“It’s nothing personal”: understanding barriers to relational harm reduction practices during inpatient hospitalization

Abstract

Background

People who use drugs (PWUD) have a higher incidence of infectious complications that require medical interventions only available in hospital settings. Hospitalizations for PWUD are also more likely to result in patient directed discharge (PDD) before completing medical treatment. Stigma directed at PWUD pressurizes and shapes clinical encounters, leading to poor communication between patient and provider. We explore how the relational philosophy of harm reduction – the premise that building relationships rooted in compassion and respect, as opposed to a transactional encounter – can redress the harms and communication barriers between PWUD and healthcare providers in the hospital setting.

Methods

We recruited sixteen patients (achieving thematic saturation) with substance use disorder during their hospital stay at a large academic medical center with an urban, suburban, and rural referral base. Interviews were semi-structured, and focused on assessing patient knowledge and experiences of accessing harm reduction services and medical care. Interviews were transcribed verbatim and analyzed using content and thematic analysis.

Findings

When discussing patient experiences accessing medical care, three key themes emerged from our interviews about their hospital experiences: 1) providers disregard for social contexts of PWUD, 2) providers withholding care because of patient’s substance use, 3) patients viewed in negative or pejorative ways because of their addiction. All participants reported experienced or anticipated stigma related to drug use. Our participants described avoiding seeking medical care and developing strategies to deal with anticipated and experienced stigma; some reported their minimization of physical complaints due to providers’ focus on their substance use as well as medical care being withheld because of their substance use. Three themes emerged around experiences of care that conferred dignity and autonomy: 1) experience dignity in and through use and access of harm reduction services, 2) peer support as a tool to model for relational harm reduction 3) harm reduction as community care (leveraging a responsibility to look out for others). Participants identified these social supports as giving them hope and motivation around their own health goals.

Conclusion

Our findings emphasize that healthcare settings remain challenging for PWUD. Patients describe how stigmatizing beliefs impact clinical reasoning and bleed into negative healthcare experiences and lower quality of care. The foundational principles of harm reduction – appreciating the social contexts in which individuals use drugs and the dignity in survival strategies – offer pathways for therapeutic communication between patients and providers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12954-025-01240-w.

Introduction

The United States is in the midst of a well-documented overdose crisis: in 2023, approximately 105,303 people died of drug overdose [1]. Compounding the overdose crisis is the rise of infectious complications, including endocarditis, skin and soft tissue infections, human immunodeficiency virus (HIV) and Hepatitis C [2, 3]. Management of infectious complications frequently require lengthy inpatient hospitalizations for administration of parenteral antibiotics and medical stabilization. While people who use drugs (PWUD) have always been at increased risk of developing infectious complications, the emergence of xylazine in the unregulated fentanyl supply has only exacerbated these conditions [2, 4, 5]. Furthermore, people who inject drugs experience higher risk of infectious complications as well as significant stigma due to their method of consumption [6, 7, 8]. Regional variance in unregulated drug supply has also led to more serious medical complications, such as xylazine associated wounds and medetomidine withdrawal syndrome [9, 10]. PWUD face significant barriers to completing treatment in the inpatient hospital setting: unmanaged withdrawal and pain, strained relations with hospital staff, and carceral-like hospital restrictions all contribute to patients leaving the hospital before medically advised [11, 12, 13[.

Harm reduction is a set of practices developed by people who use drugs in order to keep themselves and each other safe [14, 15]. Harm reduction tools have been introduced to the hospital setting in order to address the challenges of caring for patients with limited access to healthcare: for example, provision of clean syringes to prevent the transmission of bloodborne infections, encouraging those using opioids to not use alone, and providing take home naloxone in case of overdose [16, 17, 18, 19]. An acute hospitalization is an opportune moment to speak to patients about their treatment goals and safety practices [20, 21]. The philosophy of harm reduction goes beyond structural tools like naloxone distribution and clean syringes, however; harm reduction is rooted in self-determination, understanding of the role unregulated drugs can play in emotional regulation and survival, and the power of community care [2, 22, 23].

Harm reduction as a relational approach is an untapped resource to countering dehumanization and fostering therapeutic communication. Relational harm reduction is grounded in the patient-provider relationship and centers patients’ lived realities and autonomy [21]. Stigma, anticipated and experienced, pressurizes and shapes encounters between PWUD and their providers. Preconceptions that PWUD are unreliable, lacking willpower, and unlikely to recover have been found in the lay population as well as amongst medical providers [24, 25, 26, 27]. Stigma experienced by PWUD has negative repercussions on their own self-regard [13, 18]. Amidst trenchant stigma, how can medical providers reflect and reorient their clinical approach in order to provide dignified and effective care for their patients?

This study investigates what lessons can be learned from relational harm reduction practices to better meet the needs of hospitalized patients. We conducted qualitative interviews with patients hospitalized with substance use disorder. Our analysis focuses on understanding both patients’ experience in the hospital setting and also with harm reduction services (both offered by hospital and community-based providers). We focus on understanding the role of harm reduction in the hospital setting beyond distribution of supplies and naloxone, and what role, if any, relational harm reduction may play in redressing stigma and discrepancies in power.

Methods

We utilized in-person, semi-structured interviews with purposive sampling. We recruited hospitalized patients over the age of 18 years, who had a history of injection drug use from a large academic medical center with an urban, suburban, and rural referral base. Patients were purposively sampled and identified through discussions with the medical center’s Addiction Medicine Consult Service.

The interview guide asked about patients’ experiences during acute hospitalizations and office-based settings, probed about various experiences of stigma and discrimination, and asked about participants’ experiences accessing naloxone, syringe service programs, fentanyl test strips, HIV and Hepatitis C testing, and other harm reduction strategies. Key themes were generated using content and thematic analysis [28]. We reached thematic saturation at 16 participants when themes became repetitious [29].

Our theoretical orientation was grounded in constructivist grounded theory, which emphasizes co-construction of meaning between researcher and participants. This framework was chosen as it allows for the generation of rich, contextually situated insights that reflect the lived realities of participants who participated while also acknowledging the active role of researchers in interpreting the data. Preliminary findings were shared with a subset of PWUD to ensure interpretations resonated with their experiences. As a study team, we engaged in regular debriefing sessions to discuss emerging insights and refine interpretations. We engaged in regular reflections of personal biases and perspectives to maintain reflexivity throughout the study [30].

Interviews were conducted by one member of our team (RW). Interviews were audio recorded and transcribed verbatim. Transcripts were double-coded (by RW and NW), with the principal investigator (JDW) weighing in on differences in opinion in order to reach consensus. The data was coded in NVivo, and content and thematic analysis was performed by a clinical research coordinator (KL) on our team trained in anthropological methodologies in conjunction with the principal investigator (JDW).[28, 31, 32]

Results

Participants ranged in ages from 27–67 years. There were 3 Black participants, 12 white participants; one participant who preferred not to provide racial data. Six participants reported their gender as ”woman”; 10 identified their gender as “man”.

Our analyses identified six themes relating to humanizing and dehumanizing experiences accessing medical care: Three key themes described negative experiences accessing medical care (1) provider disregard for social contexts of PWUD; (2) providers withholding care because of a patient’s substance use; (3) patients viewed by in negative or pejorative ways because of their addiction. Three themes described experiences of care that conferred dignity and autonomy: (4) experience dignity in and through use and access of harm reduction services, (5) peer support as a model for relational harm reduction (6) harm reduction as community care (leveraging a responsibility to look out for others). We report in-depth participant quotes below along with pseudonyms, and include further examples of illustrative quotes in Appendix A.

Theme 1: experiences of providers disregarding social contexts of PWUD

Several participants described healthcare providers focusing on their substance use and underestimating or ignoring the significance of underlying social contexts (e.g. mental health, houselessness, trauma), which led to feelings of alienation, ineffective communication, and experiences of harm. Amy, a white woman in her 30s, described her frustration with never being able to address “underlying issues” (i.e. the social contexts triggering her drug use) with her healthcare providers:

I’m trying to get help. I’m begging for it. I wanna be better. I just can’t seem to get there, because I have all these underlying problems that don’t go away. And all they see is an addict. They don’t see the underlying issues. So once I get clean, an underlying issue causes pain and problems. And I can’t get better, so I end up self medicating again. And I try to explain and nobody really gives a shit.

Other participants underscored the impression that medical staff had “no idea” or “no clue” what people went through in regard to the physical and psychological realities of withdrawal, houselessness, and isolation. Amy also commented that although she had encountered the belief that PWUD are inherently weak, “They have no idea what we fight every day in our heads. They have no idea.”

James, a white man in his thirties, described a different communication strategy in anticipation of stigma from healthcare providers who assume he is only seeking medical care for drugs when he said:

“I want you to fix what’s right, and well-… what was wrong with me. You know, uh, when I leave, I’ll get my own shit. I- um, I’m not even worried about it.” Because they’re looking at me like, “Oh, he’s just here, because he wants to get a high.” Like, “No, I’m here because I want you to fix what’s wrong.” And then I’ll take care of myself when I get out of here.” (laughs), like, I was dead honest with them.

In contrast to Amy, James anticipated provider hostility and was transparent about his plan to continue using drugs after leaving the hospital. He specifically highlighted the contradiction inherent in the assumption of providers that he was only seeking care in order to “get high,” the reality is he would be able to “take care of [himself]” more easily on his own.

Theme 2: providers withholding care because of patient’s substance use

Participants also spoke to the apparent contradictions in the goals of hospital care. Hospital staff and providers were willing to discuss ways to support cessation of substance use, but were unwilling to provide support to patients who planned ongoing substance use at discharge. Participants also reported insufficient pain management from providers due to provider hesitancy. For example, Mark, a white man in his forties, recounted struggling to get adequate pain management treatment for a gunshot injuries to his spine and penis because of his history of substance use:

I just held my piss for four hours ‘till I got that pill […] You know how long I, how hard I fought to get off of opiates? Like this is as legit as it gets. I’m scared and I’m angry. […] Seven weeks ago, fuck no, I didn’t need anything for my pain. But, I have a bullet in my spine. I have a bullet in my dick. Come on. Like what do I gotta, like, what do I gotta do? What, what do you have to go through to, you know, be deserving of the golden ticket? […]Give me a dilaudid for every time I have to pee. That’s pretty much what I’m asking. Does that seem like drug seeking behavior? Does that seem like, you know, like, me being an addict?.

Refusal of harm reduction services or supplies was not isolated solely to the acute hospital setting. Patients describe multiple encounters with the emergency medical services that were willing to only offer treatment services. For example, Jennifer recounted when an ambulance crew refused to come to their residence because they had already reversed overdoses at that address three times that week:

Like, we were denied Narcan by the ambulance crew. They wouldn’t give us any, which is not right. It’s against the law, I heard. They can’t do that, but they said no, that they wouldn’t give us any, because they had been to the house three times in one week.

As Jennifer notes, eventually she and her fiancée gave up on calling emergency services and developed their own overdose treatment strategies to ensure their safety.

Theme 3: patients viewed in negative or pejorative ways because of their addiction

Notably, all participants reported frustration or obstacles to healthcare due to being labeled a “junkie” or “addict” by medical staff, either explicitly or implicitly. Perceived stigma led to missed symptoms or underreported pain. Mark, a white man is his thirties, described this stigma as “nothing personal”:

Definitely, some of the nurses, it’s the same thing, you know? It doesn’t matter that I’m here for something that has nothing to do with drugs. […] You know, um, but they see that in your charts, they see it in your past, and I mean, it’s nothing, it’s nothing, you know, personal. It’s just how it’s been ingrained in them since the first of day of medical school in Pittsburgh.

Mark’s impression is that stigma is taught and reinforced through medical education and embdded in professional training, which providers carry with them into their medical careers. On the other hand, several participants reported the deeply personal reverberations from being judged and poorly mistreated because of his substance use. Jeff, a white male in his 40s, said:

I just, you know, which I’ve seen doctors do that kind of stuff before… my whole life I’ve always thought, you know, the doctors are there to help us. You know what I mean? And they’re there to do the best they can for us. They take an oath for God sakes. You know what I mean? To the best of their ability. But I have seen in the field, a few places now where they, yeah, they have judged me for being an addict. Especially, you know, across the bridge from where I’m from. And, uh, it’s just, it’s disheartening. And [I] definitely have distrust.

Amy also spoke to the stigma she experienced while going through withdrawal in the hospital. Notably, this nurse had a family member with lived experience which at first created a harmful, stigmatizing interaction for Amy; yet the nurse’s experience with her brother also became a path forward for better understanding what Amy was facing, and understanding her suffering as suffering, not as punishment.

When I was like, I need to come back to Earth, like they tried to give me methadone. I puked it all up. I couldn’t keep it down. And they were like mad at me for throwing up, the nurses. And the one nurse even came in and she apologized to me because she was really mean to me at first and treated me like a junkie. And her brother was one and she was mad about it and when she came in she had said she was really sorry. She had never seen that before where I couldn’t keep it together at all. And I was crying. I was a mess. She said I didn’t understand it, and I don’t understand why my brother wants these drugs so bad. And she said, you made me understand it a little bit more. And she said, I’m so sorry for being the way I was. She did apologize.

Amy’s story illustrates the power and possibility that lies in a bedside manner informed by relational approach. The nurse’s willingness to apologize, acknowledge her judgement, and recognize the origin of her own biases allowed her to better connect with Amy.

Theme 4: experience dignity in and through use and access of harm reduction services: “I don’t have to do this in hiding”

Jeff’s experience of staff behavior at syringe exchanges stands in contrast to his experience of medical staff behavior during his hospitalization:

Have you ever been to a needle or syringe exchange? “Yes, in [city in West Virginia], West Virginia. […]” Oh, okay. What was, um, that experience like?” It was good. It was like, you know, they ma-, they almost made you feel proud of the fact that, hey, you know, I don’t have to keep this in hiding, you know what I mean? I can actually get help and they’ll actually help me do it the right way, and you know what I mean? And in the end, I- I’m getting, you know, the needles that I need. I’m able to get Narcan to help people. You know what I mean?… It doesn’t encourage people to do drugs, you know what I mean? And, they’re already on the drugs, you know.

I was connected with a place called [name redacted], and they do a lot of that. Hep C, HIV. They’re doing COVID, uh, uh, vaccinations and all of that. They were doing a lot. Like a community outreach center. […] They’re good. They’re real good, and they’re good people. Uh, you know, and they, uh… You need them, they’re there. Very, uh, that’s… It’s that type of organization…Yeah, they’re great, man.”

Multiple participants spoke positively of syringe exchanges as resources for support, clean supplies, and connections to care. Harm reduction organizations provided them with life preserving tools that could be used to help themselves and their community. They also supported participants’ health more broadly by providing vaccination clinics, dovetailing their work with broader public health aims. Services where participants could be open about their drug use without stigmatization made them more likely to access the programs and utilize their resources. Several participants lamented that harm reduction organizations like these were few in number, they were underfunded, and/or getting transportation to the sites posed a challenge that led to underutilization.

Theme 5: peer support as a model for relational harm reduction: “she talked to me like a regular person. It was awesome.”

Several participants reported positive interactions with the peer navigators who worked alongside the Addiction Medicine Consult Service. Jeff described his discussion about suboxone with a peer navigator as emphatically positive but also very “regular”:

[The peer navigator] was just talking to me about Suboxone, how it helped her and, uh, you know, she, it’s okay that, to be on Suboxone, you know what I mean? […] And it just kinda put me at ease, you know what I mean, just knowing that they’re, you know, she’s obviously successful and on it… Was it helpful to have access to someone like her who’s been through it? Oh, absolutely. You know what I mean? Down to earth and stuff, you know what I mean? She talked to me like a regular person and it was like, awesome. Um, does she treat you differently from the rest of your healthcare team? No. No. She treats me just cool, you know. If anything, she treats me, you know what I mean, like she’s known me. But, I guess she has. You know what I mean?

Peers were able to speak from a place of intimate knowledge of the challenges participants were facing and were able to demystify health interventions (in this case, buprenorphine induction). Jeff differentiated the peer’s style as talking to him “like a regular person”, which facilitated therapeutic communication. She spoke from an experience of understanding the lived reality of his situation.

Theme 6: harm reduction as community care: “I won’t let anyone die on me”

Several participants reported positive self-regard for the roles they played in keeping their community safe. Harm reduction was seen as a strategy that gave agency to PWUD to care for and help their community of PWUD: carrying naloxone, for example, was an expression of care for and solidarity with their community.

What made you decide to carry [Narcan]? Uh, just, you know, like I said, I just always cared for people. So if there was a way to have them not get OD’d at my house or wherever we were at, or you know, keep them safe, I would want it around. (Brian)

I carry Narcan with me like out of this world. Um, cause I’ve died so many times I won’t let anyone die on me. Um, I’ll call 9-1-1 and be the one that sits there while the cops come. I don’t give a fuck. Um, like I’ve said, I’ve been I’ve been left for dead several times, um, I’ll hit you with the Narcan. Um, I’ll wait and see if you are going to breathe or not. If you come back or not, I’m calling 9-1-1. Um, I know several ways you know the ice, and I know I know how to, I’ve done the CPR I’ve done, had to do all that. For people. (Mark)

Brian explicitly described carrying naloxone as an expression of caring for the community of PWUD. In a similar vein, Mark reports the isolation of being “left for dead”, and how that experience informs his personal practice of carrying naloxone as an expression of care for others and even a willingness to put himself at risk by calling 911.

In contrast, some participants describe a failure to engage in harm reduction tools as a manifestation of their lack of concern for their community. Strikingly, one participant utilized stigmatizing language about PWUD to rationalize why she and no one she knew carried naloxone:

It’s nothing to me. I don’t really give a shit about it. Most drug addicts wanna die, so it doesn’t really matter. That’s for other people I guess. I’m the only one that really carried Narcan because I was going for nursing, but everybody I know doesn’t even know where it’s at. They don’t care. That isn’t what you’re caring about. You’re on the edge of death every day when you’re using. So, Narcan isn’t really on the top of your to do list. I don’t know why you guys keep asking about that. I guess that’s the only thing you guys can do, but I mean, nobody I know carries Narcan. Nobody gives a shit about it. Not even the drug dealers that are running around, big timers and stuff, there’s no Narcan. Nobody gives a shit about Narcan. (Amy)

This suggests that this participant, and others like her, have internalized negative beliefs around PWUD that serves as a direct barrier or counter to the desire to use harm reduction supplies. For example, for Amy, she does not carry or use naloxone because she believes most PWUD want to die. For her, harm reduction is not a salient tool for caring about the community of PWUD, because she believes that the community does not care about itself or is less deserving of that type of care.

Discussion

Our findings describe the hospital setting as a hostile place for many PWUD. Patients describe being often stigmatized because of their substance use history and describe providers showing disregard or apathy to their co-occurring complex social needs. At the same time, patients describe having had positive and affirming experiences with harm reduction that give them dignity, acknowledge their self-worth, and increase their self-regard.

These results suggest harm reduction practices can serve as a relational approach to counter the frequent dehumanization experienced by patients during acute hospitalization. The set of skills and practices that fall under the harm reduction umbrella often distilled to the phrase “meeting people where they’re at”, which encompasses a nonjudgmental and individualized perspective that focuses on fostering any positive change. Participants described ways that harm reduction may provide a framework for repair. Harm reduction services removed some of the shame associated with substance use as it explicitly acknowledges both individuals using substances who also valued their own health and their community’s health. As a relational praxis, acknowledging intellectual humility and the lagging medical services available to PWUD can offer a way through for both patient and provider. Harm reduction tools and counselling can serve as a means of building trust between patients and providers by increasing staff familiarity with harm reduction. Introducing harm reduction tools into hospital settings may encourage a relational approach amongst providers and assist in dismantling stigmatizing views [16] Others have suggested that harm reduction can provider a longer view of the therapeutic relationship in contrast to the short term view of “fixing” problematic drug use and other harmful behaviors [21]. Relational harm reduction provides room for nonlinear progress, incrementalism, and enduring therapeutic relationships.

Our findings demonstrate that patients experienced barriers to medical care when providers defaulted to a stigmatizing, decontextualized understanding of their drug use: persistent labelling as a “junkie” or “addict” obfuscated other physical complaints and social factors impacting their overall wellbeing. This is supported by other studies that have shown that using negative labels or stereotypes to describe PWUD translates into lower quality of care offered by providers [24, 25, 25, 33]. Reliance on these stereotypes is an example of the shortcomings for the “medical gaze” [34]. The medical gaze refers to the clinician’s interpretive practice of fitting the patient’s presentation into the biomedically comprehensible phenomenon while eliding observations that are not deemed medically relevant, or which do not fit into the developing clinical picture. Study participants repeatedly described how providers tied back physical complaints to their history of substance use disorder. Participants also mentioned the feeling that healthcare providers were suspicious of their motives in seeking care because of their history of drug use. Participants described their drug use as superseding other clinical issues, and attributed the elision of both of their other physical concerns and their individual goals as directly connected to their substance use. Although one participant dismissed the behavior as “nothing personal”, it is clear that stigmatizing judgments, no matter their provenance, have deeply personal implications on provider-patient interaction. This aligns with similar qualitative studies of PWUD whereby PWUD highlighted their reluctance to disclose medical conditions due to anticipated stigma, avoiding seeking care altogether because of anticipated and experienced stigma, and necessary treatment withheld or deprioritized due to stigmatization [13, 24, 35]. Providers’ mistrust of PWUD results in a diabolus ex machina: drug use is the source of all physical and psychosocial maladies. It follows, then, that abstinence enters the clinical picture as the deus ex machina– the only solution that will eradicate all suffering. As our participants show, however, abstinence alone will not provide them stable housing, income, or erase traumatic memories.

The “medical gaze” is not a phenomenon limited to individual practitioners’ impressions, however: clinical impressions of the patient gain a discursive life of their own through medical documentation and research. The electronic medical record notes ongoing problems, behavior flags, and significant events all from the physician’s perspective, which is taken as the final, definitive interpretation of events. Patients describe feeling as though this impression would follow them into every clinical encounter whether they were actively using or not. Brian, for example, voiced his frustration and resignation that wherever he went he would “have to be considered an addict” which would complicate and impede care. The medical literature supports Brian’s impression, and further, there is evidence that Black and Latine patients are more likely to have stigmatizing language in their medical records [26, 33]. As we discussed, Simon et al. have shown that clinicians’ lack of understanding of their patients’ articulated physical needs (e.g., withdrawal management), psychological needs (e.g., not stigmatizing their drug use through explicit and implicit behavior), and lived experiences (e.g., unnecessary room searches and strict hospital rules bringing up memories of incarceration) widens the communication gap, leads to poorer patient experiences, and can result in discharge before medically advised [13].

Multiple participants reported that they were drawn to harm reduction services and peer support because they were treated as a whole person with legitimate health care aims beyond abstinence. Our participants describe harm reduction practices, especially carrying naloxone, as fostering a positive self-worth and solidarity with other people using drugs – both friends and strangers, which aligns with other qualitative studies [3, 23, 36, 37] Qualitative studies evaluating a hospital-based addiction consult service that offered harm reduction education identified that integrating harm reduction acts enabled providers to redress stigma and facilitate therapeutic conversations, and our results affirm their conclusions [16] Other strategies, such as street medicine consults and low barrier outpatient clinics also work to overcome anticipated stigma in the hospital setting [38–40]. However, our participants provided thoughtful reflections on the ways that stigma affects their communication with providers that is worth unpacking to understand how that stigma manifests in the clinical encounter, how holding complexity can be a transformative experience, and how peers offer a model of communication rooted in harm reduction’s ethics. Peers and harm reduction practitioners assist PWUD in fostering positive self-regard in the face of social exclusion and organized abandonment [18, 28, 30]. Peers with lived experience are able to foster a unique sense of trust and security, demystify aspects of treatment such as medications for opioid use disorder (MOUD) through embodied knowledge, and reach members of the community who are more socially isolated and less likely to engage with services.

This study has several limitations. The study was based in a Pittsburgh academic medical center that had peer recovery support and an Addiction Medicine Consult Service. The results present here may not be generalizable to hospital settings in other communities with different types of care. The restrictive legal climate in which harm reduction services operate in Pennsylvania is legible in participants’ responses. Given the regional variation of laws, the drug supply, drug use patterns, and available medical resources, these findings may not be generalizable to other regions of the country. Additionally, the sample of participants was largely white and between the ages of 30–40, with only three Black participants. While the sample may be representative of Pittsburgh’s demographic makeup, further investigation is needed to understand the intersectional experience of Black and Latine PWUD while hospitalized.

To begin addressing negative experiences of PWUD in the hospital care setting, it is necessary to acknowledge where the relational praxis of harm reduction originated and draw a distinction between harm reduction as a set of tools (providing clean needles at syringe exchange programs) and harm reduction as a philosophy of care (e.g. the care and compassion shown by staff at syringe service programs). While harm reduction’s relational philosophy is not a panacea, care experiences that confer dignity and compassion can go a long way towards repairing systemic harm and alienation. Harm reduction not grounded in relational praxis is not harm reduction at all. Where our patients describe positive experiences accessing harm reduction often outside the healthcare setting, acute hospitalization is an opportunity to incorporate some components of harm reduction into the routine care of patients. Even more importantly than offering concrete harm reduction supplies, having providers embrace the relational philosophy of harm reduction has the greatest power to transform hospitalization for PWUD. Additional studies are needed to better understand how medical providers can learn from people with lived experience and harm reduction practitioners to implement relational practices into their bedside manner.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Author contributions

Qualitative interview guide was developed by RW and JDW. Interviews completed by RW. Coding by NW with RW and JDW. Manuscript was written by KL, with the assistance of JDW, RW, RJ, and NW.

Data availability

Due to patient privacy concerns around inadvertent unmasking of identity through qualitative interview data, we will not be able to make our data pool publicly accessible.

Declarations

Competing interests

The authors declare no competing interests.