In Rochester, New Hampshire, Megan Merrill is on a mission to help vulnerable drug users stay healthy and avoid disease. As she navigates the snowy terrain, she carries a backpack filled with harm reduction supplies such as sterile syringes, condoms, emergency blankets, and hand warmers. However, the most crucial items in her bag are glass pipes. To Merrill and other harm reduction workers, pipes are essential healthcare tools that can prevent infections, abscesses, and fatal overdoses associated with injecting drugs.
In recent years, there has been a significant shift in drug consumption behavior in the United States, moving away from injecting opioids towards smoking them. This trend has been fueled by the changing landscape of the illicit drug market, with fentanyl replacing heroin as the dominant substance. The toxic nature of fentanyl and the presence of xylazine, an animal tranquilizer known for causing severe skin wounds, have led many users to opt for smoking or sniffing drugs instead of injecting.
Harm reduction organizations across the country have responded to this shift by providing foil, glass pipes, and mouthpieces to help individuals addicted to fentanyl or other substances avoid injection. Merrill, a former injection drug user herself, is part of a growing movement advocating for the benefits of smoking drugs over injecting them.
During her visits to homeless encampments, Merrill has observed a noticeable increase in the number of people switching from injecting to smoking drugs. This behavioral change is seen as a positive development by many experts, as smoking drugs can reduce the risk of overdose, prevent the spread of diseases like HIV and hepatitis C, and avoid complications associated with injection-related injuries.
While smoking is not the only alternative to injecting, it has become increasingly popular due to its perceived health benefits. Research suggests that individuals who smoke drugs are less likely to experience an overdose compared to those who inject. Moreover, smoking can help prevent infections, diseases, and other complications associated with injection drug use.
The shift towards smoking drugs highlights the importance of understanding how behavior can impact health outcomes, even in the context of substance use. It also sheds light on the disconnect between public opinion, government policy, and the evolving landscape of drug use epidemiology. While syringe exchanges are widely accepted, efforts to distribute pipes have faced resistance in some communities.
As harm reduction workers like Megan Merrill continue to advocate for safer drug use practices, the hope is that more individuals will choose smoking or other alternatives to injecting, ultimately reducing the harm and expense associated with injection drug use. By listening to the input of drug users and providing them with the tools they need to stay healthy, we can work towards a safer and more supportive environment for those struggling with addiction. The Biden administration’s support in 2021 for the distribution of “safer smoking kits” sparked controversy among Republicans. These kits included pipes designed to help drug users consume drugs safely by smoking, or to transition from injecting. Despite the backlash, some groups embraced the idea, arguing that public health officials have neglected strategies that acknowledge the realities of drug use.
One such organization, Smoke Works based in Massachusetts, saw success with its pipe distribution program. Initially embedded within a syringe exchange program, Smoke Works received a private grant in 2019 to pilot pipe distribution. Within months, half of its participants were only seeking smoking supplies, indicating a demand for alternatives to injecting. Despite opposition from the Trump administration and a tough drug policy climate, Smoke Works expanded its efforts, distributing over 5 million units and 1.9 million pipes in 2025 alone.
However, not all areas have embraced pipe distribution programs. San Francisco, for example, recently rolled back a program that provided foils and pipes to encourage smoking over injection. Pipes have faced stronger opposition than other harm reduction services, with some critics associating them with the crack cocaine epidemic and perpetuating negative stereotypes.
Drug consumption methods vary by region and age, with smoking more prevalent among younger users in certain areas like the West Coast. The shift to smoking drugs has been linked to the availability of fentanyl, which is easier to smoke and more cost-effective for users. Research suggests that smoking drugs can reduce the risk of transmitting viral infections like HIV and hepatitis compared to injecting.
While experts agree that smoking drugs can be safer than injecting, concerns remain about sharing equipment and accidental overdoses. Advocates emphasize the need to promote smoking as a safer alternative and highlight potential cost savings from reduced hospitalizations due to overdoses.
In conclusion, the debate over distributing safer smoking kits continues, with some advocating for harm reduction strategies that acknowledge the preferences and needs of drug users. Despite challenges and opposition, organizations like Smoke Works are working to provide alternatives to injecting and improve the health outcomes of drug users. Politicians are often looking to hear a conservative or crass perspective when it comes to discussing money. This may not always align with popular opinion, but it is what they want to hear. The topic of money can be a sensitive one, especially when it comes to political discussions. However, sometimes taking a more conservative approach can be seen as the lesser of two evils.
In recent years, there has been a noticeable shift in the way harm reduction workers approach their work. For example, Merrill, a harm reduction worker in New Hampshire, has seen a significant increase in the use of smoking as opposed to injecting drugs. While smoking may still pose risks, it is seen as a safer alternative to injecting, which has a higher likelihood of overdose.
George Karandinos, a Harvard physician-researcher, has also observed this shift and agrees that smoking, while still risky, may reduce the overall risk of overdose. This data aligns with the experiences of harm reductionists like Merrill, who prioritize the safety and well-being of their clients above all else.
Harm reduction services, like those provided by Merrill, play a crucial role in preventing harm, disease, and death among individuals who are unable to reduce or abstain from drug use. By providing supplies based on the wishes of their clients, harm reduction workers like Merrill are able to meet their clients where they are and offer the best possible support.
Merrill’s approach of offering the “lesser of evils” has been well-received by her clients. By providing harm reduction supplies that prioritize safety, she is able to make a positive impact on the lives of those struggling with addiction. While not a perfect solution, offering a safer alternative can make a significant difference in reducing harm.
Ultimately, the goal of harm reduction is to minimize the risks associated with drug use and provide support to those in need. By taking a conservative or crass approach to discussing money, politicians may be able to address complex issues in a way that resonates with the public. It may not always be the most popular opinion, but sometimes it is the most practical.
