. 2021 Jun 22;36(12):3810–3819. doi: 10.1007/s11606-021-06904-4

Table 3.

Incorporating Harm Reduction with Special Populations

Population	Considerations	Approach
People who do not want MOUD	- Many SUD-related harms (e.g., infection, overdose) occur upstream from MOUD engagement	- Welcome patients who are not interested in MOUD into OUD treatment programs - Normalize visits for harm reduction services and other health priorities - Build trust
People recently incarcerated	- Overdose death risk is 129× the general population in the first 2 weeks after incarceration¹⁰⁵ - In spite of the right to health care, many carceral settings do not provide MOUD¹⁰⁶ - Abrupt discontinuation of MOUD in carceral settings reduces reengagement¹⁰⁷	- Ensure patients and supports have and know how to use naloxone^22,108 - Outreach to local houses of corrections to facilitate post-release linkage - Offer to communicate with probation/parole officers if barriers to MOUD arise
Youth	- MOUD improves outcomes in youth and should be offered^109,110 - SUD programs serving youth are often abstinence-based¹¹¹ - Harm reduction and MOUD may be viewed as “condoning” substance use	- Building, maintaining trust are very important for engagement - Offer non-traditional communication (e.g., texting) and flexibility - Educate families on benefits of MOUD, naloxone, and harm reduction strategies
Couples	- Patients may present as part of a sexual or non-sexual relationship - Residential programs may not allow couples to enroll together	- Assess patients separately, ideally with different care teams - Set expectations around information sharing and screen for intimate partner violence individually before allowing partners into visits - Refer to couples/family counseling
Parents	- Parents with SUD experience structural barriers to treatment ¹¹² - Parents often fear a punitive response when disclosing ongoing substance use	- Discuss up front how providers will address ongoing substance use and mandates to assess children’s safety, noting that recurrence of substance use alone does not constitute child abuse/neglect - When reporting is required, involve the parent in the process for transparency - Discuss safe medication storage in a locked location out of reach of children - Ensure naloxone readily availability
People who are pregnant	- Time of increased motivation and stressors - Buprenorphine and methadone are standard of care and should be continued - Growing evidence that buprenorphine/naloxone does not need to be switched to buprenorphine mono product¹¹³	- Do not stop MOUD if a patient becomes pregnant¹¹⁴ - Expect a need for dose changes due to pregnancy physiology; the need for dose increases in pregnancy is not a marker of disease severity or stability¹¹⁵ - Coordinate with Family Medicine or Obstetrics to provide wrap around services for people with OUD during pregnancy

Population

Considerations

Approach

People who do not want MOUD

- Many SUD-related harms (e.g., infection, overdose) occur upstream from MOUD engagement

- Welcome patients who are not interested in MOUD into OUD treatment programs

- Normalize visits for harm reduction services and other health priorities

- Build trust

People recently incarcerated

- Overdose death risk is 129× the general population in the first 2 weeks after incarceration¹⁰⁵

- In spite of the right to health care, many carceral settings do not provide MOUD¹⁰⁶

- Abrupt discontinuation of MOUD in carceral settings reduces reengagement¹⁰⁷

- Ensure patients and supports have and know how to use naloxone^22,108

- Outreach to local houses of corrections to facilitate post-release linkage

- Offer to communicate with probation/parole officers if barriers to MOUD arise

Youth

- MOUD improves outcomes in youth and should be offered^109,110

- SUD programs serving youth are often abstinence-based¹¹¹

- Harm reduction and MOUD may be viewed as “condoning” substance use

- Building, maintaining trust are very important for engagement

- Offer non-traditional communication (e.g., texting) and flexibility

- Educate families on benefits of MOUD, naloxone, and harm reduction strategies

Couples

- Patients may present as part of a sexual or non-sexual relationship

- Residential programs may not allow couples to enroll together

- Assess patients separately, ideally with different care teams

- Set expectations around information sharing and screen for intimate partner violence individually before allowing partners into visits

- Refer to couples/family counseling

Parents

- Parents with SUD experience structural barriers to treatment ¹¹²

- Parents often fear a punitive response when disclosing ongoing substance use

- Discuss up front how providers will address ongoing substance use and mandates to assess children’s safety, noting that recurrence of substance use alone does not constitute child abuse/neglect

- When reporting is required, involve the parent in the process for transparency

- Discuss safe medication storage in a locked location out of reach of children

- Ensure naloxone readily availability

People who are pregnant

- Time of increased motivation and stressors

- Buprenorphine and methadone are standard of care and should be continued

- Growing evidence that buprenorphine/naloxone does not need to be switched to buprenorphine mono product¹¹³

- Do not stop MOUD if a patient becomes pregnant¹¹⁴

- Expect a need for dose changes due to pregnancy physiology; the need for dose increases in pregnancy is not a marker of disease severity or stability¹¹⁵

- Coordinate with Family Medicine or Obstetrics to provide wrap around services for people with OUD during pregnancy