November 14, 2025

Everyone knows about the stigma faced by people who use drugs. What’s far less visible is the stigma experienced by the people who support them: the harm reduction workers, counselors, outreach staff, nurses and peer workers who show up every day in a landscape still steeped in social judgment.

This is contributing to burnout, chronic stress, social distress and the loss of skilled staff from a sector that simply cannot afford to lose them.

Two recent Australian studies—published in Drug and Alcohol Review in 2024, and the International Journal of Drug Policy this September—examined how negative societal beliefs about people who use drugs spill over onto harm reduction workers, or “stigma by association.”

“Respondents characterized stigma as a pervasive social devaluation that shaped how workers were treated and how services were funded and supported,” said Dr. Theresa Caruana, a research associate and post-doctoral fellow at the Centre for Social Research in Health at UNSW Sydney, and part of the new Tackling Stigma in Healthcare network established there.

One worker who participated in the 2025 study, which Caruana co-authored, described it simply: “When the clients I work with are stigmatized, the work they do to better themselves is stigmatized. That includes the work that I do with them.”

Harm reduction workers see this stigma play out in health care settings, including through reluctance to provide care, or provision of care that is impersonal or inadequate. Some study participants spoke about needing to accompany clients to hospital to prevent mistreatment, which increased their own emotional strain and workload.

Stigma also shapes how services are positioned within the health care system. Harm reduction workers reported that people who inject drugs were often viewed as “problematic” or a “safety risk.” That contributes to harm reduction services being kept separate from mainstream health care, making them harder to resource or improve. Which again, adds to the strain and workload. 

“Workers who reported experiencing more of this stigma by association had poorer workplace wellbeing, greater levels of burnout and stronger intentions to leave the sector,” Caruana told Filter.

One promising finding is that workers with lived and living experience appear better able to remain in their roles. But that’s not because stigma affects them any less, but because the work carries deep personal meaning, community connection and purpose.

“People with living or lived experience reported higher levels of job satisfaction and lower intentions to quit, but their experience of stigma by association is similar to the broader sample,” Caruana said. 

In other words, meaning offers motivation, but not protection.

For Sione Crawford, CEO of Harm Reduction Victoria and a co-author of the 2024 study, this is familiar.

“Not all peer workers are treated poorly,” he told Filter. “But many frontline harm reduction peer workers who have been employed for their proximity to an illicit drug marketplace, and their connection with people at risk of overdose, are stigmatized at least twice, sadly often by their co-workers.”

Peer workers are hired for their community knowledge and trust, yet are sometimes treated as unprofessional or “too close” to the client population, especially if their drug use is not entirely in the past. The same qualities they are hired for can be reframed as liabilities.

“People with lived and living experience are often pitied or, worse, patronized for ‘making something of themselves.’ It’s the tyranny of low expectations,” Crawford said.

Workplace culture can make all the difference, however, when it strongly influences how deeply stigma affects workers.

“Organizational cultures that are supportive help workers gain meaning and satisfaction from their work, which can buffer against stigma and burnout,” Caruana said. “Understanding and reducing the impacts of stigma on workers will assist in attracting and retaining staff.”

This is echoed on the ground.

“Harm reduction peer workers often say they have good relationships within their direct teams, particularly when management has a strong understanding of harm reduction,” Nadia Gavin, who also works at Harm Reduction Victoria, told Filter. “Sadly, many peer workers report microaggressions when interacting with staff from non-direct service delivery areas or outside organizations.”

The dynamic can be even more difficult in services that are shaped by abstinence-based frameworks.

“If the management is from a recovery or abstinence background it can be quite a struggle to get their head around harm reduction,” Gavin said. “We have heard of peer workers being told they should be grateful that they are alive.”

Sarah Whipple, co-director of the Yuba Harm Reduction Collective in California (and winner of the Jude Byrne Emerging Female Leader Award for her drug-user activism), sees the same pattern play out in the United States.

“Stigma has created a culture where people think abstinence is the only worthy way of living, where sobriety is the only worthy goal,” she told Filter. “Because harm reduction supports people whether they want to stop using drugs or not, we are often seen as ‘enabling,’ or keeping people in a ‘bad place.’”

That’s something that came across in the Australian research, too, with one study participant saying: “I’ve been told more than once by [people in the] general community that this role is ‘enabling and encouraging’ drug use, [… that] I am no better than a dealer.” 

“People are tempted to appease that mindset by saying things like, ‘We’re keeping people alive so they can recover,’” Whipple said. “But that is not what harm reduction is about. Harm reduction at its core is about autonomy of people who use drugs, whether they want to quit drugs or not. We show just as much love to people who never intend on quitting drugs as to people who want to quit today, or who quit 10 years ago.”

Amid all this stigma by association, what can help harm reduction workers feel able to continue in their critical occupations?

For Crawford, it is community connection that sustains him.

“What keeps me going? One hundred percent my peers,” he said. “It isn’t for ourselves, it’s for our community. And when things are going well, a lovely byproduct is that feeling of being part of a greater whole, despite the stigma and discrimination that surrounds us.”

But this resilience should not be mistaken for an unlimited resource. The fact that workers keep showing up does not mean that the conditions they work in are acceptable.

“Understanding and reducing the impacts of stigma on workers will help attract and retain staff,” Caruana said. “One way to begin is by routinely examining how stigma shows up in everyday practice—within teams and within service processes.”

But even with empathic and diligent leadership of this kind, structural disincentives for harm reduction workers persist.

“Usually, there is no clear career path or progression into higher roles for these workers,” Crawford noted. “We need drug law reform, with savings or profits being reinvested into harm reduction and community efforts.”

Whipple is also clear that the solutions must include material investment.

“We deserve wages that allow us not just to survive, but to thrive,” she said. “We deserve housing, health care, joy, and the ability to care for the people we love. We need to take care of our movement. It is irresponsible to hire marginalized people into work that involves trauma and not care for their wellbeing.”

Stigma by association doesn’t simply harm workers. It weakens the entire harm reduction system.

When workers leave due to burnout and distress, services lose skill, continuity and community trust. In the context of ongoing overdose crises around the world, losing experienced harm reduction workers is not just a workforce issue. It is a public health threat.

 Photograph via Pickpik

This article was originally published by Filter, an online magazine covering drug use, drug policy and human rights through a harm reduction lens. Follow Filter on Bluesky, X or Facebook, and sign up for its newsletter.