(13) Implementation Determinants of Harm Reduction Integration in Outpatient Clinical Settings

Background & Introduction: Harm reduction services (HRS) are interventions to mitigate health risks associated with substance use among people who use drugs (PWUD). The ongoing U.S. opioid and polysubstance use crisis has fueled a surge in fatal overdoses and infectious complications, prompting a federal push to integrate evidence-based HRS into clinical settings. Outpatient clinics that offer addiction treatment are well-positioned to provide these services due to their widespread accessibility and cost-effectiveness. Centers of Excellence for Opioid Use Disorder (COEs) in Pennsylvania include primary care and substance use disorder clinics that offer medication treatment, behavioral health support, and case management are ideal for implementing HRS. We partnered with three COEs (peripartum, primary care, and dual diagnosis settings) in western Pennsylvania to integrate HRS into COEs including on-site naloxone distribution; safer snorting, smoking, injection kits, and boofing kits (per rectal administration); fentanyl/xylazine test strips; and wound care kits. We evaluated barriers and facilitators to HRS integration through pre- and post-implementation focus groups with COE clinic staff and providers to enhance the effectiveness and sustainability of future HRS implementation efforts.

Methods: We aimed to recruit 10-15 providers and staff from the three COEs to participate in focus groups pre- and post-implementation of HRS. We developed a focus group interview guide based on the Consolidated Framework for Implementation Research 2.0 (CFIR 2.0) to identify implementation barriers and facilitators to HRS integration. Two one-hour virtual pre-implementation focus groups were conducted in September 2023, one with COE providers and the other with COE staff. Integration of HRS at each COE began in February 2024, followed by post-implementation focus groups from May-June 2024 using the same format. Participants were compensated $30. Focus groups were transcribed verbatim, and a codebook was developed both deductively based on CFIR 2.0 domains and inductively based on recurring themes. Transcripts were coded by two trained coders, who shared coding and content analysis with the team; broad themes were then generated by the study team.

Results: In total, 5 providers and 6 staff participated in pre-implementation focus groups (with 1 provider participating in a solo interview), while 7 providers and 4 staff took part in post-implementation focus groups (with 1 provider and 1 staff participating in a group interview). Pre-implementation, participants strongly agreed that HRS integration aligned with clinic goals, and some participants highlighted prior experience with naloxone distribution and syringe prescriptions as facilitators. One participant noted the positive impact on patient-provider relationships, stating, "It helps create therapeutic relationships... Patients feel less judged and more open." However, participants also identified several pre-implementation barriers in the inner setting including the need for a clinic workflow that maintains patient privacy without burdening existing clinical practices and a lack of general knowledge regarding the entire spectrum of HRS. Participants also identified outer setting concerns about healthcare stigma related to non-abstinence based clinical care. One participant mentioned, "Stigma is huge... [HRS is] still seen as enabling ongoing use."
Post-implementation, participants reported that HRS integration was well received by clinic staff, providers, and patients, with site-specific workflows effectively addressing pre-implementation inner setting concerns. However, the main implementation barriers remained in the outer setting. Notably, community stigma from social service workers and pharmacists, who lacked familiarity with HRS negatively impacted patients, which was countered by staff and providers who advocated for patients to validate the possession of harm reduction kits as part of medical care. Funding was described as the primary barrier to the sustainability of HRS. While participants expressed enthusiasm for continuing and expanding HRS integration, securing financial resources for kit supplies and staff time was critical. All clinics pursued external grant opportunities to support ongoing efforts, underscoring the alignment of HRS with their core values. One participant emphasized, "There's a lot of support for expanding this, but it ultimately comes down to funding."

Conclusion & Discussion: ): Our findings underscore the vital role of outpatient clinics in integrating HRS into clinical practice. Participants noted a strong alignment between HRS and clinic goals, highlighting positive impacts on patient relationships and care. While pre-implementation concerns about workflow and stigma were largely resolved, external stigma from community stakeholders and funding sustainability remained significant challenges. Participants showed commitment to this work by advocating for the ongoing provision of HRS. The enthusiasm for expanding HRS reflects a commitment to enhancing patient safety and care outcomes. Future efforts should prioritize securing financial resources and promoting community education to establish harm reduction as a standard practice, benefiting individuals and communities affected by substance use.

References: Lindenfeld Z, Hagan H, Chang JE. Exploring Barriers and Facilitators to Integrating a Harm Reduction Approach to Substance Use in Three Medical Settings. J Gen Intern Med. 2023;38(15):3273-3282. doi:10.1007/s11606-023-08231-2.

Shang M, Thiel B, Liebschutz JM, Kraemer KL, Freund A, Jawa R. Implementing harm reduction kits in an office-based addiction treatment program. Harm Reduct J. 2023 Nov 2;20(1):163. doi: 10.1186/s12954-023-00897-5. PMID: 37919741; PMCID: PMC10621216.

Fraimow-Wong L, Martín M, Thomas L, et al. Patient and Staff Perspectives on the Impacts and Challenges of Hospital-Based Harm Reduction. JAMA Netw Open. 2024;7(2):e240229. doi:10.1001/jamanetworkopen.2024.0229

Jawa R, Tin Y, Nall S, Calcaterra SL, Savinkina A, Marks LR, Kimmel SD, Linas BP, Barocas JA. Estimated Clinical Outcomes and Cost-effectiveness Associated With Provision of Addiction Treatment in US Primary Care Clinics. JAMA Netw Open. 2023 Apr 3;6(4):e237888. doi: 10.1001/jamanetworkopen.2023.7888. Erratum in: JAMA Netw Open. 2023 May 1;6(5):e2315795. doi: 10.1001/jamanetworkopen.2023.15795. PMID: 37043198; PMCID: PMC10098970.