Harm reduction refers to a set of strategies aimed to limit the negative consequences associated with drug use, but without requiring complete abstinence. Some harm-reduction strategies aim to reduce the risk of overdose, such as the use of naloxone rescue kits, fentanyl testing strips, and implementation of Good Samaritan laws. Other strategies lower the risk of overdose but also the likelihood of contracting infectious diseases such as HIV and hepatitis. Syringe services programs, also referred to as needle exchange programs, and supervised consumption facilities all fall under this category. Medications for opioid use disorder (MOUD), which include methadone, buprenorphine, and naltrexone, have been proven to lower the risk of overdose, improve the likelihood of maintaining sobriety, and therefore lower rates of disease transmission. Finally, harm reduction is utilized in criminal justice system through the use of drug decriminalization, police diversion programs, and drug treatment courts.

Tennessee’s fetal assault statute, and the systems in which it was embedded, did not appear out of thin air. To the contrary, both the statute and the systems in which it operated are deeply rooted in the history and practices of US punishment and social support systems and in the stigmas about race, sex, and socioeconomic status that undergird and inform those systems. Similarly, this book does not stand alone. It is rooted in, and in conversation with, the work of many other scholars writing in the fields it touches. This chapter lays the historical ground and locates this book in these larger academic conversations.

Tennessee’s fetal assault law was originally proposed in the spring of 2013. It became law about a year later, in the spring of 2014. It remained in effect until June 30, 2016. The law was proposed again in the spring of 2019, but that proposal did not make it out of committee. Although the United States has a long history of prosecuting women for this conduct, Tennessee’s law was the first and, as of this writing, the only state law of its kind in the United States.2 Before moving on to how the law was justified by those who supported it, we first need to understand some information about how the law was structured. This chapter begins with that information and then moves into the hearing rooms where the fetal assault law was debated.

Cindy Jones1 has lived and worked in and around the criminal courts in a rural East Tennessee county for decades. What she told me epitomizes what happens when three phenomena – bias, reliance on punishment systems for care, and incredibly resource-poor environments – collide. Cindy has been a jail administrator, a treatment coordinator, and a probation officer, among other jobs. I originally got her name from the local public defender who is assigned to her courthouse. When I explained my project he said that he was happy to talk to me but that the person I really had to talk to was Cindy. She was his go-to person to get help for his clients and she, more than anyone else in his community, knows how to get people treatment. So my research assistant and I got in the car and drove out to meet her.

In 2014, the FDA approved Innovative Health Solutions’ wearable NSS-2 Bridge device for chronic and acute pain management. In 2017, the FDA cleared the device’s use for managing opioid withdrawal symptoms. Critics have raised substantive concerns about the evidence used to support the determination that the device could safely and effectively be used for opioid withdrawal, and the methods used by the manufacturer (both pre- and post-FDA approval) to gain support for the implementation of the device. The manufacturer and pharmaceutical companies have begun to engage with judges and other key personnel associated with drug courts and other court systems around the country with significant censuses of cases involving people who use opioids. This chapter draws upon empirical and theoretical research approaches to address significant ethical, public health, and oversight concerns raised by these burgeoning relationships, including the following questions: (1) How prevalent is industry-court personnel contact? (2) What do court personnel receive from industry? (3) How might such contacts affect the lives of justice-involved people who use opioids? (4) What ethical and health-related concerns arise with the development of such relationships? (5) What, if any, oversight do (or could) local and state court systems provide for industry-court personnel relationships?