. 2023 Sep 6;2023:10.31478/202309b. doi: 10.31478/202309b

Table A-3. Evidence-Based Interventions at the Tertiary Level of Prevention.

Tertiary Prevention
I. Targeted Level of Action	II. Risk(s) at the Targeted Level of Action	III. Protective Factor(s) Addressed	IV. Intervention	V. Intervention Description	VI. Examples of Programs/Models
Individual	Internalization of stigma and discrimination Unaddressed comorbidities (HIV, hepatitis C virus [HCV], wound care)	Receipt of harm reduction services/supplies (e.g., overdose education and naloxone distribution, syringe services, fentanyl test strips)	Low-barrier access to sterile drug supplies and other harm reduction services Remote harm reduction services	Despite the efficacy of harm reduction services in mitigating drug use–related risks, including spread of infectious disease and overdose deaths, many people who use drugs (PWUD) cannot access these services because of geographical constraints and/or the prevailing stigma tied to these services. [⁵²] Remote harm reduction services, such as NEXT Distro, overcome these challenges by leveraging digital technologies for mail-based distribution of supplies and information, thus providing low-barrier access to essential and lifesaving resources. [⁵³,⁵⁴]	1. NEXT Distro: https://nextdistro.org/
Interpersonal	Internalization of stigma and discrimination	Knowledge of safer injection practices Overdose prevention knowledge	Education on safer injection practices and overdose prevention	Education for PWUD on safer drug use and overdose risks empowers individuals to take steps to minimize potential harms associated with drug use. [⁵⁵,⁵⁶]	1. Getting Off Right: A Safety Manual for Injection Drug Users: https://harmreduction.org/wp-content/uploads/2020/08/ResourceSaferDruguse-GettingOffRightASafetyMan ualforInjectionDrugUsers.pdf 2. Guide to Developing and Managing Overdose Prevention and Take-Home Naloxone Projects: https://harmreduction.org/wp-content/uploads/2020/08/ResourceOverdosePrevention-GuidetoDevelopingandManagingOverdosePreventionandTakeHomeNaloxoneProjects.pdf 3. Overdose training—Chicago Recovery Alliance: https://anypositivechange.org/overdose-training/
Interpersonal	Stigma against people with SUD Lack of provider knowledge about SUD	Co-prescribing of naloxone along with medications with elevated risk profiles for SUD	Co-prescribing of naloxone	Prescribing naloxone along with opioids is recommended as a best practice, particularly at higher opioid doses, to increase access to naloxone for individuals at high risk of experiencing an opioid overdose and to reduce overdose deaths. [⁵⁷]	1. Prescribe to Prevent—Prescribe Naloxone, Save a Life: https://prescribetoprevent.org/ 2. Naloxone for Opioid Safety: https://www.dos.pa.gov/ProfessionalLicensing/BoardsCommissions/Documents/SN%20-%20Naloxone%20for%20Opioid%20Safety%20-%20A%20Provider%27s%20Guide%20to%20Prescribing%20to%20Patients%20Who%20Use%20Opioids.pdf
Interpersonal	Stigma against people with SUD Social isolation	Peer recovery support in nontraditional settings	Peer support programs	Individuals with lived experience serve as a resource to PWUD. Peer support workers use their own experiences to connect with and assist PWUDs. They may assist in community building, provide education, and link PWUD with resources, such as harm reduction services or treatment. [⁵⁸,⁵⁹,⁶⁰]	1. New Mexico Peer Education Project: https://f6f10dcd-f59d-42bc-bec9-c2b204cf568a.usrfiles.com/ugd/f6f10d_c9f0f0d817524f2984fecce04afd574d.pdf
Interpersonal	Lack of provider structural, cultural, or linguistic competency Social isolation		Syringe service programs in culturally relevant settings (e.g., faith-based institutions)	Faith-based settings, particularly in rural areas, often serve as important cultural institutions. Syringe service programs in these settings can reach people who may not otherwise have access to harm reduction measures.	1. Faith Leaders’ Perceptions of Needle Exchange Programs in the Rural Illinois Delta Region: Religion as a Social Determinant of Health: https://onlinelibrary.wiley.com/doi/10.1111/ajad.13213
Macro	High threshold treatment policies (e.g., requirements of abstinence)	Availability of quality treatment, including medications for opioid use disorder (MOUD)	Low-threshold MOUD treatment	A treatment approach that emphasizes principles of medication access, engagement, and treatment retention, and minimizes excessive barriers to treatment. In many cases, these programs offer open access or deliver services outside of traditional clinic settings. [⁶¹,⁶²]	1. Begin the Turn: A Mobile Recovery Program for a Targeted Urban Population: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7489971/ 2. Street Medicine and Shelter Health, San Francisco Department of Public Health: https://sf.gov/street-medicine
Macro	Unaddressed comorbidities (HIV, HCV, wound care) Stigma against people with SUD	Receipt of harm reduction services/supplies (e.g., overdose education and naloxone distribution, syringe services, fentanyl test strips) Overdose prevention knowledge Knowledge of safer injection practices	Syringe services programs	These programs provide access to and disposal of sterile syringes and injection equipment. Syringe service programs are associated with preventing transmission of blood-borne infections (such as HIV and HCV), improving public safety, and increasing linkage to SUD treatment. [⁶³]	1. Guide to Starting and Managing Needle and Syringe Programmes: https://www.unodc.org/documents/hivaids/NSP-GUIDE-WHO-UNODC.pdf 2. IDEA Exchange Florida: https://ideaexchangeflorida.org/ 3. Expanding the Circle of Care: Practical Guide to Syringe Services for Tribal and Rural Communities: https://www.rcorp-ta.org/resources/expanding-circle-care-practical-guide-syringe-services-tribal-and-rural-communities 4. Start a Harm Reduction Program: https://harmreduction.org/take-action/start-a-harm-reduction-program/ 5. Connecting—A Guide to Using Harm Reduction Supplies as Engagement Tools: http://ohrn.org/wp-content/uploads/2021/06/Connecting_Full-Guide.pdf
Macro	Illicit market trends toward increasingly toxic drug supply	Receipt of harm reduction services/supplies (e.g., overdose education and naloxone distribution, syringe services, fentanyl test strips) Overdose prevention knowledge	Drug checking (e.g., fentanyl test strips and/or more robust drug checking services)	Drug checking services, which can include the use of fentanyl test strips, provide information to PWUD about what substance(s) are in the drug supply they are using. This information allows individuals to adapt and reduce risks. [⁶⁴,⁶⁵,⁶⁶,⁶⁷]	1. The Drug Resource and Education Project: https://dredproject.ca/
Macro	Stigma against people with SUD	Bystander naloxone and other approaches to make naloxone widely available	Naloxone distribution programs	These programs distribute naloxone to individuals who may observe an overdose and provide education on how to respond when one occurs. [⁶⁸]	1. Preventing Overdose and Naloxone Intervention: https://poniri.org/ 2. Find Harm Reduction Resources Near You: https://harmreduction.org/resource-center/harm-reduction-near-you/ 3. NEXT Distro: https://nextdistro.org/ 4. “Feeling Confident and Equipped”: Evaluating the Acceptability and Efficacy of an Overdose Response and Naloxone Administration Intervention to Service Industry Employees in New York City: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6237076/
Macro	Lack of accountability for or ineffective implementation of harm reduction laws Illicit market trends toward increasingly toxic drug supply	Community penetration of naloxone Naloxone access legislation	Bystander naloxone legislation	Legislation to increase access to naloxone may provide civil, criminal, or disciplinary immunity for medical professionals who prescribe or dispense naloxone. It may also provide civil and criminal immunity for laypeople who administer naloxone. It may permit organizations, such as nonprofits or syringe service programs, to distribute naloxone. In some cases, such legislation allows naloxone to be prescribed to individuals who are not themselves at risk of overdose, allowing them to intervene if an overdose occurs. [⁶⁹]	1. Legal Interventions to Reduce Overdose Mortality: Naloxone Access Laws: https://www.networkforphl.org/resources/legalinterventions-to-reduce-overdose-mortality-naloxone-access-and-goodsamaritan-laws/
Macro	Societal stigma and discrimination Punitive criminal legal policies	Good Samaritan law with proper implementation	Good Samaritan laws	These laws provide immunity from criminal charges for individuals who report an overdose to emergency services and to those who experience the overdose. Such laws encourage people to seek medical help for individuals experiencing an overdose. [⁷⁰,⁷¹]	1. Good Samaritan Fatal Overdose Prevention and Drug-Induced Homicide: Summary of State Laws: https://legislativeanalysis.org/wp-content/uploads/2020/08/GSFOPlaws.8.10.2020-version.FINAL_.pdf
Macro	Jails and prisons that do not offer MOUD Forced withdrawal during recent incarceration	Transition from punitive, criminal legal responses toward supportive, person-centered services	MOUD for people in jails and prisons or reentering society	Individuals with OUD who are incarcerated have a significantly increased risk of death in the days and weeks following release. Offering MOUD inside the jail/prison, with linkage to community services for ongoing treatment at the time of release, is considered a best practice and has been shown to reduce mortality. [⁷²,⁷³,⁷⁴] Not allowing an individual to continue MOUD while incarcerated violates the Americans with Disabilities Act. [⁷⁵]	1. Medications for Opioid Use Disorder in Jails and Prisons: Moving toward Universal Access: https://americanhealth.jhu.edu/sites/default/files/2021-08/JHU-014%20OUD%20in%20Jail%20Report%20FINAL%202.pdf 2. Pennsylvania Department of Corrections Medication Assisted Treatment: https://www.cor.pa.gov/About%20Us/Initiatives/Pages/Medication-Assisted-Treatment.aspx 3. Behavioral Health Leadership Institute Project Connections at Re-Entry: https://www.bhli.org/projectconnections-at-re-entry.html
Macro	Punitive criminal legal policies	Transition from punitive, criminal legal responses toward supportive, person-centered services	Diversion programs	Diversion programs, such as Law Enforcement Assisted Diversion (LEAD), allow police officers the option to divert individuals away from arrest and incarceration to a community-based, harm-reduction intervention for legal violations driven by unmet behavioral health needs. [⁷⁶] While results are encouraging, challenges with low treatment referral rates and racial disparities in program enrollment persistent, and the need for staff training remains. [⁷⁷,⁷⁸]	1. LEAD Support Bureau: https://www.leadbureau.org/
Macro	Punitive criminal legal policies	Transition from punitive, criminal legal responses toward supportive, person-centered services	Outreach to people who survive an opioid overdose	Under the Houston Emergency Opioid Engagement System [HEROES], police officers are trained to conduct outreach and provide referrals for individuals who experienced a law enforcement–reported overdose. Enrollment in HEROES entails MOUD, peer recovery coaching, clinical behavioral counseling, and educational and support group sessions. [⁷⁹]	1. HEROES: https://sbmi.uth.edu/heroes/
Macro	Societal stigma and discrimination	Availability of affordable housing Employment that supports PWUD	Employment programs that support recovery	These programs support the employment of individuals in recovery by educating employers on hiring and retaining employees in recovery and connecting people in recovery to employers and workplaces that support their recovery. Employment encourages recovery by creating consistency and purpose, while potentially supporting financial independence.	1. Creating Opportunities for Recovery Employment, Marshall Health: https://www.marshallhealth.org/services/addiction-medicine/core/ 2. Recovery Friendly Employer Training Modules: https://recoveryohio.gov/resources/all-resources/recovery-friendly-employer-modules
Macro	Unaddressed comorbidities (HIV, HCV, wound care)	Availability of quality treatment, including MOUD	Screening and treatment of individuals who inject drugs for HIV, HCV, and sexually transmitted infections (STIs)	These macro-level solutions provide strategies for implementing programs that screen and treat individuals who inject drugs for HIV, HCV, and STIs. People who inject drugs are at an increased risk of HIV, HCV, and STIs. Screening ensures that individuals are aware of any comorbidities and that they can receive appropriate treatment, thus reducing the spread of infectious diseases. [⁸⁰]	1. Wound Care: https://www.health.state.mn.us/people/syringe/woundcare.pdf 2. An introductory guide for assessing and understanding common wounds with people who inject drugs: https://www.rcorp-ta.org/resources/introductory-guide-assessing-and-understanding-common-wounds-people-who-inject-drugs 3. Wound Aware: A Resource for Commissioners and Providers of Drug Services, GOV.UK: https://www.gov.uk/government/publications/wound-aware-a-resource-for-drug-services/wound-aware-a-resource-for-commissioners-and-providers-of-drug-services 4. Implementing Comprehensive HIV and HCV Programmes with People Who Inject Drugs: Practical Guidance for Collaborative Interventions: https://www.unaids.org/sites/default/files/media_asset/2017_HIV-HCV-programmespeople-who-inject-drugs_en.pdf 5. Be in the KNOW: HIV Programming and Best Practice, Prevention: https://www.beintheknow.org/hiv-programming-and-best-practice/prevention
Macro	Societal stigma and discrimination Illicit market trends toward increasingly toxic drug supply	Availability of safe consumption spaces	Safe consumption spaces Overdose prevention sites	These spaces are sites where individuals may consume previously obtained drugs in a hygienic, monitored environment without fear of arrest and where trained personnel can respond in the event of overdose. [⁸¹]	1. Rhode Island Harm Reduction Centers: https://health.ri.gov/addiction/about/harmreductioncenters/ 2. OnPoint NYC: https://onpointnyc.org/
Macro	Punitive criminal legal policies		Personal drug possession decriminalization policies	These policies remove the criminal penalties for drug possession. Decriminalization can reduce stigma around drug use, encourage people to access treatment and other services, and free up resources that can be redirected to better support PWUD. [⁸²]	1. Oregon’s Measure 110: https://www.oregon.gov/oha/hsd/amh/pages/measure110.aspx

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NOTES: Some interventions address both risks and protective factors; other interventions may address only one.

The interventions included in the table have been limited to those with promising evidence to reduce the risks associated with precursors of SUD, SUD incidence, SUD morbidity, or SUD-related mortality. In some cases the interventions are specific to harms related to opioid use/opioid use disorder, and this is clearly described in the table. However, their inclusion does not suggest, and should not be taken as, an endorsement by the National Academy of Medicine or any of the authors’ organizations. Additionally, it should be noted that this table does not encompass an exhaustive list of all tertiary level interventions.

The selection process involved a thorough review of existing scientific literature, including published studies, meta-analyses, systematic reviews, and program evaluations. In determining the inclusion of interventions, the authors considered various factors, such as the strength of evidence supporting the program’s effectiveness, the quality of research studies conducted on the intervention, the consistency of positive outcomes across multiple studies, and the intervention’s relevance to the prevention of OUD and its associated risks.