Meeting people where they are, whenever they are here: the implementation of harm reduction programs in two U.S. emergency departments

Abstract

Background

Complications related to drug use, including overdose, withdrawal, and infection, represent a significant proportion of emergency department (ED) visits in the United States (US). Within addiction medicine, harm reduction focuses on strategies that minimize negative outcomes associated with continued drug use through interventions such as preexposure prophylaxis, naloxone distribution, and safer use supplies. Integration of harm reduction measures into acute care settings may enhance patient trust and engagement in medical care, and may reduce the risk of overdose, viral transmission and serious bacterial infections for patients who use drugs. While there has been an increased interest in incorporation of harm reduction into acute care, data on successful implementation is limited.

Main body

We describe the successful implementation of two unique programs designed to decrease risk and stigma for patients who use drugs and access acute care services in two tertiary care ED’s in Massachusetts, US. This article details two different implementation strategies utilized to integrate harm reduction into bedside emergency care. We utilize the CFIR framework to identify barriers and facilitators to successful programmatic implementation, and report on reception by ED teams through post-implementation interviews and program utilization data.

Conclusion

Integration of harm reduction into acute care can be safe and feasible. Creating partnerships with community organizations, leadership from an ED champion, and pairing implementation with education for ED staff are key for programmatic success.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12245-026-01380-1.

Background

People who use drugs (PWUD) account for nearly 10% of emergency department (ED) visits in the United States (US) [1]. ED visits for substance use frequently involve high resource utilization [2, 3]. One-year mortality following ED visit for non-fatal overdose is 9%, with the highest incidence 24 h following discharge, highlighting the critical role of ED clinicians initiating evidence-based care [4–6]. Despite increasing visits, 25–30% of PWUD leave the ED prior to medical care completion, often due to stigma and undertreated withdrawal symptoms [1, 7–10].

Addiction-related ED care has focused on initiating opioid agonist therapy (OAT) such as methadone and buprenorphine, which reduce the risk of opioid overdose death [11, 12]. Yet, less than 25% of eligible patients are administered or prescribed OAT in US EDs [13, 14]. Many EDs offer little support for patients who decline medications or plan to continue using drugs, despite evidence-based recommendations to increase the health and safety of PWUD [15].

Harm reduction (HR) is a set of preventative measures that limit infectious disease, decrease bacterial infections, and decrease risk of fatal overdose (Table 1) [16–22]. These include naloxone, not using drugs alone, taking medications to prevent infections (pre-exposure prophylaxis), distributing injection equipment to discourage sharing or reuse, and OAT itself (Table 2) [23–26]. The most widely studied example of ED HR, naloxone distribution following opioid overdose, decreases opioid-related ED visits without increasing risky substance use [24, 25, 27].

Table 1.

Definitions of harm reduction from medical (WHO) and community (NHRC) experts

What is Harm Reduction?
World Health Organization (WHO)	“Harm reduction – including needle/syringe programmes, opioid substitution therapy and community distribution of naloxone – is an evidence-based approach to HIV and HCV prevention, treatment and care for people who inject drugs.”
National Harm Reduction Coalition (NHRC)	“Harm reduction is a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use. Harm Reduction is also a movement for social justice built on a belief in, and respect for, the rights of people who use drugs.”

Table 2.

List of patient, provider, departmental, and community level harm reduction interventions

Harm Reduction Strategies
Level of Intervention	Harm Reduction Strategy
Patient	● Test-shot (start with small amount of the substance to test potency before taking the full amount) ● Not using alone, taking turns using, utilizing overdose prevention hotline (Safe Spot: 800-972-0590) ● Using where you might be easily found when using alone ● Utilizing sterile equipment each time ● Injecting bevel up ● Not licking needle tips, cleaning injection area with alcohol wipes, hand hygiene ● Drawing up with one needle and backfilling (sharing solution by transferring from one new syringe to others) ● Switching to a lower risk route of use (e.g. smoking/sniffing instead of injecting) ● Using fentanyl test strips (Fig. 1) ● Carry naloxone, have it out
Provider	Medical Interventions ● STI testing (HIV, HCV, HBV, Syphilis, gonorrhea, chlamydia, trichomonas) ● PrEP/nPEP ● Take-home naloxone ● Low-dose naloxone Counseling/Language ● Counseling on safer use strategies (see above) ● Person centered language ● Familiarity with colloquial terms for substances and supplies
Emergency Department	● Humane overdose response (limiting naloxone use for RR ≤ 8, push-dose naloxone) ● Dispensing harm reduction supplies ● EMS education (indications for administering naloxone and leave behind naloxone)
Community	● Sedation Monitoring Sites & Overdose Prevention Centers ● Overdose prevention hot lines (i.e. Safe Spot: 800-972-0590) ● Reverse motion detectors in bathrooms ● Syringe Service Programs ● Increased Naloxone Access (Vending machines, kept with AED machines)

International work has demonstrated benefits of incorporating HR into clinical care [28, 29]. However, HR services in the US have been largely siloed from the medical system. Community-based HR programs have significant gaps in access, geographic disparities, and are misaligned with the 24/7 nature of emergency care [17, 30–32]. Where hospital-based HR services exist, they are often consult-based or located in the outpatient setting, and limited to daytime hours [33–35]. A recent scoping review of HR in acute care settings found increased interest in ED HR, but limited data on successful implementation [36].

We describe the implementation processes and outcomes from two geographically disparate EDs located in the US who independently implemented HR programs. We use the Consolidated Framework for Implementation Research (CFIR) to contextualize barriers and facilitators that influenced implementation using quantitative and qualitative outcomes.

Methods

Setting

Site A

Boston Medical Center is a 514-bed academic medical center and safety-net hospital located in Boston, MA, US with annual ED volume of 130,000. In 2012, 17% of patients admitted had a substance use disorder, and this number has increased over the last decade [37, 38]. The ED has offered buprenorphine and methadone for the treatment of opioid withdrawal and opioid use disorder (OUD) since 2018. In 2019, Boston Medical Center’s low-barrier addiction bridge clinic added HR supplies to their care offerings following discussion with hospital legal team. Despite numerous addiction-focused resources, new HIV infections among PWUD have risen locally [39].

Site B

Baystate Medical Center is a 754-bed academic medical center and teaching site of the UMass Chan Medical School located in Springfield, MA, US, with annual ED volume of 122,000. The ED has offered buprenorphine since 2018 and methadone since 2021 for the treatment of opioid withdrawal and OUD. In 2023, the age adjusted opioid death rate in Springfield was 75 deaths/100,000 people, twice the state’s average, with surrounding rural communities disproportionately affected [40].

Harm reduction strategy bundle

Both Site A and Site B independently implemented similar programs to incorporate harm reduction into the emergency care of PWUD. The programs included take-home naloxone, fentanyl test strips (Fig. 1), and harm reduction equipment (Table 3). Programs also paired supply distribution with an educational curriculum including instructions on how to counsel patients on safer use, encouraged STI screening, and initiation of HIV pre- and post-exposure prophylaxis. The HR programs included OAT as a HR intervention, as OAT offers protection from overdose and infectious disease even in those patients who continue to use drugs [26].

Fig. 1.

Example of a negative fentanyl test strip. Fentanyl Test Strips

Table 3.

Examples of harm reduction supplies that can be distributed from the emergency department

Example Harm Reduction Item Supply List
Route of Use	Supplies
Any	Naloxone
Injection	● Syringes ● Cookers ● Cottons (sterile dental cottons or cotton balls, filters debris in injected solution) ● Tourniquets ● Sterile water ● Alcohol wipes ● Bleach (for patients who reuse syringes/needles) ● Vitamin C ● Sharps Container
Intranasal	● Plastic razor ● Plastic straw ● Saline bullet/nasal spray
Smoking	● Pipes  ○ Hammer (fentanyl)  ○ Straight (cocaine)  ○ Bubble (methamphetamine) ● Rubber mouthpiece ● Lip balm ● Chore/filters ● Push-stick
Miscellaneous	● Fentanyl/xylazine test strips ● Condoms/diaphragms/personal lubricant ● Safer use instructional pamphlets ● Hand sanitizer ● Snacks

Study design

We performed a retrospective mixed-methods evaluation of implementation processes, barriers, facilitators, and outcomes. Data was collected via the electronic health record, hospital safety-event reporting systems, emails and internal documents, supply orders, post-implementation surveys (Appendix B), and implementation team recollections. Survey data were collected and managed using REDCap (Research Electronic Data Capture) hosted at Boston University, CTSI 1UL1TR001430 [41]. We applied CFIR 2022 as a deductive framework to compare the two programs, evaluate common barriers and facilitators, and analyze the success of implementation (Fig. 2).

Fig. 2.

CFIR Framework as applied to the harm reduction program at Site A & Site B. Image adapted from Damschroder, L. J., Reardon, C. M., Widerquist, M. A. O., et al. (2022) [64]

Results

Harm reduction program implementation and timeline

Site A

Following discussions with hospital leadership regarding expanding HR, an ED physician who was an addiction medicine fellow (funded by HRSA T25HP37593 “Addiction Medicine Fellowship”) partnered with Project TRUST (HR organization), a low-barrier HIV prevention/treatment drop-in center staffed by people with lived experience. The ED physician served as clinical champion and led a HR implementation team that additionally included ED Quality Improvement and Clinical Operations, pharmacy, nursing and physician addiction leaders, emergency medicine faculty, and the hospital public health team.

Initial attempts to introduce HR into the ED revealed ethical and legal concerns (Table 4). The HR implementation team pivoted, pursuing a formal policy to foster open dialogue and standardize practice. During physician and nursing administrative meetings, the ED champion and addiction bridge clinic nurse manager presented workflows and ethical & legal considerations regarding ED HR supplies and counseling. They incorporated feedback into the HR policy. Simultaneously, the public health team secured grant funding for HR supplies from the Massachusetts Department of Public Health (Award #: INTF4944MM3181926007). Supplies cost on average $15 per patient.

Table 4.

Frequently asked questions and answers. Commonly asked questions and answers that arise when discussing implementing harm reduction programs in the US

Administration
Is this legal?	Distributing harm reduction supplies is not illegal in most states in the USA. If you are unsure about your own state, check out the Network for Public Health Law. While in a few states it is explicitly illegal to distribute syringes and pipes, in no states is it illegal to distribute wound care supplies or naloxone. https://www.networkforphl.org/
How are we going to pay for this?	Many harm reduction supplies cannot be billed to insurance. Supplies can be purchased through private, local, state, and federal grants or through partnerships with community-based harm reduction organizations. If no other funding can be obtained, some community-based harm reduction organizations may be willing to donate supplies.
Other Members of the Care Team
Is this enabling drug use?	No, harm reduction’s goal is to meet people where they are, treat them with dignity, and provide safer options to minimize the risk of overdose and transmission of disease while undertaking an inherently unsafe activity. Many patients are going to continue to use drugs whether we give them the tools to use more safely or not. Giving our patients a chance to be safer, gives them a greater chance of long-term health and recovery as harm reduction services increase treatment entry.
This does not feel like my responsibility, why am I supposed to do this?	If our job as emergency physicians is to provide lifesaving care, and drug overdoses continue to be a problem in our communities, then preventing death from drug overdose is our job. Harm reduction is an important element of providing evidence-based care for our patients who use drugs. American College of Emergency Physicians has highlighted the importance of incorporating harm reduction into discharge planning for patients at risk for overdose. Like reminding bikers to wear helmets and motor vehicle passengers to wear seatbelts, we can remind our patients who use drugs of strategies they can use to keep themselves safer.
Why are you offering pipes?	Many people would rather smoke than inject drugs, but pipes break and can be more difficult to access. Providing pipes helps reduce the risk of injection-related infections by preventing injection events. Increased access to pipes decreases sharing supplies and direct transmission of diseases like Hepatitis C which can live on a glass surface for 6 weeks.
My patients often tell me they do not plan to use drugs again. Why should I offer this?	Many patients have been taught by the healthcare system that they are treated better if they tell doctors they never plan to use drugs again. While we want to fully support our patients who plan to never use again, we also want patients to be able to access supplies if they are hesitant to admit their plans for ongoing drug use. In these cases, using destigmatizing language, such as asking “if anyone they know” might find these supplies helpful, may decrease the barrier to acceptance. Furthermore, many patients initiating opioid agonist therapy have a period of ongoing drug use while their medication is titrated to a therapeutic level.
My patient only uses stimulants, so they don’t need naloxone, right?	Incorrect! There have been many documented instances of fentanyl entering the stimulant supply in the USA. Fatalities from fentanyl overdose have been increasing in patients intending to only use stimulants. All patients who use drugs should be counseled to carry and discharged with intranasal naloxone.

The final HR policy went live in Month 6 and included an EMR order linked to take-home naloxone (Appendix A). The policy stipulated supply distribution at time of discharge to alleviate safety concerns. Designed for the ED, the policy was structured to be adaptable for future integration into other care areas.

The HR initiative launched 8 months after conception with the implementation team displaying information at nursing shift change. They also presented at faculty, resident, and advanced practice practitioner (APP) meetings. Supplies were stored in a locked medical equipment room with 24/7 badge-access for ED staff. Informational guides in English and Spanish described best practices and how to properly use fentanyl test strips. The HR organization and public health team managed inventory. The ED champion sent biweekly “Good News” emails to highlight success stories, reinforce best practices, and link to the policy.

An informal assessment revealed the need for HR education for ED staff. The implementation team developed a HR curriculum, led by the ED champion and staff with lived experience from the HR organization. The ED champion obtained funding from a Society for Academic Medicine Foundation/National Institute on Drug Abuse Mentor-Facilitated Training Award (#RE2022-0000000296) to support curricular development, and honorariums for HR staff. The curriculum was presented to ED attendings, residents and APPs in Months 9–16.

Following completion of fellowship training in Month 13, the ED champion received grant funding from Massachusetts Department of Public Health Bureau of Infectious Disease and Laboratory Sciences, Office of HIV/AIDS (INTF4944MM3181926007) to sustain the project.

Nurses were excluded from the original policy due to concerns around scope of practice. HR nurse champions requested comment from the state nursing board. Fourteen months after policy implementation, the Board of Nursing provided an advisory ruling affirming that provision of HR supplies and services are within nursing scope of practice [42]. The policy was updated to include nurses the following year.

Site B

In response to increased addiction-related complications, Site B partnered with a local syringe service provider, Tapestry. An ED physician served as clinical champion and worked directly with the HR organization to identify supplies and create educational brochures.

The clinical champion presented to hospital legal and compliance, who approved the distribution of HR supplies. This program was implemented in phases based on provider comfort, policy change, and insurance coverage. The program initially distributed kits composed of alcohol wipes, cottons/cookers, and informational brochures (English, Spanish.) Kits were stored in a locked medication room and distributed by ED staff (physicians, APPs, nurses and technicians). Distribution was accompanied by hands-on HR training. Kits were funded by the ED and through donations and cost $8 each.

Syringes and small sharps containers were added to the kits during the second phase of the program in Year 2, after increased comfort with HR and following further discussion with hospital compliance. Take-home naloxone was added the same year following updates to state legislation allowing direct distribution of naloxone to ED patients with reimbursement from state insurance.

The HR program expanded in Year 4 to include smoking, sniffing and safer sex supplies after obtaining funding from RIZE Foundation [43]. In partnership with the Massachusetts Community Naloxone Program take-home naloxone was placed in the ED waiting room and staff lounges. This same year HR supplies were moved to a centrally located HR cart with passcode access. Research assistants assumed responsibility for stocking.

Following feedback from PWUD, HR informational brochures were updated to improve engagement. A narwhal character, created in conjunction with an advisory group of PWUD who felt the irreverence was destigmatizing, became a mascot for the program. It was utilized on educational materials to encourage discussion, decrease stigma, and remind people to dispense naloxone (Fig. 3).

Fig. 3.

Narwhal Ambassador for Baystate Medical Center. Example of “Narwhal Ambassador” created by researchers at Site B to decrease stigma around intranasal naloxone

Outcomes

Site A

In the program’s first 4 months, orders for HR equipment surged. (Fig. 4). Safer smoking, sniffing kits, and condoms were the most frequently restocked items. HR orders stabilized, averaging 10 kits/month. Take-home naloxone was ordered more frequently.

Fig. 4.

Harm reduction supply distribution over time at Site A and Site B. Site A: Harm reduction supply distribution went live on May 29, 2023, and so we report on take-home naloxone and HR supplies as of that date. Site B: Structured monthly data collection of harm reduction materials started in Year 4 (May 2024) with the introduction of Sniff / Smoke kits. Prior counts were based on quarterly supply ordering forms and are not presented here

The hospital safety incident reporting system was queried from May 2023-Dec 2024, and zero patient safety-incidents were reported involving HR kits.

ED physicians reported adopting a HR approach led to increased trust and engagement. On a post-implementation survey, one attending stated: “…Overall, my interactions with patients on this have been extremely positive, with patients expressing their gratitude and appreciation for available supplies, particularly overnight.” One resident noted: “I think I deliver more equitable care to patients who use substances, and it makes me feel fulfilled…to provide primary prevention tactics to high-risk populations.”

Site B

For the first 3 years of the program, 10–20 h kits were distributed monthly. In the six months following the introduction of the cart in Year 4, 500 individual supplies were distributed to over 100 patients (Fig. 4). In Year 4 & 5, 388 take-home naloxone boxes were dispensed to ED patients, and a total of 1,083 boxes of Naloxone were distributed anonymously via access points in staff lounges and the ED waiting room. No episodes of in-hospital overdose or harm to patients or staff have been reported.

Identified CFIR domains

Table 5 includes a summary of implementation strategies and CFIR domains identified, comparing both sites.

Table 5.

Center For Implementation Research (CFIR) Domains Common to Both Sites

Implementation Strategy	Barrier/Facilitator (CFIR Domain)	Site A	Site B
Access new funding	Cost of supplies & faculty/ administrative time (Innovation: Cost; Inner Setting: Available Resources & Funding)	Multiple pathways funded supplies: ● Hospital Public Health Team obtained grant from MA Department of Public Health ● ED pharmacist developed protocol to bill insurance for take-home naloxone Implementation led by an ED physician completing HRSA T25 funded addiction fellowship. A SAEMF/NIDA mentor-facilitated training grant funded development of the HR educational curriculum development. Following fellowship, ED champion funded by grant from MDPH.	Multiple pathways funded supplies: ● Community HR organization provided supplies and were reimbursed via grant funding (RIZE Foundation) ● Pharmacy set up pathway for billing for take-home naloxone so patients no longer needed a prescription or trip to the pharmacy. ● MA Department of Public Health funded take-home naloxone without order (set up around ED for staff, patients, and visitors). Protected time: Implementation led by ED attendings/fellows with grant finding via RIZE Foundation.
Assess for readiness & identify barriers & facilitators	Stigma/Knowledge (Innovation: Design; Outer setting: local attitudes, policies & laws; Inner setting: Culture, Tension for Change, Mission alignment)	Informal interviews with key informants (e.g., patients, harm reductionists, nurses, physicians, operations leadership) identified stigma and knowledge gaps as a barrier to HR innovation. ● Lack of formal policy stalled progress. ● Paused implementation to discuss innovation at faculty and nursing administrative meetings. ● Clarified with legal team legality of HR supply distribution from hospital setting, building on prior approval given to bridge-clinic.	Variable knowledge and attitudes towards different harm reduction supplies lead to staged implementation plan. Initial implementation focused on generally accepted practices (wound care, safe injecting) and moved towards more controversial practices, providing education with changes (provision of needles, then provision of supplies for safe use of stimulants).
Build a coalition	Partnership with local harm reduction organizations; ED operations support for new ED programs, Addiction Medicine teams (Outer setting: local conditions, partnerships & connections; Inner setting: work infrastructure, culture, learning- centeredness)	Implementation team: ● ED physician & addiction specialist ● Harm reduction staff ● Addiction bridge clinic nurse manager ● Addiction medicine faculty ● Lead ED pharmacist ● ED operations ● ED education faculty	Implementation team: ● ED physician & addiction specialist ● Community harm reduction staff and PWLE ● ED physician & population health specialist ● Health Equity fellow
Capture and share local knowledge	Literature review identified limited local examples and published best practices for implementing ED-based harm reduction programs. (Innovation: design; Outer setting; Inner setting: structural characteristics, work infrastructure)	Met with regional and national teams experienced with a spectrum of hospital based HR programs ● Discussion with implementation teams from national organizations who implemented addiction consult based harm reduction programs. ● Discussion with addiction bridge clinic with outpatient HR intervention.	Held ongoing meetings with local harm reduction providers regarding content of supplies, education, and follow-up resources.
Change physical structure and equipment	Limited physical space in the ED, secure location for supplies (contain sharps) (Inner setting: physical infrastructure, available resources, materials & equipment)	ED campion with ED operations identified under-utilized space in locked medical supply closet with ID badge access to ED staff	HR kits initially stored in badge-access, ED medication rooms. Desire to increase visibility as more supplies available: ● Created a HR Cart (visible colorful and centrally located) ● Included drug use supplies such as granola bars. ● Key to cart located in a badge-accessed medication room.
Conduct local consensus discussions	New HIV infections locally, increased policing, local public health support. (Outer setting: Policies & laws, critical incidents; Inner setting: relational connections, communications, human equality-centeredness)	Followed pattern of rising local HIV infections ● Local HR organizations closed at 5PM, PWUD continue to use after 5PM ● Practice of disposing of drug use supplies in ED undermined trust and compromised health ● Desire for improved patient-medical team interactions ● Discussed with local HR organization willingness of clients to accept supplies & counseling from ED providers ● Discussed public health acceptability of ED HR supply distribution.	Presented and discussed HR implementation plan at residency conference and faculty meetings to build engagement
Distribute educational materials	Limited knowledge regarding harm reduction practices and associated health benefits, Stigma. (Inner setting: access to knowledge & information, relative priority)	Multiple pathways to enhance knowledge of HR and new policy: ● Emailed formal guidance to ED providers and nursing. ● Tabled at RN shift change with copies of HR policy and literature on the evidence base. ● Followed with weekly “Good News” de-identified patient stories related to ED harm reduction innovation. ● Developed HR educational curriculum for medical providers with HR organization	Developed educational materials with community HR organization. Delivered via: ● Residency and faculty conferences ● Pre-shift nursing huddles. ● Short lectures (25 min) and mini lectures (2 min) were available online and publicized via QR codes around the ED.
Identify & prepare champions	Recognition of existing practice undermines patient-provider trust. Need to overcome stigma, scope-of-practice, and time-constraint concerns. (Individuals: implementation leads; Inner setting: relational connections, relative priority)	ED physician in addiction medicine fellowship with knowledge of ED culture and norms championed intervention and led implementation team	ED attending and addiction specialist with knowledge of ED culture and norms championed intervention and implementation team. Subsequent iterations led by ED population health attending and research fellow
Mandate change	Stigma/resistance to change (Inner setting: tension for change, relative priority)	Strategy not pursued	Strategy not pursued
Purposely reexamine the implementation	Lack of uptake of intervention (Innovation: adaptability; Inner setting: relative priority, incentive systems; Individuals: motivation)	● Creation of harm reduction curriculum for providers to address identified knowledge gaps. ● Nursing queried Massachusetts Board of Nursing for comment regarding the role of harm reduction in nursing practice. Nursing Board determined it is within nursing scope of practice. ● Policy amended to include nursing.	Staged implementation plan to increase acceptability as comfort with HR concept grew: ● Phase 1: wound care supplies, sterile cottons/cooker ● Phase 2: syringes/ needles & naloxone ● Phase 3: safer smoking and sniffing materials, fentanyl/xylazine test strips, updated educational brochures and community resources
Remind clinicians	Unenthusiastic provider attitudes, competing priorities, attrition (Individual: motivation; Inner setting: incentive system, physical infrastructure; Outer setting: performance- measurement pressure)	● Weekly “Good News” email updates to all nursing and medical providers with de-identified patient positive outcome after receiving treatment for substance use in the ED. ● ED champion provided periodic reminders during ED “teaching rounds” and resident conference lectures	● Decorated centrally-located HR Cart ● Distributed naloxone narwhal stickers ● Posted related narwhal-themed signage around the ED

Outer setting

Policies & laws

Many supplies in Table 3 are not considered drug paraphernalia (e.g. wound care and skin cleansing supplies) and permissible to distribute in any state. (Table 2). Varying state laws and support from local health departments regarding other HR supplies remain a challenge. Evolving definitions and priorities by the federal government have decreased HR resources [44]. We found success with engaging hospital leadership and counsel early. The Harm Reduction Legal Project offers a tool that helps clarify state HR regulations [45].

Partnerships & connections

Where available, local HR organizations are strong collaborators and both sites found community members enthusiastic about partnering with EDs. Departments of Public Health may have resources, materials, or grants [46].

Financing

Cost remains a challenge. While supplies may be donated or obtained at relatively low cost (<$3,000 USD/year for both our sites), the personnel-time for management of supplies and staff education is higher. Provision of in-hand naloxone at discharge is covered by some insurers [47].

Inner setting

Culture

Stigma towards PWUD, legal ambiguity, and uncertainty regarding sustainability may limit initial support [48].

Compatibility

Competing priorities may cause staff to resist a program that is adding yet another task [49, 50].

Individuals domain

Access to knowledge and information

Knowledge gaps may cause undervaluing of HR and resistance to incorporation.

Motivation

Previous experiences with inappropriate or aggressive patient behavior and moral injury, may influence attitudes about HR [51, 52].

Need

Need for HR is high, but patient willingness to discuss drug use, influenced by experiences with discrimination, hinders care. In meetings at Site B, PWUD reported they learned not to disclose sensitive information that could compromise their care:

Sometimes I tell them. ‘I’m never going to use drugs again!’ Because that’s what they want to hear. [53].

Discussion

Both sites achieved sustained integration of HR services into ED practice. Site A’s approach to pursuing formal policy change prior to program launch allowed for more rapid implementation of all HR measures, provided clarity for ED staff on workflows, and reduced uncertainty and concerns among providers [54]. While it created space to voice concerns and to dismantle stigmatizing beliefs, it also led to initial resistance to policy incorporation. Site B’s staged implementation took longer to fully implement, but allowed for progressive expansion once staff demonstrated comfort, allowing smoother adaptation into bedside care.

CFIR analysis identified three influential determinants: leadership by an ED champion, partnership with local HR agencies, and combining implementation with education. Leadership by a ED physician-HR champion increased willingness of staff to engage in a new topic and allowed for key insights privy to be incorporated into program implementation [55, 56]. Including people with lived experience as part of the implementation team strengthened patient engagement by building trust and improving effectiveness through credible, empathetic, real-world insight [57–59].

Feedback from ED teams indicated positive associations with HR. ED providers reported a greater ability to engage PWUD, aligning with outcomes from other hospital based HR programs [60]. Importantly, no safety incidents were reported related to the HR supplies. These results may underscore the feasibility of safely implementing HR strategies within EDs.

Both programs encountered shared challenges. Perceptions of legal, financial, and logistical barriers were significant. High demands of providing ED care posed a challenge to the integration of HR practices [54].

The public health implications of HR programs in EDs are profound, particularly in addressing disparities in HR access in rural and underserved areas. While overdose rates have declined in the US, significant disparities persist among people of color [61]. EDs can play a role in addressing the impact of substance use on these communities by offering a variety of HR options including those for patients that primarily use stimulants [62].

Limitations

We did not track the proportion of PWUD seen in our EDs who are offered supplies. We cannot report on whether these supplies decreased morbidity and mortality from substance use, nor whether they were being deployed equitably. Lastly, we are concerned about the future of similar programs in the US, due to the increasing financial constraints upon hospital systems and current federal restrictions limiting education about HR [63].

Conclusions

Integrated ED HR programs that offer medications and provide essential resources are feasible and cost-effective. Clinicians recognized the positive impact incorporating HR had on improving physician-patient relationships. These findings support incorporating HR as a routine component of ED care for PWUD.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

PWUD

People who use drugs

ED

Emergency department

US

United States

OAT

Opioid agonist treatment

HR

Harm reduction

Author contributions

KW, ZW, JT, SJ, GRM, NS, WS, ES conceived of the project, designed the implementation strategy. SJ, GRM, NS, WS, ES obtained funding. KW, JT, ZW, JE, NS, ES, WS, MP, NF supervised the implementation of the program. KW, WS, SJ, ES, NS, NF managed data collection. JS, SJ, LW, MP, KW, NS, ES designed education materials. KW, SV, NS, WS, ES drafted the manuscript, all authors contributed substantially to its revision. KW takes responsibility for the manuscript as a whole.

Funding

KW: Dr. Weisenthal received funding for her addiction medicine fellowship from HRSA T25HP37593 “Addiction Medicine Fellowship”), and support from the Society for Academic Medicine Foundation/National Institute on Drug Abuse Mentor-Facilitated Training Award (#RE2022-0000000296) for the development of the harm reduction curriculum, and from the Massachusetts Department of Public Health Bureau of Infectious Disease and Laboratory Sciences, Office of HIV/AIDS (INTF4944MM3181926007) to support this work and funding from the MA Department of Public Health Bureau of Substance Addiction Services to support hospital-based substance use disorder services (INTF2344MM3242332011, PI: Taylor). NS: Dr. Strokes receives funding from the RIZE Foundation for hospital-based harm reduction. ZW: Dr. Weinstein receives grant funding from NIH and NIDA. GRM: Dr. Ruiz-Mercado receives funding from Gilead Sciences for the Frontlines of Communities in the United States (FOCUS) grant that supports HIV, hepatitis C virus, and hepatitis B virus screening and linkage to care. Gilead Sciences had no role in the development of this paper. JT: Dr. Taylor receives funding from the MA Department of Public Health Bureau of Substance Addiction Services to support hospital-based substance use disorder services (INTF2344MM3242332011, PI: Taylor and Massachusetts Department of Public Health Bureau of Infectious Disease and Laboratory Sciences, Office of HIV/AIDS (INTF4944MM3181926007). WS: Dr. Soares receives funding from SAMHSA for ED ALT (5H79TI086283). ES: Dr. Schoenfeld receives funding from the RIZE Foundation for hospital-based harm reduction.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

Boston University Chobanian and Avedisian School of Medicine institutional review board deemed this study as not human research and exempt under 45 CFR 164.514.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.