The social construction of harm reduction expertise: disjointed actors across a fragmented urban health landscape

In the last two decades, overdose deaths have risen to over 100,000 people each year in the United States, facilitating an outpouring of federal, state, and opioid lawsuit payout funds toward a range of initiatives that intervene in the lives of people who use drugs. One of these initiatives, and the focus of this dissertation, is harm reduction (HR)—the loosely unifying set of beliefs and practices centered around “meeting a person where they are, without leaving them there.” In 2021, I began to research the harm reduction landscape in Philadelphia with several questions: how do people understand harm reduction? How do they attempt to practice it? What facilitates or hinders a person’s ability to mobilize their principles and beliefs into practice? How is this process of moving from values to action different across different professional roles and lived experiences? To address these questions, I conducted in-depth interviews with 43 harm reduction workers and over 300 hours of participant observation with people as they bought, sold, and used drugs—primarily fentanyl, crack, cocaine, methamphetamine, and k2. In addition, I completed over 100 ethnographic interviews with outreach workers, police officers, EMS workers, neighbors, and business owners. In this dissertation, I report on the perspectives of the people included in my project to provide deeper insights into formal and informal harm reduction work. Across the chapters of this dissertation, I argue that HR often struggles to achieve its central goal of prioritizing autonomy while substantially reducing harm. I argue that this is the case because of the organizational and structural pressures HR workers and PWUD face in their attempts to mobilize their beliefs about HR into practice. I find that these constraints are dealt with differently across areas of formal and informal expertise, and whether HR is oriented around treatment. To demonstrate this process, I present the concept of I define expertise repertoires: the ways workers construct HR values through the lens of their professional knowledge, lived experience that then inform strategies for action. In these chapters, I introduce two HR orientations across a continuum of professional HR work that take HR’s central mandate to respect user autonomy, while supporting incremental change seriously: (1) unconditional HR, whereby workers were more likely to push back against institutional powers to protect user autonomy, and (2) treatment-oriented HR, whereby workers were more likely to acquiesce to, or justify institutional powers and less likely to protect user autonomy. Next, I demonstrate how PWUD attempt to protect their own autonomy as an of their interests and identity, a process related to expertise repertoires called survival expertise, whereby PWUD employ different repertoires of knowledge and self-protection strategies in response to risk and uncertainty shaping their lives. In chapter 1, develop the conceptual and theoretical background for the subsequent chapters, focusing on how formal and informal HR operates as a site of expertise. In chapters 3, 4, and 5 I focus on three different areas of professional expertise and lived experience utilizing expertise repertoires across an unconditional-treatment-oriented HR continuum. In Chapter 6, I explore how PWUD make meaning of their lives and attempt to reduce risk to themselves. In Chapter 7, I conclude this dissertation, returning to the primary empirical and theoretical contributions of this study, limitations, and policy recommendations.

Grantor dc:publisher

Temple University. Libraries

Year dc:date.issued

2026

Author dc:creator

• Chelius, Andrew F.

Advisor dc:contributor.advisor

• Wray, Matt, 1964-

Committee members dc:contributor.committeemember

• Olsen, Lauren D.
• Orrico, Laura A.

• Sociology
• Social research
• Social structure
• Addiction
• Drugs
• Ethnography
• Harm reduction
• Medical sociology
• Philadelphia

Statement dc:rights

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Licence dc:rights.uri

• http://rightsstatements.org/vocab/InC/1.0/

Language dc:language.iso

eng

Repository record dc:identifier.uri

https://scholarshare.temple.edu/handle/20.500.12613/12252

OAI identifier oai:identifier

oai:scholarshare.temple.edu:20.500.12613/12252