How Should Harm Reduction Be Included in Care Continua for Patients With Opioid Use Disorder?

Background

Harm reduction, often described as a form of tertiary prevention, represents a set of practices that aim to reduce the negative consequences of substance use by adopting patient-centered approaches that are nonpunitive, nonjudgmental, and practical.^1,

²Its origins in the United States date back to the HIV epidemic of the 1980s, when transmission rates were high among people who injected drugs, which led activists, people who use drugs, and their allies to implement syringe exchange programs beginning in the late 1980s.^{3, 4}This approach was politically controversial and illegal in many states at the time and would not be federally supported for decades.^{4, 5}Currently, some harm reduction approaches, such as naloxone distribution (now available in all 50 states)⁶and syringe service programs, are becoming more accepted in the United States as a result of HIV outbreaks in rural settings such as Scott County, Indiana⁷; the national hepatitis C virus epidemic⁸; and the ongoing opioid overdose crisis.^{9, 10}However, harm reduction efforts still face major barriers due to a combination of stigma, preferences for punitive approaches to substance use, and policy and legal-moral objections.¹¹Political opposition to harm reduction interventions also impacts willingness to adopt harm reduction-inspired, evidence-based interventions for addressing opioid use disorder (OUD).

A professional duty to offer comprehensive evidence-based health care to all those who use drugs within the context of the ongoing opioid overdose crisis, inequitable opioid-associated outcomes in low-income and minoritized communities, and underlying contributors to multiple health challenges require physicians caring for people who use drugs and policy makers to (1) include harm reduction in the continuum of services for people who use substances; (2) embrace evidence-based policies and practices, including harm reduction approaches in health care systems and public health; (3) develop strategies to address underlying social determinants of health (SDoH); and (4) address health inequities in outcomes related to OUD treatment and opioid overdoses.

Harm Reduction Services

From an ethical standpoint, an important component of the success of harm reduction programs has been their focus on the autonomy and consent of people who use drugs. What in the medical field might be considered person-centered care has been key to the behavior changes and health benefits associated with harm reduction strategies. People who use drugs vary in their interest in engaging in treatment services, so providing a continuum of options (ranging from residential treatment to outpatient, low-barrier buprenorphine and syringe services programs or overdose prevention sites) is essential for improving health outcomes for all people who use drugs. Without a full range of interventions for OUD, individuals may be dissuaded from participating in health care, with avoidable adverse health outcomes. For instance, patient-directed discharge is more common among people who have substance use disorders (SUDs) than other populations,¹²

yet harm reduction practices could reduce patient-directed discharge among people with OUD, given the discrimination experienced by people who use drugs in hospital settings,¹³by actively managing opioid withdrawal symptoms,¹⁴consistently prescribing evidence-based medications for opioid use disorder (MOUD),¹⁵ providing naloxone upon discharge from inpatient settings, and improving systems for care continuity as patients transition through health care and community settings.¹⁶

During the COVID-19 pandemic, the regulations for MOUD were loosened. The changes included permitting telehealth prescribing of controlled substances, wider buprenorphine prescribing authority based on a telehealth evaluation, and more flexibility in methadone dosing and take-home protocols.^17,

¹⁸These types of person-centered care approaches that are informed by harm reduction practices could be critical to expanding the availability of highly effective medications to the many patients who need them. Implementation of better payment schemes for MOUD is also helpful in making it more widely available.¹⁹Codifying approaches that safely maximize access to MOUD (including low-barrier access), naloxone, and other harm reduction approaches are likely to have significant impacts on patient outcomes and population health.²⁰

Adopt Evidence-Based Policies and Programs

From a tertiary prevention standpoint, evidence demonstrating reduced morbidity and mortality outcomes from harm reduction interventions²¹

is compelling enough to support expansion of evidence-based policy interventions across the country. The Substance Abuse and Mental Health Services Administration (SAMHSA), the Centers for Disease Control and Prevention (CDC), and the Office of National Drug Control Policy convened stakeholders to develop a harm reduction framework to help guide policies, programs, and practices at SAMHSA. The Harm Reduction Framework²² acknowledges that structural inequities and SDoH contribute to substance use and SUDs. While SAMHSA’s identified core practice areas focus on specific services related to reducing harms at the individual level,²²it is critical that national harm reduction efforts have a broader focus and address the underlying structural factors and policies that actively cause harm to people who use drugs.

Policies and programs need to be based on evidence of reduced morbidity and mortality; and when reliable evidence of benefit of innovative practices exists, integrating, scaling, and spreading these practices to achieve improved health outcomes is necessary. Examples include community-based naloxone programs, which are associated with decreased opioid mortality,^23,

²⁴ and syringe service programs, which are associated with reduced transmission of HIV and hepatitis C, as well as reduced soft tissue skin infections.^{25, 26}While adoption of interventions that have been shown to reduce morbidity and mortality seems a straightforward policy choice, even when harm reduction approaches have strong supporting evidence, uptake has taken decades.²⁷New harm reduction practices and policies are emerging quickly, such as drug-checking programs,²⁸ overdose prevention sites,²⁹and decriminalization of personal substance possession.³⁰Research evaluating these measures will be critical to understanding their impacts on morbidity and mortality, as well as their impact on community health. Conversely, when research identifies existing practices or policies that are causing harm, steps must be taken to modify or eliminate those practices or policies. Examples of policies associated with harm include prohibiting MOUD in jails and prisons, criminalizing possession of drug use equipment (which has long been known to increase infectious pathogen transmission, including of HIV and hepatitis C virus),²⁵and closing syringe services programs.³¹

Structural Determinants of Health

Naloxone distribution and syringe service programs are critically important and effective interventions, but they are also downstream approaches that do not directly address the risk factors associated with the development of OUD. A prevention framework additionally encourages a focus on primary prevention interventions that address risk factors associated with a health condition and thereby aim to prevent the development of that condition. SDoH, by contrast, address factors such as access to food, education, housing, affordable health care, job security, and social inclusion that provide a foundation for achieving well-being³²

by moving even more upstream to what is known as primordial prevention.¹Addressing upstream factors such as these could reduce the development of OUD, therefore also reducing its associated morbidity and mortality.^{1, 2}SDoH that are associated with the development of OUD include adverse childhood experiences (ACEs),³³limited access to educational and job opportunities, lack of affordable housing, lack of available mental health services, racism, and lack of health insurance. For example, broad exposure to ACEs is associated with a 4- to 12-fold increase in the risk of substance use, depression, or suicide attempt in adulthood.³³Preventing ACEs is one strategy that could reduce opioid morbidity and mortality; known evidence-based interventions include community-level strategies, such as strengthening economic supports for families (eg, universal basic income³⁴) and supporting positive parenting and resiliency to protect against adversity.^{2, 35}

People who use drugs vary in their interest in engaging in treatment services, so providing a continuum of options is essential.

In addition to impacting the risk of opioid use and development of OUD, SDoH also affect an individual’s ability to recover from OUD. SAMHSA describes the 4 major dimensions of recovery as health, home, purpose, and community.³⁶

Ensuring access to health care and housing is a necessary step in supporting individuals with OUD. An excellent example is the Housing First approach, which provides permanent supportive housing to those experiencing homelessness and SUD without a requirement of abstinence, unlike the standard treatment-first approach that requires people to first engage in treatment and to be substance use free before they are eligible for housing. Compared to treatment-first models, Housing First programs reduced homelessness by 88% and, in patients living with HIV, decreased emergency department visits by 41%, hospitalizations by 36%, and mortality by 37% within 2 years or less in most studies.³⁷Moreover, among individuals who were chronically homeless with severe alcohol problems, housing first was associated with a decrease in total costs (including costs associated with jail bookings, days incarcerated, and substance use and health care services) at 6 months relative to wait-list controls.³⁸Housing First programs, however, have faced political barriers, including stigma and perceived high costs associated with program implementation. Typically, strategies are funded by a specific sector (eg, housing, health care, or carceral settings), neglecting the interconnected nature of OUD impacts that transcend these silos. This oversight can lead to insufficient investment in innovative cross-sector strategies.

Strategies to Reduce Inequity

Implementing strategies to reduce inequity is imperative. Although community naloxone distribution and MOUD have gained national acceptance and increased funding, inequities in access exist. For example, a recent study found that among Medicare beneficiaries who experienced an opioid-related emergency department visit or hospitalization, White patients were more likely to receive buprenorphine treatment and naloxone than Black or Hispanic patients.³⁹

Another study found that, among Medicaid participants diagnosed with OUD, Black enrollees were less likely than White enrollees to start MOUD, and incarceration in county jail was associated with lower likelihood of initiating MOUD within 180 days of an OUD diagnosis.⁴⁰Community-based studies similarly show inequitable uptake of naloxone, including in receipt of naloxone training and possession of naloxone among Black and Latinx compared to White people who use illicit opioids.⁴¹These examples demonstrate the failure of current strategies to adequately address inequity in receipt of evidence-based services.

In addition to disparities in access to evidence-based services, there are also significant disparities in how the War on Drugs has been implemented, with disproportionate impact on Black and Latino communities.⁴²

The Controlled Substances Act of 1970,⁴³which established the current drug scheduling system, was motivated by the Nixon Administration’s desire to target countercultural movements and racial minorities.⁴⁴This punitive approach to drug policy, focused on criminalization and tough-on-crime policies, has been disproportionately enforced in Black and Latino communities—thereby perpetuating stigma—and failed to effectively address public health concerns. Despite similar rates of substance use compared to White people, Black people are more likely to face arrest, prosecution, conviction, and incarceration for drug-related offenses and, once convicted, face harsher criminal penalties.⁴⁵Harsh criminal penalties and fear-based education campaigns have had little impact on reducing drug supply or demand, while incarcerating individuals with SUD is traumatizing and actively increases harm to these individuals.⁴⁶Additionally, drug-related felony charges limit individuals’ future housing, educational, and employment opportunities,⁴⁷making their path to recovery even more challenging.

The combined forces of the War on Drugs, stigma against people who use illicit substances, and structural inequalities have created the conditions for multiple health crises and epidemics among people who use drugs. Stigma affects risk behaviors, help seeking, remaining in care, availability of services, and willingness to invest in nonpunitive approaches to substance use-related health problems.^48,

^{49, 50}Prohibition and stigma interact with existing structural inequalities to increase health harms and impede efforts to improve health outcomes among people who use drugs. Poverty, structural violence, and structural racism all contribute to health risk in this population.⁵¹

Conclusion

Harm reduction should be embraced as a core component of the continuum of services required for an effective response to the opioid overdose epidemic. Harm reduction interventions, such as syringe services, naloxone distribution, Housing First models, and low-barrier MOUD, are evidence based and should be funded and expanded nationally, with an eye toward reducing inequities. Programs and policies that are not effective or that contradict best practice standards should be dismantled.

To be effective at reducing harms, efforts should focus on not only the late-stage sequelae of OUD but also the structural factors that predispose people to developing OUD in the first place. Factors such as access to physical and behavioral health care, educational and job opportunities, and housing are all critical, as is a greater focus on reducing ACEs and other forms of community trauma.

Physicians have significant influence in advancing harm reduction services for individuals who use substances and in advocating for policies and programs that tackle SDoH. Within clinical practice, it is crucial for physicians to integrate harm reduction measures, thereby ensuring patients’ access to a nonstigmatizing continuum of OUD care. This care includes prescribing naloxone and low-barrier MOUD as a routine part of outpatient and inpatient medical care, as well as establishing referral pathways to connect patients with community-based resources like syringe services and drug-checking programs. Additionally, physicians must be trained in treating SUDs, as such training has been found to increase physicians’ perceived preparedness for and comfort in treating SUDs.^52,

⁵³At the policy level, by voicing concerns and advocating for structural interventions, physicians can contribute to broader initiatives that address societal contributors to the ongoing opioid overdose mortality crisis and associated inequities.

Summary

Harm reduction, a patient-centered approach minimizing negative consequences of substance use, is crucial in addressing the opioid overdose crisis. Its ethical foundation emphasizes autonomy and consent, offering a continuum of care—from residential treatment to low-barrier buprenorphine and syringe service programs—to improve health outcomes. Evidence-based policies, including harm reduction interventions like naloxone distribution and syringe service programs, are vital to reduce morbidity and mortality. However, these interventions alone are insufficient; addressing underlying social determinants of health (SDOH), such as access to housing, education, and employment, is paramount for primary prevention. Equitable access to evidence-based services is critical, requiring the dismantling of discriminatory policies and practices stemming from the War on Drugs. Physicians play a crucial role in integrating harm reduction into clinical practice and advocating for systemic change.

Harm Reduction Services

Ethical considerations underscore the importance of patient autonomy in successful harm reduction. A range of options, accommodating varying patient preferences, is essential for optimal health outcomes. Addressing barriers such as patient-directed discharge, common among individuals with substance use disorders, requires proactive management of withdrawal symptoms, consistent MOUD prescription, naloxone provision upon discharge, and improved care continuity across healthcare settings. Pandemic-era flexibilities in MOUD regulations, such as telehealth prescribing and expanded buprenorphine access, highlight the potential of person-centered care approaches. Maximizing access to MOUD, naloxone, and other harm reduction strategies is critical for improved patient and population health.

Adopt Evidence-Based Policies and Programs

The substantial evidence demonstrating reduced morbidity and mortality from harm reduction necessitates nationwide expansion of evidence-based policy interventions. A comprehensive harm reduction framework should address individual-level harms while also tackling underlying structural factors contributing to substance use. Policies and programs must be grounded in evidence of effectiveness, with a focus on scaling proven interventions like community-based naloxone programs and syringe service programs. Furthermore, research evaluating emerging practices, such as drug-checking programs and overdose prevention sites, is essential to inform policy development. Conversely, policies contributing to harm, such as MOUD prohibitions in correctional facilities and criminalization of drug paraphernalia, require modification or elimination.

Structural Determinants of Health

While interventions such as naloxone distribution and syringe service programs are crucial, they represent downstream approaches. Addressing upstream risk factors through primary prevention is critical. Focusing on SDOH, encompassing access to resources like food, education, housing, and healthcare, is essential for promoting well-being and preventing OUD. Adverse childhood experiences (ACEs) significantly increase the risk of substance use, highlighting the need for interventions targeting community-level support and strengthening family resilience. SDOH also affect recovery; Housing First models, providing permanent supportive housing without requiring abstinence, demonstrate reduced homelessness and healthcare utilization compared to treatment-first approaches.

Strategies to Reduce Inequity

Addressing inequities in access to evidence-based services is paramount. Disparities exist in access to buprenorphine and naloxone, with racial and ethnic minorities experiencing lower rates of receipt. The War on Drugs has had a disproportionately negative impact on Black and Latino communities, perpetuating stigma and limiting access to care. Harsh penalties and fear-based campaigns have proven ineffective in reducing drug use while contributing to incarceration and further marginalization. This punitive approach interacts with existing structural inequalities to exacerbate health harms. Combating stigma, addressing structural inequalities, and dismantling discriminatory policies are crucial for equitable access to harm reduction services.

Summary

Harm reduction, a patient-centered approach to substance use, is crucial for addressing the opioid overdose crisis. Its ethical foundation emphasizes individual autonomy and informed consent, offering a continuum of care ranging from residential treatment to low-barrier options like buprenorphine and syringe services. The COVID-19 pandemic highlighted the effectiveness of harm reduction through relaxed regulations on medication-assisted treatment (MAT), demonstrating its potential to expand access to vital care.

Harm Reduction Services

Effective harm reduction requires a comprehensive approach. A continuum of care options is essential, accommodating diverse patient needs and preferences. Addressing barriers like patient-directed discharge, often higher among individuals with substance use disorders (SUDs), can be achieved through proactive measures including managing withdrawal symptoms, consistent MAT prescriptions, naloxone provision, and improved care coordination. Person-centered care, informed by harm reduction principles, is paramount to improving outcomes. This includes increased access to MAT, naloxone, and other harm reduction strategies, improving both patient outcomes and overall population health.

Adopt Evidence-Based Policies and Programs

The efficacy of harm reduction is supported by substantial evidence demonstrating reduced morbidity and mortality. Evidence-based policies and programs are essential, with a focus on interventions like community-based naloxone programs and syringe service programs which have proven effectiveness in reducing mortality and transmission of infectious diseases. The integration and expansion of successful practices are critical. Conversely, policies that exacerbate harm, such as prohibiting MAT in correctional facilities or criminalizing drug paraphernalia, should be revised or eliminated. Emerging approaches such as drug checking programs and overdose prevention sites require further research to determine their impact.

Structural Determinants of Health

While crucial, interventions such as naloxone distribution and syringe service programs represent downstream approaches. Addressing upstream factors, such as social determinants of health (SDOH), is essential for primary prevention. SDOH encompass factors like access to food, housing, education, and employment, all of which influence the development and trajectory of OUD. Addressing these factors, including mitigating adverse childhood experiences (ACEs), can significantly reduce the incidence and severity of OUD. Innovative approaches like Housing First demonstrate the potential of upstream interventions to improve health outcomes and reduce costs. However, these programs often face political obstacles related to stigma and perceived costs.

Strategies to Reduce Inequity

Despite progress, inequities in access to harm reduction services persist. Studies reveal disparities in MAT and naloxone access based on race and ethnicity, highlighting the need for targeted interventions to address systemic inequalities. The legacy of the War on Drugs has disproportionately impacted marginalized communities, perpetuating stigma and hindering access to care. Addressing these historical inequities requires a comprehensive approach that tackles both systemic racism and the stigma surrounding substance use. To be effective, harm reduction strategies must actively strive to address these disparities to achieve equitable outcomes.

Summary

Harm reduction, a non-judgmental approach to substance use, aims to minimize negative consequences. Its origins lie in the 1980s HIV epidemic, initially facing legal and political hurdles. Now, with growing acceptance, harm reduction strategies like naloxone distribution and syringe service programs combat the opioid crisis and related health issues. However, stigma and punitive approaches remain significant barriers.

Harm Reduction Services

Ethical harm reduction prioritizes patient autonomy and choice. Offering a range of services, from residential treatment to outpatient options, is crucial. A continuum of care prevents patients from avoiding healthcare due to fear or stigma. Improving care continuity, managing withdrawal, consistently prescribing medication-assisted treatment (MAT), and providing naloxone upon discharge are vital. COVID-19 relaxed regulations for MAT, highlighting the potential of person-centered care. Expanding access to MAT and harm reduction services through better payment schemes will significantly improve outcomes.

Adopt Evidence-Based Policies and Programs

Evidence strongly supports expanding harm reduction policies nationwide. The Substance Abuse and Mental Health Services Administration (SAMHSA) provides a framework, emphasizing addressing structural inequities. Policies must prioritize evidence-based practices proven to reduce morbidity and mortality. Community-based naloxone programs and syringe service programs are examples of effective interventions. However, even with strong evidence, adoption of harm reduction approaches has been slow. New strategies such as drug-checking and overdose prevention sites require evaluation. Harmful policies, like prohibiting MAT in prisons, must be changed.

Structural Determinants of Health

While naloxone and syringe programs are crucial, they address downstream effects. Primary prevention targets risk factors before OUD develops. Social determinants of health (SDOH), such as access to food, housing, and education, are foundational for well-being. Addressing SDOH, like adverse childhood experiences (ACEs), can prevent OUD. Housing First programs, which provide housing without requiring abstinence, show significant positive results in reducing homelessness and healthcare costs compared to treatment-first models. However, these programs face political barriers.

Strategies to Reduce Inequity

Despite increased funding for harm reduction, inequities persist. Studies reveal racial disparities in access to buprenorphine and naloxone. The "War on Drugs" disproportionately impacts minority communities. The Controlled Substances Act of 1970, with its punitive approach, exacerbated this issue. Harsh penalties and stigma limit opportunities for recovery. Structural inequalities and stigma hinder effective health outcomes.

Conclusion

Harm reduction is essential for addressing the opioid crisis. Evidence-based interventions should be expanded, focusing on equity. Ineffective or harmful policies need to be eliminated. Addressing structural factors that contribute to OUD, such as improving access to healthcare, education, housing, and reducing ACEs, is critical. Physicians play a key role in implementing harm reduction in practice and advocating for policy changes.

Summary

Harm reduction helps people who use drugs by focusing on reducing the bad things that can happen. It's like giving people tools to stay safe. This is important because many people who use drugs face many problems.

Harm Reduction Services

Harm reduction programs help people make safer choices. They offer many different kinds of help, from places to live to medicine that helps people avoid withdrawal. This is important because it helps people get the care they need, when they need it. During the COVID-19 pandemic, it became easier for people to get the medicine they need, showing how important this kind of help is.

Adopt Evidence-Based Policies and Programs

Many studies show that harm reduction works. Things like giving people medicine to prevent overdoses and clean needles help save lives. We need to make sure everyone has access to this help. Sometimes, though, laws and rules make it hard for people to get help.

Structural Determinants of Health

Harm reduction isn't just about helping people who are already using drugs. We need to help prevent people from starting in the first place. Things like having a safe place to live, good food, and a good education can make a big difference. Difficult things that happen in childhood can also make it more likely that someone will use drugs. We need to help kids and families before problems start.

Strategies to Reduce Inequity

It's not fair that some people have easier access to help than others. We need to make sure everyone has the same chance to get help, no matter who they are or where they live. The way we've dealt with drugs in the past has hurt some communities more than others.. It is also important to remember that stigma and prejudice are harmful to all communities involved.

Conclusion

Harm reduction is super important for helping people who use drugs. It helps people stay safe and get better. We need to make sure everyone has access to it, and change the rules that make it hard for people to get the help they need. We also need to look at the large problems that lead to drug use and fix those, too. Doctors and other healthcare workers have a big part to play in helping everyone get the best help.