Table 2. Harm-Reduction Programs for Active Drug Users.

Program	Purpose/Activities	Outcomes
Widespread naloxone distribution	Naloxone is a μ-opioid antagonist with well-established safety and efficacy that can reverse opioid overdose and prevent fatalities. Broadened accessibility to naloxone for individuals commonly in a position to initiate early response to evidence of opioid overdose including family and companions. Laws that allow prescribers to give naloxone prescriptions to friends/family of users (rather than the end-user). Access to naloxone at pharmacies either by a standing prescription for eligible individuals or by designating naloxone as an over-the counter medication. Good Samaritan laws that provide persons administering naloxone in emergencies immunity from prosecution and civil liability.	A naloxone distribution program in Massachusetts reduced opioid overdose deaths by an estimated 11% in the 19 communities that implemented it without increasing opioid use (Walley et al., 2013). A trial published in 2016 found that coprescribing naloxone rescue kits to patients treated with opioids for chronic pain in primary care resulted in reduced opioid-related emergency department visits (Coffin et al., 2016). A systematic review showed that evidence from 21 studies demonstrated that educational and training interventions for peers and family members, complemented by take-home naloxone, may help decrease overdose-related mortality (European Monitoring Centre for Drugs and Drug Addiction, 2015).
Needle or syringe exchange program (NSP)	Provide injection drug users with clean needles and a way to safely dispose of used needles, generally free of charge. Provide access to education and counseling—geared to meeting the person where they are, and gradually move them across the therapeutic continuum from harm reduction to moderation of use, to substance use treatment, to control of addiction. Nurses enhance the services of many syringe exchange programs by providing counseling about reproductive health; conducting pregnancy, HIV and STD testing; offering adult vaccines; teaching safer injection practices; providing wound care consultation; and arranging referrals for care (Wodak & Cooney, 2006).	An international review of the evidence of needle syringe programs to reduce HIV infection among injecting drug users found compelling evidence of effectiveness, safety, and cost-effectiveness (Wodak & Cooney, 2006). In addition to reducing rates of blood-borne infections, syringe exchanges also provide users with access to treatment. Outcome research of the impact of needle exchange programs as part of the HIV epidemic has shown that they reduced HIV incidence by 93% in New Haven and 70% in New York City (Hilton, Thompson, Moore-Dempsey, & Janzen, 2001). Improved environmental safety as contaminated needles are kept off streets, parks, and dumpsters.
Pharmacy sale of needles/syringes	In many states, people who inject drugs can also obtain sterile needles and syringes at pharmacies without a prescription.	Pharmacy-based syringe purchases have been shown to increase the number of pharmacy-based syringe purchases while reducing the sharing of syringes between injecting drug users (Cotten-Oldenburg, Carr, DeBoer, Collison & Novotny, 2001).
Medication-Assisted Treatment (MAT)	MAT, which combines behavioral therapy and medications to treat substance use disorders, can be prescribed by clinicians who are registered with the Drug Enforcement Administration (DEA) to dispense controlled substances. MAT can include methadone, buprenorphine (a combination of opiate mimic and blocker that can be taken as a sublingual tablet), Suboxone (buprenorphine combined with naloxone to discourage abuse as it does not produce a “high” if injected or snorted), or Vivitrol (an extended-release formulation of naltrexone, an opioid receptor antagonist) (Balhara, 2016).	Patients on MAT have been consistently shown to use fewer illicit opiates, commit fewer crimes, and reduce their odds of contracting infections, such as hepatitis C virus and HIV, compared with those not taking substitution (Drug Policy Alliance, 2015; Kastelic, Pont & Stöver, 2008). When it comes to treatment, overwhelming evidence shows that MAT, when combined with behavioral therapy, is vastly more effective than behavioral therapy alone. Statistics show that a person with an opioid addiction is more likely to die from an overdose after attending a behavioral therapy-only treatment program than if they had not sought treatment at all.
Legalized safeinjection houses	Safe infection houses are supervised injecting facilities that provide injecting drug users with a safe, medically monitored space in which to shoot up. Safe houses provide injecting drug users with access to clean needles, emergency care in cases of overdose, and (if they are ready) counseling about rehabilitation, treatment, and other health service options.	A 2014 systematic literature review found that “all [of the 75 relevant articles] converged to find that SISs [supervised injection services] were efficacious in attracting the most marginalized PWID [people who inject drugs], promoting safer injection conditions, enhancing access to primary health care, and reducing the overdose frequency” (Potier, Laprévote, Dubois-Arber, Cottencin & Rolland, 2014, p. 48). SISs were not found to increase drug injecting, drug trafficking, or crime in the surrounding environments. SISs were found to be associated with reduced levels of public drug injections and dropped syringes. At least eight countries worldwide host safe or supervised injection spaces. Most of these sites are in Europe; the only North American site was in Vancouver, Canada (Beach House, 2018).
Safe disposal of unused opioids	Programs that allow members of the public to dispose of unused and expired medications anonymously, 365 days a year, at prescription drug drop boxes generally located within the headquarters of participating police departments, sheriff offices, and State Police barracks. The National Prescription Drug Take-Back Day and the American Medicine Chest Challenge are both 1-day events to dispose of unused medications. They are typically sponsored by the state DEA in collaboration with local partners.	Opioid prescriptions returned for disposal had greater than 60% of the amount dispensed remaining unused (Welham, Mount, & Gilson, 2015). In comparing data from prescription drug monitoring database to drugs returned at a “take-back” program, authors concluded that controlled medications collected by take-back events and permanent drug donation boxes constituted a miniscule proportion of the number dispensed. The findings suggested that organized drug disposal efforts might have a minimal impact on reducing the availability of unused controlled medications at a community (Egan, Gregory, Sparks, & Wolfson, 2017).