Countering the institutionalization of harm reduction through critical pragmatism

Although harm reduction practices have been increasingly adopted within health and social service systems globally over the last few decades, this process of institutionalization has not brought conceptual or theoretical clarity to the field of harm reduction. Instead, the growth of harm reduction practices within institutions has revealed the tension between grassroots approaches to harm reduction that focus on social activism and changing the underlying structural harms surrounding substance use, and the depoliticized institutional uses of harm reduction that focus on pragmatically managing individual substance use behaviour. In response to this tension and lack of theoretical clarity, the current paper proposes a critical pragmatist theoretical framework for harm reduction. First, I outline the basic principles of critical theory and pragmatism, and situate various harm reduction movements within these two theoretical foundations. Second, I explain how institutionalization has contributed to pragmatism being positioned as the primary underlying theory of harm reduction and the resulting limitations of this theoretical framing. Finally, I propose a theoretical framework that explicitly integrates both pragmatism and critical theory to help resist this process of institutionalization. I describe the key characteristics of critical pragmatism and outline the epistemological considerations of this pluralist approach as a theoretical framework for harm reduction. To conclude, I reflect on some of the challenges for harm reduction within a shifting political landscape in North America.