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Integrating Harm Reduction into Primary Care Practices

Date

Like diabetes, asthma, and heart disease—all disorders that are routinely managed in primary care—substance use disorders (SUDs) are chronic health conditions that cannot be cured but can be effectively managed in primary care. Immediate complete abstinence is not a realistic or preferred expectation for many patients. Therefore, as with other chronic diseases such as diabetes that are managed, clinical care should include helping patients reduce or prevent the harms of substance use in addition to treating the underlying disorder.  The National Harm Reduction Coalition states that harm reduction “incorporates a spectrum of strategies that includes safer use, managed use, abstinence, meeting people who use drugs ‘where they’re at,’ and addressing conditions of use along with the use itself.”  Harm reduction principles and practices prioritize engaging directly with patients with SUDs in order to prevent overdoses and infectious disease; improve physical and mental health; and offer tailored, culturally competent, low-threshold substance use and mental health disorder treatment.[1]

While it has sometimes been viewed skeptically in the past, harm reduction is now a key evidence-based element of the Department of Health and Human Services Overdose Prevention Strategy. The strategy describes harm reduction as, “Helping people where they are, without judgement, stigma, or discrimination.” The Overdose Prevention strategy also states that:

Individuals inherently deserve services that promote health, regardless of whether they use drugs. Evidence-based harm reduction strategies minimize negative consequences of drug use.

Harm reduction approaches are especially important in primary care, which is responsible for care of the whole person. By taking a harm reduction approach to serving people who use drugs as part of routine healthcare, primary care clinicians can reduce stigma and improve outcomes for their patients. Harm reduction can also act as a means to empower patients with substance use disorders (SUDs) to take responsibility for their therapeutic goals. Harm reduction services that can be offered in primary care may include: 

  • Provision of overdose reversal medications (naloxone) and related education and training services
  • Provision of or referral for education on prevention of HIV and viral hepatitis 
  • For injection drug users, provision of or referral for education on smoking as a safer alternative to injection drug use to prevent transmission of infectious diseases. 
  • Testing and treatment for HIV and viral hepatitis — including antiretroviral therapy for hepatitis C virus and HIV, pre-exposure prophylaxis (PrEP), post-exposure prophylaxis (PEP), prevention of mother-to-child transmission, and partner services and 
  • Provision of or referral to hepatitis A and hepatitis B vaccinations (to reduce risk of viral hepatitis infection).

While primary care practices will vary in the extent to which they are able and willing to provide harm reduction services on site, versus by referral to other community-based organizations, the following is a list of supplies that could potentially be made available in a primary care setting.[1]

  • Overdose reversal supplies, including naloxone kits (this may include syringes for the purpose of administering injectable naloxone only)
  • Substance test kits, including fentanyl test strips
  • Safer sex kits, including condoms
  • Sharps disposal and medication disposal kits, excluding sterile needles, syringes, and other drug paraphernalia
  • Wound care supplies
  • Medication lock boxes
  • As allowed by state or federal law or regulation, supplies to promote sterile injection and reduce infectious disease transmission through injection drug use
  • FDA-approved home testing kits for viral hepatitis (i.e., HBV and HCV) and HIV
  • Written educational materials on safer injection practices and HIV and viral hepatitis and prevention, testing, treatment, and care services
  • Distribution mechanisms (e.g., bags for naloxone or safer sex kits, metal boxes/containers for holding naloxone) for harm reduction supplies, including stock as otherwise described and delineated on this list.

There are a number of ways you can adopt a harm reduction orientation in your practice, from simply stocking wound care supplies to setting up additional services or training programs. The approach should be adapted to fit your patient population and practice setting, and may be constrained by state laws and regulations. Your practice may not have the resources or the environment to implement all of them, but any steps you can take have the potential to save lives and improve the quality of life for people with SUDs and their communities.

For more information on harm reduction, please see:

[1] National Harm Reductions Coalition. Harm Reduction Principles. https://harmreduction.org/about-us/principles-of-harm-reduction. Accessed September 15, 2023.