The Double Bind of Evidence: Harm Reduction, Structural Change, and the Institutional Constraints of Randomized Controlled Trials in Criminal-Legal Settings

Although harm reduction’s effectiveness is rooted in decades of advocacy and community-led research, recent US federal support has directed unprecedented funding toward expanding this approach’s evidence base through the randomized controlled trial (RCT). Applying the RCT’s evidentiary standards to harm reduction, however, exposes a fundamental tension between the movement’s calls for structural change and the methodological and political constraints of clinical trials, particularly within criminal-legal settings. Drawing on a 2-year ethnography of the Harm Reduction Peer Recovery clinical trial in midwestern jails, this article examines how researchers and practitioners negotiate calls for structural change while navigating the evidentiary demands of RCTs funded by the US federal government. The study finds that the established institutional and epistemic commitments of RCTs, including alignment with the institutional priorities of criminal-legal administrators and the quest for politically neutral evidence preferred by policy makers, constrain pathways for social change. Ultimately, I show how the features of the RCT that foster credibility with policy makers and criminal-legal systems—political neutrality and clear causality—can also undermine efforts to address the structural issues, such as naloxone criminalization and housing insecurity, identified by frontline practitioners and researchers themselves.