(6) Perceptions of Harm Reduction Integration in Treatment: A Qualitative Study

Background & Introduction: Harm reduction is an evidence-based approach that aims to reduce substance-related harms while respecting autonomy and supporting engagement in care. Despite increasing recognition of harm reduction in health systems, integration within formal substance use treatment settings remains inconsistent, and abstinence-only norms can limit relapse safety planning and overdose prevention education. Evidence suggests overdose risk is elevated following periods of reduced use or abstinence, making discharge planning and harm reduction education particularly important. However, less is known about how people in treatment experience harm reduction practices within programs, including whether they receive practical resources (e.g., naloxone, fentanyl test strips) and education (e.g., tolerance loss, fentanyl contamination). This study sought to characterize patient-reported harm reduction practices within treatment settings and to understand how people in treatment perceive these practices and their relevance to safety during and after treatment.

Methods: From February 2023 to October 2023, we conducted 48 semi-structured interviews with participants from Project RENEW, a cohort study which examined the contextual factors influencing substance use and treatment engagement among people in treatment for SUDs in Connecticut and Georgia. Participants were recruited through social media posts, flyers, in person recruitment at health clinics, referrals from partnering treatment centers, and peer referrals. Inclusion criteria were: age ≥18; English proficiency; enrollment in a formal substance use treatment program within the past 12 months; alcohol use within past 12 months; and ability to complete smartphone based follow up surveys. Interviews (30–60 minutes) were conducted via Zoom by trained staff, audio recorded, and participants received $40. Audio files were transcribed in Trint, reviewed by at least two team members for accuracy, cleaned, and de identified. Transcripts were coded in Dedoose using an iteratively developed codebook. Two coders established reliability (κ ≥ 0.80) on an initial subset before coders applied the finalized codebook to remaining transcripts. Thematic analysis was used to identify patterns related to harm reduction experiences. All procedures were approved by the Central Yale WCG IRB (1280127).

Results: Participants had a mean age of 39 years; 56% identified as men, 40% as women, and 4% as transgender/nonbinary. Most identified as White (56%) or Black/African American (36%). Thirteen participants (27%) were recruited from Connecticut and 35 (73%) from Georgia. Most described their most recent treatment as inpatient (79%), and approximately half were legally mandated to attend (51%). Although all participants were enrolled in treatment related to alcohol use, many also reported treatment related to stimulants (69%) and opioids (38%).
Four key themes were identified:
1. Tension between abstinence-focused models and safety planning. Participants described treatment expectations centered on abstinence, with limited discussion of relapse related overdose risk or harm reduction strategies.
2. Inconsistent access to harm reduction resources and education. Many participants reported naloxone availability, though training was inconsistent; fentanyl test strips and other tools were often absent or provided without instruction.
3. Emotional and social dimensions of harm reduction. Participants highlighted community responsibility, social support, and prior experiences as key motivators for safer practices and wanting harm reduction resources (e.g., carrying naloxone, avoiding solitary use).
4. Misinformation and missed opportunities. Some participants reported inaccurate or absent information about overdose risk, tolerance loss, and harm reduction tools, indicating gaps in provider education and discharge planning.

Conclusion & Discussion: Participants described variable and often insufficient integration of harm reduction practices while they were in treatment, especially regarding education, training, and discharge safety planning. While some programs provided naloxone instruction or overdose response training, many emphasized abstinence without addressing relapse risk as a predictable feature of a chronic, relapsing condition and without equipping patients with practical strategies to reduce overdose risk after treatment. Findings suggest that embedding harm reduction into treatment—through staff training, consistent provision of evidence-based supplies (e.g., naloxone, fentanyl test strips, safer smoking kits where appropriate), and structured education on tolerance loss and overdose response—may better align programs with patient safety needs and support continuity of care. Study limitations include self-reported data, a sample anchored in treatment for alcohol use, and overrepresentation of inpatient experiences and two primary regions, which may limit broader applicability. Integrating harm reduction into treatment settings may improve patient-centered care and reduce preventable harms during transitions out of treatment.

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

Gugala E, Briggs O, Moczygemba LR, Brown CM, Hill LG. Opioid harm reduction: A scoping review of physician and system-level gaps in knowledge, education, and practice. Substance Abuse. 2022;43(1):972–987. doi:10.1080/08897077.2022.2060423.

Strang J, McCambridge J, Best D, et al. Loss of tolerance and overdose mortality after inpatient opiate detoxification: follow up study. BMJ. 2003;326(7396):959–960. doi:10.1136/bmj.326.7396.959.

Substance Abuse and Mental Health Services Administration (SAMHSA). Harm Reduction Framework. 2023. https://www.samhsa.gov/sites/default/files/harm-reduction-framework.pdf.