Substance Use Guidelines: Foundations of Harm Reduction Introduction
September 2023
• In the United States, an estimated 46.3 million people aged 12 and over (16.5% of the population) met criteria for an alcohol or drug use disorder in 2021 Of those 46.3 million, only 4.1 million had received any substance use treatment in the past 12 months. i
• In 2021, 106,699 people died from drug overdoses in the United States. The majority of deaths were a direct result of fentanyl in the drug supply. ii Among people experiencing homelessness (PEH), drug overdose is the leading cause of mortality based on available data. iii
• Multidisciplinary primary care teams, including outreach, street medicine, and medical respite care, are vital entry points to support people with substance use and related medical and behavioral health needs
• With the elimination of the x-waiver, primary care providers can and should significantly increase access to the life-saving medication for opiate use disorder, buprenorphine.
• Harm reduction approaches, including non-judgment, open communication, and patient-led goal setting are evidence-based interventions that improve engagement in substance use treatment, reduce overdose deaths, and increase engagement in health care and other services, like housing support. iv
Key Terms and Definitions
• Harm Reduction: A philosophical approach to care that establishes individual agency and selfdetermination as central to all efforts toward well -being. Harm reduction approaches focus on providing non-judgmental and non-coercive provision of services and resources to people who use substances which reduce harms related to their substance use and other health behaviors. Harm reduction-based care is collaborative, provides education on available interventions, and centers the goals of the individual in care planning.
• Trauma-informed care (TIC): A patient-centered approach to care that recognizes the impacts of trauma and actively works to prevent re-traumatization and promote recovery. The principles of TIC are grounded in establishing a trusting relationship within a safe physical and psychological space in which to address needs.
• Person/Patient-Centered Care: Person-centered care is care that is guided by each individual’s goals, preferences, and values, with plans developed collaboratively by the individual and the care team based on that person’s unique circumstances. v It is based on the work of Dr. Carl Rogers who emphasized the importance of reflective listening skills and providing empathic responses based on genuine concern for the patient.
• Low Threshold Programs: Refers generally to an approach to substance use treatment that removes traditional barriers to entering and remaining in treatment. Low-threshold programs typically offer same day admissions/treatment starts, flexible scheduling, ongoing support through relapse events or ongoing use, and care delivery at non-traditional settings in the community. vi
Principles of Harm Reduction
• Harm reduction is a philosophical approach designed to meet people who use substances “where they are at” by utilizing patient-centered goals as a starting place for collaborative action and working to reduce harms related to substance use and other health behaviors. Harm reduction also refers to practical interventions that are in line with this methodology, including syringe service programs, naloxone distribution, and low-threshold buprenorphine programs. vii
• Harm reduction approaches recognize that people are the experts in their own lives and as such lead the way in setting drug and alcohol use-related goals. This is done with support, education, and ongoing open communication with primary and behavioral health care team members.
• Harm reduction recognizes that not everyone has the goal of abstinence and that abstinence also has a place in harm reduction. Recovery can be understood on a spectrum, with goals ranging from maintaining current use levels while taking steps to decrease risk, decreasing use, or stopping altogether. An understanding that recovery is non-linear is vital to supporting people through their own recovery process.
• Some people may never want to stop their use or may not yet feel ready to attempt to do so. In a harm reduction framework, decisions about when and if to modify or stop use are accepted without judgment. Everyone has a right to self-determination and to define their own goals regarding safety and well-being.
Supporting Recovery Goals
• Interactions with primary or behavioral health care team members are opportunities to normalize conversations about substance use as part of the overall health care plan while the clinician facilitates a non-judgmental stance and environment.
• Normalizing conversations about substance use reduces internalized stigma and allows people the opportunity to share what they are experiencing and identify priorities for their health.
• One evidenced-based intervention which utilizes person-centered care and is helpful in creating space to explore and resolve mixed feelings about change is Motivational Interviewing.
• In Motivational Interviewing, a clinician can start with problems or goals that are motivating to the client or patient. For example, a person may have as a priority addressing injection-related wounds or setting aside some money that they do not want to spend on substances. Starting with patientdirected goals ensures that you are working towards something of mutual interest Having a small success can go a long way to building someone’s confidence around achieving bigger substance use related goals in the future.
• Remember that a patient’s priorities may not always mirror those of a clinician or service provider However, they are very often moving in the same direction. Begin where the patient wants to start and provide education on risks and concerns as needed.
• Support open-ended and non-judgmental conversations about what is and is not working with someone’s substance use-related goals. If someone seems stuck with a goal, explore what might be happening and what options are available to move forward.
• Harm reduction approaches do not mean that one must always remain at their starting point; the work of harm reduction is to engage in dialogue about what is and is not working, what someone wants to change, and how the care team can support them to reach to their goal step-by-step.
Supporting People Through Relapse
• As with other chronic diseases that are impacted by health behaviors, such as diabetes and heart disease, people who use drugs and alcohol will struggle with behavior modifications as they work towards their goals to reduce or stop use, including missing or stopping medications to support their recovery.
• People who are struggling with substance use, wish to decrease their use, or want to stop use altogether often feel a great deal of shame around their use. These feelings can increase dramatically with relapse.
• It is not helpful to reinforce feelings of shame or to punish someone for a relapse through discharge from support, recovery, or housing programs. Often, when a person relapses, it is an indication that they need additional supports, not less. Discharging someone from services for one episode of relapse can lead to profound harm through continued use, loss of housing, loss of employment, related engagement in criminal activity, a break down in relationships, etc.
• Low-threshold programs recognize that when people are struggling with their use, for example continuing to use or not taking prescribed medications like buprenorphine, this does not indicate that they are “not ready for” or “do not want” recovery. What is needed is more support and further exploration of how they might achieve their goals.
• When someone is struggling with ongoing use above their goal or with relapse, it can help to have conversations about what other supports might be beneficial For example, additional behavioral health interventions, peer support, intensive outpatient treatment, and/or inpatient treatment can all be helpful strategies. Additionally, working to identify and address some of the drivers of their use such as lack of housing, feeling unsafe, past trauma, or working multiple jobs can be an important part of their recovery journey.
• It is important to recognize that while someone may have success with decreasing or stopping the use of one substance, they may continue to struggle with others For example, many people who achieve recovery from opiates by using the medication buprenorphine may continue to struggle with cocaine, alcohol, or methamphetamine use. This is common, and it is important to recognize that the reasons people use different substances can vary. At this time, medication treatments are not available for all substance use disorders. Thus, different approaches may be needed for the same person to address the use of different substance use disorders.
Additional Resources
• National Harm Reduction Coalition: Resources on harm reduction approaches and practices
• Substance Abuse and Mental Health Services Administration: Resources on harm reduction
• Bevel Up
References
i Substance Abuse and Mental Health Services Administration. (2022). Key substance use and mental health indicators in the United States: Results from the 2021 National Survey on Drug Use and Health (HHS Publication No. PEP22-07-01-005, NSDUH Series H-57). Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration.
https://www.samhsa.gov/data/report/2021-nsduh-annual-national-report
ii National Institute on Drug Abuse. (2023). Drug overdose death rates. Retrieved from: https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates
iii Fine, D. R., Dickins, K. A., Adams, L. D., De Las Nueces, D., Weinstock, K., Wright, J., Gaeta, J. M., & Baggett, T. P. (2022). Drug overdose mortality among people experiencing homelessness, 2003 to 2018. JAMA Network Open, 5(1).
https://doi.org/10.1001/jamanetworkopen.2021.42676
iv Substance Use and Mental Health Services Administration. (2022.) Harm reduction. Retrieved from: https://www.samhsa.gov/find-help/harm-reduction
v Centers for Medicare and Medicaid Services. (n.d.) Person-centered care. Retrieved from: https://innovation.cms.gov/key-concepts/person-centered-care
vi Jakubowski, A., & Fox, A. (2020). Defining low-threshold buprenorphine treatment. Journal of Addiction Medicine, 14(2), 95–98. https://doi.org/10.1097/adm.0000000000000555
vii Suarez E , Jr, Bartholomew TS, Plesons M, Ciraldo K, Ostrer L, Serota DP, Chueng TA, Frederick M, Onugha J, Tookes HE. Adaptation of the Tele-Harm Reduction intervention to promote initiation and retention in buprenorphine treatment among people who inject drugs: a retrospective cohort study. Ann Med. 2023 Dec;55(1):733-743. doi: https://doi.org/10.1080/07853890.2023.2182908 PMID: 36856571; PMCID: PMC9980015.