn’t just political in Louisiana — it can sometimes be dangerous.

“Talking to different people who are doing this work throughout the state, their lives are very actively threatened at times,” Boyle said. “There are places where it’s so criminalized, and the criminalization is so active, that providing harm reduction services is a risk.”

A place like NOSAP, Boyle said, couldn’t exist just a few years ago. But the catastrophic death toll from overdoses called for new approaches.

“Harm reduction is a deeply politicized thing, but the opioid epidemic isn't. It affects everyone,” Boyle said. “And as horrible as that is, it is helpful in helping us find allies everywhere.”

The opioid crisis has forced people who dogmatically believe in abstinence-only approaches to substance use treatment, she said, to admit that something has to be done to keep people alive so they can even get treatment.

Because NOSAP relies heavily on federal grants, the Trump administration’s budget cuts have Boyle and the NOSAP staff concerned about whether or not they’ll be able to continue doing their work. NOSAP is currently only able to be open twice a week due to budget constraints. The need already vastly outpaces the demand for its services, Boyle said. They’ve started stockpiling supplies and filling cabinets and closets with syringes in anticipation of funding cuts.

NOSAP was recently awarded a $1.2 million grant from New Orleans’ opioid settlement funds — money received from lawsuits with opioid manufacturers, marketers, and distributors. But that funding is specifically for expanding outreach work and can’t be used to supplement their general budget.

Funding from the state of Louisiana covers staff time for NOSAP, as well as Hepatitis C and wound care, hygiene, and medical supplies. But state law does not allow them to purchase syringes.

If the federal funding that trickles down to support NOSAP goes away, Boyle said the impact on the community they serve would be devastating.

“The main concern is death and losing our people,” Boyle said. “Everyone here has put so much into building relationships with the community. We're terrified to see what would happen if we can't keep that up.”

This story is part of a reporting fellowship sponsored by the Association of Health Care Journalists and supported by The Commonwealth Fund. 

This story was produced by the Gulf States Newsroom, a collaboration between Mississippi Public Broadcasting, WBHM in Alabama, WWNO and WRKF in Louisiana and NPR. Support for health equity coverage comes from The Commonwealth Fund.