The Prevention Path Forward: What We Have Learned and What Is Next

Part 3 - Rethinking Risk: The Evolution of Harm Reduction^[1]

^[1] Part 1- How Treatment Shaped the Prevention Landscape; Part 2- The Rise of Prevention Science; Part 4-What Is Next in Prevention: Research, Practice and Action.

Image © Canadian Alliance to End Homelessness, used for educational purposes

According to the Substance Abuse and Mental Health Services Administration harm reduction is “… an evidence-based approach that is critical to engaging with people who use drugs and equipping them with life-saving tools and information to create positive change in their lives and potentially save their lives.” (https://www.samhsa.gov/substance-use/harm-reduction).

Harm reduction strategies are most often associated with substance use; however, the concept of harm reduction has recently been noted as important to the management of other chronic diseases such as diabetes, anorexia nervosa, and cardiovascular disease (e.g., Birch et al., 2024; Gentsch et al., 2024; Hawk et al., 2017; Hayhow & Lowe, 2006; Macklin et al., 2024).

For substance abuse, the range of harm reduction strategies are aimed at reducing the risk of overdose and infectious diseases by and include:

• Distributing opioid overdose reversal medications (e.g., naloxone) to individuals at risk of overdose, or to those who might respond to an overdose.

• Lessening harms associated with drug use and related behaviors increase the risk of infectious diseases, including HIV, viral hepatitis, and bacterial and fungal infections.

• Reducing infectious disease transmission among people who use drugs, including those who inject drugs by equipping them with accurate information and facilitating referral to resources.

• Reducing overdose deaths, promote linkages to care, facilitate co-location of services as part of a comprehensive, integrated approach.

• Reducing stigma associated with substance use and co-occurring disorders; and significantly,

• Promoting a philosophy of hope and healing by utilizing those with lived experience of recovery in the management of harm reduction services, and connecting those who have expressed interest to treatment, peer support workers and other recovery support services (https://www.samhsa.gov/substance-use/harm-reduction).

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 Research on harm reduction has shown that by making naloxone available to substance users and their families as well as First Responders, overdose deaths were reduced (e.g.,.  Furthermore, research has demonstrated that syringe-services programs have not only reduced the spread of HIV and other infectious diseases but also made connections for substance users with treatment (Jakubowski et al., 2023).

In addition, from 2020 to 2022, the HEALing Communities Study (HCS), a randomized controlled trial was conducted with funding from the National Institutes of Health and the Substance Abuse and Mental Health Services Administration.  HCS assessed the integration of prevention, overdose treatment, and medication-based treatment in select communities hard hit by the opioid crisis (N=67). The comprehensive treatment model was tested in a coordinated array of settings, including primary care, emergency departments, and other community settings. The outcomes of interest were death rates involving an opioid and noncocaine psychostimulant. The researchers found significant differences in death rates involving substances other than cocaine but nonsignificant reductions in overdose deaths that included cocaine or a benzodiazepine (Freisthler et al., 2024).  They point out that life under COVID may have contributed to the use of opiates and other psychoactive substances.

Other studies such as Hill et al. (2022)  and Surez et al. (2024) show how harm reduction strategies help transition substance users to treatment facilities.

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 References

Birch, E., Downs, J. & Ayton, A. Harm reduction in severe and long-standing Anorexia Nervosa: part of the journey but not the destination—a narrative review with lived experience. J Eat Disord 12, 140 (2024). https://doi.org/10.1186/s40337-024-01063-3

Freisthler, B., Chahine, R.A., Villani, J., Chandler, R., Feaster, D.J., Slavova, S., Defiore-Hyrmer, J., Walley, A.Y., Kosakowski, S., Aldridge, A., Barbosa, C., Bhatta, S., Brancato, C., Bridden, C., Christopher, M., Clarke, T., David, J., D'Costa, L., Ewing, I., Fernandez, S., Gibson, E., Gilbert, L., Hall, M.E., Hargrove, S., Hunt, T., Kinnard, E.N., Larochelle, L., Macoubray, A., Nigam, S., Nunes, E.V., Oser, C.B., Pagnano, S., Rock, P., Salsberry, P., Shadwick, A., Stopka, T.J., Tan, S., Taylor, J.L., Westgate, P.M., Wu, E., Zarkin, G.A., Walsh, S.L., El-Bassel, N., Winhusen, T.J., Samet, J.H., Oga, E.A.. (2024). Communities That HEAL Intervention and mortality including polysubstance overdose deaths: A randomized clinical trial. Journal of the America Medical America Association Network Open, 7(10):e2440006. doi: 10.1001/jamanetworkopen.2024.40006. Erratum in: JAMA Netw Open. 2025 May 1;8(5):e2515507. doi: 10.1001/jamanetworkopen.2025.15507. PMID: 39432308; PMCID: PMC11581668.

Gentsch, A.T., Reed, M.K., Cunningham, A. et al. “Once I take that one bite”: the consideration of harm reduction as a strategy to support dietary change for patients with diabetes. BMC Endocrine Disorders, 24:3. https://doi.org/10.1186/s12902-023-01529-6

Hawk, M., Coulter, R.W.S., Egan, J.E. et al. Harm reduction principles for healthcare settings. Harm Reduct J 14, 70 (2017). https://doi.org/10.1186/s12954-017-0196-4

Hayhow BD, Lowe MP. Addicted to the good life: harm reduction in chronic disease management. Med J Aust. 2006 Mar 6;184(5):235-7. doi: 10.5694/j.1326-5377.2006.tb00209.x. PMID: 16515435.

Hill, K., Nussdorf, L., Mount, J.D., Silk, R., Gross, C., Sternberg, D., Bijole, P., Jones, M., Kier, R., Mccullough, D., Mathur, P., Kottilil, S., Masur, H., Kattakuzhy, S. & Rosenthal, E.S. (2022). Initiation of low-threshold Buprenorphine in nontreatment seeking patients with opioid use disorder engaged in Hepatitis C treatment. Journal of Addiction Medicine, 16(1):10-17. doi: 10.1097/ADM.0000000000000807. PMID: 33560694; PMCID: PMC8923533.

Jakubowski A, Fowler S, Fox AD. Three decades of research in substance use disorder treatment for syringe services program participants: a scoping review of the literature. Addict Sci Clin Pract. 2023 Jun 10;18(1):40. doi: 10.1186/s13722-023-00394-x. PMID: 37301953; PMCID: PMC10256972.

Macklin, J., Samson, B., Zsager, A. et al. Cardiovascular disease management and healthcare delivery for people experiencing homelessness: a scoping review. BMC Health Serv Res 24, 1080 (2024). https://doi.org/10.1186/s12913-024-11503-0

Sprague Martinez, L., Rapkin, B.D., Young, A., Freisthler, B., Glasgow, L., Hunt, T., Salsberry, P.J., Oga, E.A., Bennet-Fallin, A., Plouck, T.J., Drainoni, M.L., Freeman, P.R., Surratt, H., Gulley, J., Hamilton, G.A., Bowman, P., Roeber, C.A., El-Bassel, N. & Battaglia, T. (2020). Community engagement to implement evidence-based practices in the HEALing communities study. Drug and Alcohol Dependence, 217:108326. doi: 10.1016/j.drugalcdep.2020.108326. Epub 2020 Oct 6. PMID: 33059200; PMCID: PMC7537729.

Suarez, E. Jr., Bartholomew, T.S., Plesons, M., Ciraldo, K., Ostrer, L., Serota, D.P., Chueng, T.A., Frederick, M., Onugha, J. & Tookes, H.E. (2023). Adaptation of the Tele-Harm Reduction intervention to promote initiation and retention in buprenorphine treatment among people who inject drugs: A retrospective cohort study. Annals of Medicine, 55(1):733-743. doi: 10.1080/07853890.2023.2182908. PMID: 36856571; PMCID: PMC9980015.