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. 2025 Oct 16;13:62. doi: 10.1186/s40352-025-00369-x

Implementation of harm reduction strategies in criminal-legal systems: a scoping review of the literature

Kiersten L Johnson 1,✉, Sheila V Patel 1, Jessica Cance 1, Ivette Rodriguez Borja 1, Mia-Cara Christopher 1, Jennifer Counts 1, Monica Desjardins 1, Sarah M Philbrick 1, Leo Beletsky 2, Bradley Ray 1
PMCID: PMC12532404  PMID: 41100011

Abstract

Background

Harm reduction is a public health approach that emphasizes strategies to reduce the negative consequences of drug use. Rising overdose deaths in the United States have prompted integration of harm reduction strategies within criminal-legal systems (CLS), which have historically emphasized deterrence. However, the scope and nature of these strategies across the CLS remain poorly understood.

Methods

We conducted a scoping review, in accordance with PRISMA guidelines, to identify harm reduction strategies targeting illicit drug use that have been implemented within CLS settings in the United States. We searched seven databases for peer-reviewed articles published in the last 10 years. Eligible articles reported on implementation of a harm reduction strategy focused on reaching PWUD in a CLS setting. Using the Sequential Intercept Model as a guiding framework, we mapped strategies to law enforcement, initial detention/court hearings, jails and courts, reentry, and community corrections settings. We used DistillerSR to screen articles and abstract data.

Results

From 455 records, 99 articles met inclusion criteria, representing 51 discrete instances of harm reduction strategy implementation. Implementation was most common in custody settings (e.g., jails and courts) and frequently included initiation of medication for opioid use disorder, naloxone distribution, and CLS referral/diversion. Fewer instances of implementation were documented in early stage or community-based settings. CLS staff were directly involved in delivering over 75% of the harm reduction strategies, and one-third included partnerships with non-CLS government agencies. Nearly one-third of the strategies were implemented as part of research studies.

Conclusions

Harm reduction strategies have increasingly been integrated into CLS, though unevenly and often with a narrow clinical focus. Expanding harm reduction within CLS will require broader definitions, system-level buy-in, and efforts to align practice with public health evidence.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40352-025-00369-x.

Keywords: Harm reduction, Implementation, Illicit drug use, Criminal-legal system, Evidence-based

Background

The U.S. Department of Health and Human Services currently defines harm reduction as a practical and transformative approach that incorporates community-driven public health strategies—including prevention, risk reduction, and health promotion—to empower people who use drugs (PWUD) and their families with the choice to live healthy, self-directed, and purpose-filled lives (Knopf 2021; 2023). This approach centers PWUD, especially those in underserved communities, in these strategies and the practices that flow from them. For example, syringe services programs are rooted in harm reduction and have a strong evidence-base for reducing transmission of infectious diseases among people who inject drugs (Adams 2020; Fernandes et al. 2017; Foreman-Mackey et al. 2022; Jakubowski et al. 2023). Beyond this institutional lens, harm reduction is carried out across grassroots movements emphasizing autonomy, dignity, and social justice (Marlatt 1996). As a broader public health practice, encompassing both clinical and community-led response, harm reduction identifies pragmatic strategies that acknowledge the inevitability of risk-taking behaviors and seek to minimize negative consequences rather than demand abstinence.

In light of the ongoing North American overdose epidemic, which has resulted in more than 1.5 million deaths over the past two decades, harm reduction strategies have emerged as evidence-based overdose prevention practices in the United States (Ciccarone et al. 2019; Monnat 2022; Woolf and Schoomaker 2019). Common strategies in the United States include community-based distribution of naloxone to reverse opioid overdose and paper test strips or other technologies to detect specific drugs (like fentanyl or xylazine). Harm reduction practices are intended to prioritize autonomy and dignity, meet individuals where they are at (even when they are not ready to alter behaviors), and offer noncoercive support, recognizing any positive change as progress (Bhai et al. 2025; Doe-Simkins and Wheeler 2025; Krieger et al. 2018; Moustaqim-Barrette et al. 2021).

Criminal justice practices are often cast as diametrically opposed to harm reduction. For example, criminal-legal systems (CLS) in the United States (e.g., policing, prosecution, courts, and corrections) have historically viewed drugs and drug use as a threat to public safety and rely largely on punishment, deterrence, and surveillance (2012). In spite of this established framing, there have been attempts to integrate harm reduction strategies into CLS in an effort to prevent overdose deaths (Brinkley-Rubinstein et al. 2017, 2018; Rouhani et al. 2024; Inciardi 1996; Johnson et al. 2025; 2024). Thus, just as criminal-legal agencies are enacting policies criminalizing drug use (e.g., paraphernalia laws) (Guilamo-Ramos et al. 2025), further stigmatizing PWUD and increasing risks and barriers to social services and health care, they are also providing them with lifesaving naloxone due to an acceptance that individuals are at risk of continuing or resuming use of illicit drugs (Balter and Howell 2024; Showalter et al. 2021; Wenger et al. 2019; Victor et al. 2024).

Historically, CLS have been significantly constrained in delivering harm reduction services (Carroll et al. 2022; Des Jarlais 2017; Heller et al. 2004), despite serving a population at high risk for overdose. Harm reduction strategies have often originated and been implemented in unsanctioned environments, and it is unclear the extent to which they are available and accessible within CLS. For example, the extant research has documented instances of equipping police with naloxone (Ray et al. 2023; Davis et al. 2014)and providing new inductions of medications for opioid use disorder (MOUD) within jails (Flanagan Balawajder et al. 2025; Hoover et al. 2023), suggesting the need for a broader scoping review (Sucharew 2019).

In this study we aimed to identify harm reduction strategies that have been implemented across CLS in the United States. We used the Sequential Intercept Model (SIM) to extend beyond initial policing encounters and include integration of harm reduction strategies across the spectrum of complex interactions and entanglements with jails, courts, prison, and community supervision (probation/parole) (Munetz and Griffin 2006). Our review was guided by the central research question—what harm reduction strategies to address illicit drug use are being implemented in and across different intercepts of the criminal legal system?—to identify innovation and gaps across the intercepts of these systems.

Methods

The scoping review was conducted using Arksey & O’Malley’s five-step framework: (1) identifying the research question, (2) identifying relevant studies, (3) study selection, (4) charting the data, and (5) collating, summarizing, and reporting the results. Review methodology and reporting is presented in accordance with the PRISMA Scoping Review (PRISMA-ScR) checklist (Tricco et al. 2018). An unregistered protocol exists and can be provided upon request.

Search strategy

The search strategy was developed in consultation with a CLS workgroup funded by the National Institute on Drug Abuse. The research team identified key terms to capture implementation of harm reduction strategies in and across relevant intercepts of the CLS, informed by SAMHSA’s Harm Reduction Framework and the SIM.

The literature search combined the selected key terms using Boolean operators to find relevant English-language, peer-reviewed articles published between January 1, 2015, and December 31, 2024. The search was conducted by an information services specialist on February 5, 2025, within the following databases: PubMed, Web of Science, APA PsycInfo, Criminal Justice Database, EBSCO Discovery Services, Google Scholar, and Perplexity.ai (see Supplemental Appendix A for the full electronic search strategy).

Article selection

Articles were reviewed using the DistillerSR platform (2023). This software automates and manages the process of screening and abstraction, including the preservation of a full audit trail of inclusion/exclusion decisions, and adjudication in cases of disagreement. Of note, the Harm Reduction Framework describes meeting PWUD “where they are, engaging with them and providing support,” as fundamental to harm reduction; consequently, strategies may be “inclusive of abstinence as a chosen pathway but not inclusive of abstinence as a coerced pathway.” (2023) For this review, we defined harm reduction as noncoercive strategies aimed at minimizing the negative consequences of illicit drug use, including overdose education, naloxone distribution or administration, MOUD, non–medication-based treatment, drug checking, wound care, and diversion or referral to supportive services.

The SIM was originally developed to identify key points where individuals with behavioral health disorders can be diverted into services instead of progressing deeper into the criminal-legal system (Munetz and Griffin 2006). Of the six intercepts defined by the SIM, the scoping review focused on: (1) law enforcement and policing; (2) initial detention and court hearings; (3) custody in jails and courts; (4) reentry into the community following incarceration; and (5) community corrections, where there is surveillance by corrections agencies like probation (community supervision instead of further jail/prison) or parole (supervised release after prison). We intentionally exclude intercept 0: community services prior to entry into the system, because it does not inherently demonstrate CLS involvement.

Eligible articles included empirical studies, protocols, program and policy evaluations, model overview/description, or case studies (article type) in English (language) reporting on a harm reduction strategy targeting illicit drug use (intervention) for PWUD as a primary or secondary target (population) in a CLS intercept or by a CLS provider in the United States (setting). We developed screening guides for both title and abstract and full-text review phases, including detailed definitions and examples of all inclusion criteria. For example, following a joint review of the screening guide, team of researchers screened the titles and abstracts of the articles identified in the initial search to determine eligibility for full-text review and identify opportunities for further handsearching, where applicable. All abstracts marked for inclusion advanced to full-text review; any exclusions required confirmation by a second reviewer.

In full-text review, inclusion criteria in the screening guide were expanded to include article scope, such that eligible articles documented discrete implementation, or implementations, of a harm reduction strategy rather than presented prevalence of harm reduction strategies more broadly. Articles that reported on multiple instances of implementation were included as long as the eligible harm reduction strategy was being implemented in tandem across sites (e.g., multiple jails within a state implementing the same intervention) or the article documented implementation of each intervention separately. The screening form also included a field for reviewers to flag instances where articles described conditions or prerequisites for participation in or receipt of the harm reduction intervention. The lead author reviewed all flagged articles to exclude any in which interventions included some form of abstinence (e.g., opiate-free/detox) or coercion (e.g., participation as a condition of release) as a requisite of the intervention. This step was carried out as an additional quality assurance measure to ensure consistency in our operationalization of harm reduction, particularly as it pertains to any potentially coercive practices.

All reviewers piloted full-text review on the same 12 articles and resolved disagreements by discussion before proceeding to the rest of the review. During both title and abstract screening and full-text review, DistillerSR’s AI capabilities were used to continually prioritize articles with a high likelihood of meeting our inclusion criteria. We conducted dual independent review for all full-text articles, with any conflicts resolved by the lead author. For the final 20 percent of articles in full-text review, one of two independent reviewers were substituted with DistillerSR’s AI function for screening. In this process, DistillerSR completed the same full-text screening form as the human reviewer for each article. Any disagreements regarding inclusion or exclusion between the AI function and human reviewer were resolved by the lead author. Specifically, in any cases of disagreement (AI-involved or not), the lead author reviewed the full-text article, checked reviewer inputs, and resolved disagreements on the screening form, including the subsequent determination to include or exclude the article.

Data abstraction & synthesis

The study team extracted data about each included study using DistillerSR. The abstraction form included study identifiers and detailed information about the intervention. This included CLS intercept, or intercepts, that the intervention was implemented within; harm reduction strategy, or strategies, used; a description of the target population, including whether PWUD were a primary or secondary target of the intervention; timeframe of the intervention, including whether ongoing, study-limited, or ended; state and urbanicity of implementation area; and level of key stakeholder involvement, including whether the study team participated in implementation and the degree of involvement by the CLS setting and any non-CLS government agencies. All reviewers piloted data abstraction on the same four articles and resolved disagreements by discussion prior to full, independent extraction using the calibrated form. Each data abstraction was reviewed by the lead author for accuracy.

Prior to synthesis, data were reviewed to identify when multiple publications described the same instance of intervention implementation. These were then consolidated, as appropriate, to reflect a single implementation of a harm reduction strategy.

Results

From 455 records identified, we included 67 articles reflecting 51 discrete instances of implementation (Fig. 1).

Fig. 1.

Fig. 1

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PRISMA Flow Diagram

For nearly three-quarters (n = 38, 74.5%), people with or at risk of opioid use disorder (OUD) were a primary target of the intervention; these interventions frequently included MOUD and CLS referral/diversion strategies, either separately or together (Table 1). In contrast, the interventions that did not directly engage with OUD populations were more likely to provide overdose education or naloxone distribution, most often to law enforcement officers. Interventions were carried out over a wide range of reported states, with notable concentrations in California (n = 6), Massachusetts (n = 6), Maryland (n = 6), and Rhode Island (n = 5). Of the 40 interventions that reported urbanicity of the implementation area, most were in mixed (n = 20), urban (n = 12), or suburban (n = 6) settings; only two interventions were carried out solely in rural areas.

Table 1.

Overview of included studies

Article(s) CLS Intercept Harm reduction strategies Population PWUD Primary or Secondary Timeframe State(s) Urbanicitya Involvement in Implementation
Study Team CLS Actors Non-CLS Agency

Ryan, (2025)

Stopka,  (2024)

Stopka, (2022)

Matsumoto,  (2022)

 3, 4 MOUD, CLS referral/diversion Incarcerated individuals with OUD Primary Ongoing or planned to be ongoing MA Mix No Led Consulted

Martin, (2023)

Kaplowitz, (2023)

Martin, (2022)

Martin, (2019)

Green,  (2018)

 3, 4 MOUD, CLS referral/diversion Incarcerated individuals with OUD Primary Ongoing or planned to be ongoing RI Unspecified No Led None

Mitchell, (2016)

Friedman,  (2015)

 3, 4, 5 CLS referral/diversion Community corrections staff and community health agencies Secondary Has or will end (study-limited) AZ, CA, CT, DE, IL, KY, MD, PA, RI Unspecified Yes Received information None

Blue,  (2019)

Vocci,  (2015)

 3, 4 MOUD, Non-medication treatment of illicit drug use Incarcerated individuals with OUD nearing release Primary Has or will end (study-limited) MD Unspecified Yes None None

Payne, (2024)

Lloyd,  (2023)

Pourtaher,  (2022)

 1 Overdose education, Naloxone distribution or administration Law enforcement Secondary Ongoing or planned to be ongoing NY Mix Yes Involved Collaborated

Gilbert, (2023)

Paul, (2018)

 1 CLS referral/diversion PWUD who would otherwise be charged with low-level criminal offenses or be at risk for future arrest Primary Ongoing or planned to be ongoing NC Mix No Led None

Dahlem, (2023a)

Dahlem, (2023b)

 1 Overdose education Law enforcement officers Secondary Has or will end (study-limited) MI Urban Yes Collaborated None

Dahlem, (2022)

Dahlem, (2017)

 1 Overdose education, Naloxone distribution or administration Law enforcement officers Secondary Has or will end (study-limited) MI Suburban Yes Led None

Molfenter, (2025)

Vechinski, (2023)

Molfenter, (2021)

 3 MOUD, Other; implementation training and coaching for MOUD delivery Jails seeking TA to implement or expand MOUD practices within their site or increase MOUD use post-incarceration Secondary Has or will end (study-limited) 48 providers nationally Unspecified Yes Involved None
Yang, (2019) 4, 5 MOUD, Non-medication treatment of illicit drug use Male offenders (most on probation or parole) who were referred to community based MAT treatment Primary Has or will end (study-limited) Large city in the Midwest Urban Yes None None
Victor, (2024) 3, 4 Naloxone distribution or administration, CLS referral/diversion Jail visitors and those who were recently released from jail; those being released from jail (either those with suspected OUD or by request) Primary Ongoing or planned to be ongoing MI Mix No Led None
Victor, (2023) 3, 4, 5 MOUD, Non-medication treatment of illicit drug use, CLS referral/diversion Individuals in prison with co-occurring OUD and mental health disorders Primary Ongoing or planned to be ongoing Midwestern state Unspecified No Led None
Lee, (2021) 3, 4 MOUD, CLS referral/diversion Adults with OUD incarcerated in jail & nearing release/post-release Primary Ongoing or planned to be ongoing NY Urban No Led Collaborated
Martin, (2025) 3, 5 Naloxone distribution or administration, Drug checking test strips, Wound care supplies Justice-involved individuals being served by the DOC (for those incarcerated, those leaving), as well as the general public Primary Ongoing or planned to be ongoing RI Unspecified No Led None
Tamburello, (2024) 3 MOUD Incarcerated persons with OUD Primary Ongoing or planned to be ongoing NJ Unspecified No Led None
Ray, (2024) 3 Overdose education, Naloxone distribution or administration, CLS referral/diversion PWUD in the court system Primary Ongoing or planned to be ongoing CT, ME, MA Mix No Led None
Pourtaher, (2024) 3 Naloxone distribution or  administration, MOUD, CLS referral/diversion Incarcerated individuals with OUD Primary Ongoing or planned to be ongoing NY Unspecified No Led Involved
Purviance, (2017) 1 Overdose education Law enforcement officers who respond to potential opioid overdoses Secondary Has or will end (other) IN Mix No Received information None
Showalter, (2021) 3 Overdose education, Naloxone distribution or administration People exiting jail Primary Ongoing or planned to be ongoing CA Mix No Led Involved
Wenger, (2019) 3 Overdose education, Naloxone distribution or administration Incarcerated adults within 30 days of their release date Primary Ongoing or planned to be ongoing CA Unspecified No Led Collaborated
Sprunger, (2024) 3, 4 Overdose education, Naloxone distribution or administration, MOUD, CLS referral/diversion Incarcerated individuals, including re-entering from incarceration Primary Unclear OH Mix No Led None
Neeki, (2024) 3, 4 Overdose education, Naloxone distribution or administration, MOUD, CLS referral/diversion Youth with OUD in corrections facilities Primary Ongoing or planned to be ongoing CA Unspecified No Collaborated Collaborated
Lim, (2024) 3, 4 MOUD, CLS referral/diversion Adults with OUD who were incarcerated and released to the community Primary Ongoing or planned to be ongoing NY Urban No Led None
Gimbel, (2024) 3, 4 MOUD, CLS referral/diversion Individuals on MOUD during incarceration, subsequently referred to MOUD clinics in the community upon release Primary Ongoing or planned to be ongoing WA Unspecified Yes Led None
Fix, (2024) 5 Non-medication treatment of illicit drug use Youth with SUD in juvenile probation settings Primary Unclear ID, OR, NV Mix No Unclear None
Belcher, (2024) 3 MOUD Incarcerated individuals with diagnosed OUD Primary Ongoing or planned to be ongoing MD Rural No Collaborated None
Bailey, (2024) 3 MOUD, CLS referral/diversion Court-involved individuals with OUD Primary Ongoing or planned to be ongoing MA Unspecified Yes Led None
Klemperer, (2023) 3 MOUD Incarcerated individuals with OUD Primary Ongoing or planned to be ongoing VT Unspecified No Led
Donnelly, (2023) 1 CLS referral/diversion People with SUD seeking help or in lieu of arrest Primary Ongoing or planned to be ongoing DE Suburban No Collaborated Involved
Perrone, (2022) 1 CLS referral/diversion PWUD or sex workers at risk of arrest Primary Ongoing or planned to be ongoing CA Urban No Led Collaborated
Hunt, (2022) 3 Overdose education Female jail inmates Primary Ongoing or planned to be ongoing TN Rural Yes Led Collaborated
Gooley, (2022) 1 Overdose education Law enforcement officers Secondary Ongoing or planned to be ongoing WI Urban No Collaborated None
Evans, (2022) 3 MOUD Incarcerated individuals with OUD Primary Ongoing or planned to be ongoing MA Mix No Led None
Staton, (2021) s 3, 4 MOUD, CLS referral/diversion Women with OUD nearing release from jail Primary Has or will end (study-limited) KY Unspecified No Collaborated Collaborated
Reed, (2021) 3 Overdose education HIV positive, incarcerated adults Primary Has or will end (study-limited) PA Urban Yes Collaborated None
Matusow, (2021) 2, 3, 5 CLS referral/diversion OUD clients under judge supervision Primary Unclear OH Mix No Involved None
Gallagher, (2021) 2, 3, 4 MOUD Justice-involved adults with diagnosed OUD Primary Ongoing or planned to be ongoing IN Unspecified No Led None
Donelan, (2021) 3, 4 MOUD, Non-medication treatment of illicit drug use, CLS referral/diversion Individuals in jail with OUD Primary Ongoing or planned to be ongoing MA Unspecified Yes Led Involved
Adams, (2021) 1 Overdose education Law enforcement officers Secondary Has or will end (study-limited) IN Unspecified Yes Involved None
Winograd,  (2020) 1 Overdose education Law enforcement officers Secondary Has or will end (study-limited) MO Mix No Received information None
Waddell, (2020) 3, 4, 5 Overdose education, Naloxone distribution or administration, MOUD, Non-medication treatment of illicit drug use, CLS referral/diversion Women nearing release from prison Primary Has or will end (study-limited) OR Urban Yes Involved None
Nath, (2020) 1 Overdose education Law enforcement officers Secondary Has or will end (other) MD Suburban No Led None
Lowder, (2020) 1 Overdose education, Naloxone distribution or administration Police officers Secondary Has or will end (other) IN Urban No Led Collaborated
Banta-Green, (2020) 3 Non-medication treatment of illicit drug use, CLS referral/diversion Incarcerated adults with potential OUD nearing release from jail Primary Ongoing or planned to be ongoing WA Unspecified No Led None
Rouhani, (2019) 1 CLS referral/ People who use drugs at risk for police interaction/incarceration Primary Has or will end (study-limited) MD Urban No Collaborated Collaborated
Krawczyk, (2019) 3 MOUD, CLS referral/diversion Persons with OUD who are exiting jail or who have been recently incarcerated Primary Ongoing or planned to be ongoing MD Urban No Collaborated None
Gicquelais, (2019) 3 CLS referral/diversion Justice involved adults with history of opioid misuse Primary Has or will end (study-limited) MI Suburban No Involved None
Ferguson, (2019) 3, 4 MOUD, CLS referral/diversion Incarcerated individuals with OUD Primary Ongoing or planned to be ongoing RI, CT, MA Unspecified No Led Involved
Wagner, (2016) 1 Overdose education, Naloxone distribution or administration, CLS referral/diversion Law enforcement officers Secondary Has or will end (study-limited) CA Mix Yes Collaborated Collaborated
Saucier, (2016) 1 Overdose education Law enforcement officers Secondary Ongoing or planned to be ongoing RI Unspecified No Involved None
Kitch, (2016) 1 Overdose education, Naloxone distribution or administration Law enforcement officers Secondary Ongoing or planned to be ongoing NC Unspecified No Collaborated Collaborated
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CLS criminal-legal systems, PWUD person who uses drugs, MOUD medication for opioid use disorder

aUrbanicity reflects how each article’s authors described the implementation area (e.g., urban, rural, suburban, mixed). If urbanicity was not explicitly stated in the article, it is coded as “unspecified.”

Nearly one-third of interventions (n = 15, 29.4%) involved direct participation in implementation by study-affiliated staff, with roles such as providing MOUD to incarcerated individuals or leading overdose education and naloxone distribution training for law enforcement officers. Notably, these interventions were more frequently time-limited and part of defined research studies (e.g., randomized controlled trials), whereas those without study team involvement were typically non-empirical descriptions of a preexisting program.

Staff at the CLS settings in which the interventions took place were often deeply involved, with roles that ranged from leading (n = 27) or collaborating with the study team or community partners (n = 11) to plan and implement the intervention. In other instances, the staff at CLS settings were not responsible for initiating the intervention but were involved in its delivery (n = 7). In rare cases, CLS setting involvement was limited to receiving the intervention (n = 3) or simply serving as the site of implementation (n = 2).

Non-CLS government agencies, spanning federal, state, or local entities, were engaged in some capacity in one-third of interventions (n= 17). Among these interventions, the degree of involvement varied. For example, the New York State (NYS) Naloxone Distribution program was developed by a partnership of public health and public safety agencies, including the NYS Department of Health, Division of Criminal Justice Services, Albany Medical Center, the Harm Reduction Coalition, and the Office of Addiction Services and Supports (Pourtaher et al. 2022; Payne et al. 2024). In other instances, representatives from these agencies contributed to developing or delivering training. For instance, the Healthy Outcomes Post Release Education (HOPE) program (Hunt et al. 2022), an overdose education intervention for incarcerated women in a rural area of Tennessee (TN), includes a TN Department of Health training course on the use and administration of intranasal naloxone for opioid overdose. A nurse educator from the Department of Health was also involved in program delivery.

Across CLS intercepts

Harm reduction interventions targeting illicit drug use were implemented across all five CLS intercepts, although the frequency and type of intervention ranged widely (Fig. 2). We mapped the distribution of each documented harm reduction strategy against each SIM intercept; notably, these frequencies exceed the number of interventions because most interventions (n = 42, 82.4%) involved multiple harm reduction strategies (e.g., combining MOUD and CLS referral/diversion).

Fig. 2.

Fig. 2

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Heatmap of Harm Reduction Strategies by CLS Intercept

Intercept 1: law enforcement

Harm reduction strategies implemented in Intercept 1 included overdose education, naloxone distribution or administration, and CLS referral/diversion. Wagner and colleagues described a pilot program in California that included aspects of all three strategies: deputies were trained on overdose recognition, response techniques, and protocols—including a procedure for referring overdose victims to substance use treatment—and were provided with intranasal naloxone kits at the beginning of each shift (Wagner et al. 2016).

Intercept 2: initial detention and court hearings

We only identified two instances of harm reduction strategies (MOUD and CLS referral/diversion) at Intercept 2, each carried out in the context of drug courts. Gallagher and colleagues carried out a focus group analysis of a drug court in Indiana that incorporated MOUD into its programming, offering new inductions of buprenorphine/suboxone, methadone, and naltrexone to justice-involved adults when clinically warranted (Gallagher et al. 2021). The second instance was a pilot test of an intervention designed to increase referrals to MOUD in Ohio drug courts (Kaplowitz et al. 2023).

Intercept 3: custody in jails and courts

Intercept 3 had the highest overall frequency of implemented harm reduction strategies, with MOUD and CLS referral/diversion most commonly reported. However, several interventions in this intercept also incorporated overdose education and naloxone distribution for incarcerated individuals approaching release. For example, Wenger and colleagues reported on the San Francisco County Jail overdose education and naloxone distribution program, which involves showing an overdose education video and providing one-on-one private training for people approaching release from incarceration (Wenger et al. 2019).

Intercept 4: reentry

No interventions in the review were implemented exclusively at Intercept 4; all reentry-focused implementations were part of broader initiatives that typically included Intercept 3. Indeed, nearly one-third of all interventions (n= 16, 31.4%) spanned both Intercepts 3 and 4. For example, multiple articles reported on the Rhode Island Department of Corrections’ comprehensive MOUD program, which includes screening all incarcerated individuals for OUD; continuing or initiating individuals on buprenorphine/suboxone, methadone, or naltrexone while incarcerated; and linking individuals with treatment in the community post-release, typically with the same contracted behavioral health organization that provides MOUD pre-release to ensure continuity of care (Green et al. 2018; Kaplowitz et al. 2023; Martin et al. 2023, 2022, 2019).

Intercept 5: community corrections

Intercept 5 featured fewer interventions than Intercepts 3 and 4 but similarly spanned all harm reduction strategy types. As with Intercept 4 the interventions that took place in community corrections were typically tied to Intercepts 3 or 4. For exampleVictor et al. described a Midwestern reentry program for incarcerated individuals with co-occurring opioid use and mental health disorders, in which participants were assigned a case manager and peer support specialist that facilitated MOUD, dual recovery therapy in the 3 months pre-release through up to 6 months post-release, and referrals to community treatment upon reentry. (Victor et al. 2023)The only identified intervention that was bounded within Intercept 5 was a randomized controlled trial conducted by Fix and colleagues among adolescents with substance use disorder under probation orders in Idaho, Oregon, and Nevada (Fix et al. 2024). The experimental condition comprised substance use contingency management (i.e., a behavioral therapy that uses positive reinforcement for desired behaviors), provided as part of the adolescents’ probation by their juvenile probation officer.

Discussion

This scoping review found that harm reduction strategies are being implemented across nearly every intercept of the CLS in the United States, although frequency and scope of intervention vary substantially. The majority of interventions occurred in Intercept 3 (jails and courts), where strategies most often included MOUD, naloxone distribution, and CLS referral/diversion. Nearly one-third of interventions spanned both Intercepts 3 and 4 (reentry), which reflects efforts to maintain continuity of care during reentry. Intercept 1 (law enforcement) comprised interventions where PWUD were a secondary target of the harm reduction intervention, including overdose education delivered to law enforcement officers. Other common strategies in this setting included naloxone distribution and CLS referral/diversion. In contrast, few interventions were identified as taking place in Intercept 2 (initial detention and court hearings), no intervention was implemented solely within Intercept 4, and just one intercept was bounded within Intercept 5 (community corrections). Most interventions featured multiple harm reduction strategies, and MOUD and CLS referral/diversion were most commonly paired.

The prominence of jail-based interventions in our review may be, in part, a reflection of the definition of harm reduction used in our review. Though medications are generally prescribed as part of standard treatment for OUD, they can be delivered outside of traditional clinical settings as a tool to reduce harm. Screening persons at booking for OUD, initiating medications that reduce painful withdrawal symptoms, and providing naloxone at discharge is reducing harm for PWUD, and thereby falls within the scope of our review. However, it is also important to recognize that access to MOUD in jail is required by federal law, and facilities that do not provide the medications are a violation of disability rights protections under the Americans with Disabilities Act (Macmadu et al. 2020). Not providing these medications not only disrupts essential medical care but can increase risk of withdrawal, relapse, and overdose (Joudrey et al. 2019). As a result, interventions involving MOUD in Intercept 3 may represent both a harm reduction strategy and a legal imperative. Additionally, these interventions largely reflect a clinical focus that prioritizes medication access but does not inherently address risk factors for illicit drug use.

In contrast, there were few examples of harm reduction strategies at Intercept 2 (initial detention and court hearings). One concerned MOUD in a drug court program, which met our criteria and similarly reflects the legal requirements noted above. The other was an example of peer recovery specialists working as navigators in courthouse settings. Despite research on the risk of overdose following incarceration in a prison facility, our review surprisingly found no studies reporting on implementing harm reduction strategies solely within prison settings (Brinkley-Rubinstein et al. 2017; Pizzicato et al. 2018; Binswanger et al. 2011, 2013; Hill et al. 2024; Ray et al. 2023b; Seaman et al. 1998). This gap may reflect reporting limitations or true lack of implementation. Our findings support calls for harm reduction strategies to support PWUD upon reentry (Brinkley-Rubinstein et al. 2017; Curtis et al. 2018).

While our scoping review is descriptive by design, our results depict geographic patterns reflecting where implementation has predominantly occurred and includes clusters in California, Maryland, Massachusetts, and Rhode Island. These areas have long histories of supporting syringe services, naloxone distribution, and substance use treatment, and benefit from collaborations between public agencies and researchers (Bramson et al. 2015). Moreover, state-level efforts (such as Rhode Island Department of Corrections’ comprehensive MOUD screening program) signify larger, incremental shifts within harm reduction expansion. The geographic spread observed in this review prompts questions related to equity of access to harm reduction strategies, particularly in regions with more punitive drug policies or limited public health infrastructure. Similarly, other structural or policy contexts (e.g., funding models, political climate, legal mandates) no doubt play a role in the shifting harm reduction landscape and merit future research.

Limitations

The definition of harm reduction has notoriously been contested, and a debate continues among government agencies – and especially criminal-legal agencies – who seek to integrate harm reduction approaches without undermining mandates to criminalize drugs and drug use. At the same time, debate also occurs among harm reduction practitioners who are concerned that its radical roots—centered on user autonomy and social justice—can be diluted during integration. Our use of the HHS definition of harm reduction as “a practical and transformative approach that incorporates community-driven public health strategies — including prevention, risk reduction, and health promotion — to empower PWUD and their families with the choice to live healthier, self-directed, and purpose-filled lives” is grounded in current policy. However, it may not fully capture the breadth of non-clinical harm reduction interventions being implemented in grassroots settings. Similarly, we excluded grey literature from our scoping review to ensure necessary information for coding and to limit the introduction of bias from nonstandardized reporting or unpublished results that limit replication. The focus on peer-reviewed literature hampers our ability to identify all harm reduction interventions, particularly in grassroots settings. Conversely, some of the MOUD interventions we identified in this may reflect a simple fulfillment of a legal mandate rather than a true effort to reduce harm for PWUD. Knowing the intentionality behind these efforts is beyond our scope, and so we have elected to include some MOUD efforts as harm reduction rather than exclude all of them. Our review period (January 2015 through December 2024) means that we missed some of the initial onset of studies documenting harm reduction strategies within the CLS. For example, naloxone distribution, most often offered to law enforcement officers and intended for use with PWUD intersecting with CLS, was first pioneered prior to the review period and was therefore not as widely reported as we may have expected (Davis et al. 2014; Green et al. 2013). We also limited our review to the United States and harm reduction focused on illicit drug use, not infectious disease. Finally, it was beyond the scope of our current review, and beyond that of this current literature base, to review the efficacy of the implementation of the harm reduction strategies.

Conclusions

Despite the recent decrease in overdose deaths in the United States, there remains an urgent need to reduce harms associated with illicit drug use, particularly for PWUD with CLS involvement. Our scoping review findings demonstrate a clear need for more innovation and research into the implementation of harm reduction strategies across CLS in the United States. Criminal justice practitioners are slowly integrating a public-health approach to drug use, developing and implementing a number of new and innovative practices (e.g., pilot implementations of jail-based MOUD) but much of the current implementation of harm reduction interventions within the CLS is likely driven by legal mandates, or restrictions, in the United States. For example, syringe distribution is an evidence-based harm reduction strategy that has been implemented in multiple prison systems globally (Dolan et al. 2003), but is not prevalent in the United States because syringe distribution is still criminalized.

Perspectives from CLS and harm reduction stakeholders are needed, particularly as it pertains to harm reduction practices that can be integrated into CLS outside of legal mandates or systematic changes. Additionally, the first funding for harm reduction services research in the United States only occurred 3 years prior to this review period. We anticipate that harm reduction strategies are being implemented in more CLS settings, warranting an update of this scoping review in the future. Indeed, this scoping review lays the groundwork for further research into implementation, including evaluation of barriers and facilitators using a theoretical framework (e.g., the Consolidated Framework for Implementation Research) to help guide expansion of harm reduction strategies in the CLS.

Supplementary Information

Additional file 1. (23.4KB, docx)

Acknowledgements

The authors gratefully acknowledge the members of the NIDA-funded criminal legal services workgroup for their guidance and feedback on the development of this review.

Authors’ contributions

K.J. and B.R. wrote the main manuscript text and K.J., S.V.P., J.C., and B.R. led development of the screening and data abstraction tools. I.R.B. oversaw DistillerSR programming and prepared Fig. 1. I.R.B., M.C., J.C., M.D., and S.M.P. conducted screening and data abstraction. K.J. reviewed all abstractions for accuracy and led data synthesis, including preparing Table 1 and Fig. 2. All authors reviewed the manuscript.

Funding

This study was supported by the National Institutes of Health (NIH) Helping to End Addiction Long-Term (HEAL) Initiative®, through a coordinating center grant (U24DA057611-03S1). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Data availability

The authors declare no competing interests.

Declarations

Ethics approval and consent to participate

Not applicable.

Competing interests

The authors declare no competing interests.

Footnotes

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Change history

11/13/2025

The original version of this article was revised: the grant number relating to National Institutes of Health (NIH) Helping to End Addiction Long-Term (HEAL) Initiative® in the Funding section was incorrectly given as U24DA057632 and should have been U24DA057611-03S1.

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Supplementary Materials

Additional file 1. (23.4KB, docx)

Data Availability Statement

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