Table 2 Emergent themes for barriers to harm reduction in Texas

Healthcare not Reducing Harm for PWUD

Stigmatizing behavior by healthcare providers highlight negative experiences of PWUD:

ERs noted stigmatizing behavior by first responders and emergency dept personnel

HRs noted experiencing stigma by emergency dept personnel, physicians, and SUD treatment providers

PWUD noted experiencing stigma by emergency dept personnel

"…it’s always fascinatin’ to me when we were doin’ outreach and bring someone in with a compound fracture, and doctors thought they did that shit on purpose so they could get drugs from the emergency department. And it’s just crazy. But it perpetuates the whole stigma…” (108, Harm Reductionist)

"So when I went to the hospital…and I went in there on a wheelchair I couldn’t even walk. He said, ‘Uh, we’ll give you a couple muscle relaxers. We’ll give you something for the pain, and you’ll be okay. Go away.’ Well two weeks later, it got to the point where I couldn’t even hold my bowels. It was real bad. So I went back to the same hospital…and a different doctor came…he said, ‘Do you have an attorney?…Because, uh, they should’ve never let you leave from this hospital two weeks prior’” (160, PWUD)

"There's a huge stigma. And then—but they're taking away of, like, you know, these are people, these are someone's son or daughter…there's people that just don't care. Like, if somebody overdoses, they're like, ‘Well, you know, they made that choice.’”(150, Emergency Responder)

n = 11 HRs

n = 14 PWUD

n = 3 ERs

PWUD will not Engage in 911 System after an Overdose

PWUD will not call 911 due to fear of being arrested and incarcerated

ERs, HRs, and PWUD all indicated that PWUD will not call 911 (emergency management services) due to fear of legal repercussions; if they do call 911, they won’t share info related to OD

“…at the time, I’d be worried about them, like wantin’ to search my place-or-um, you know, or the person dies. You know I’d be worried about them coming back and trying to put it on me, you know” (135, PWUD)

“I would also be hesitant to call 911 for fear of, uh, and it sounds so selfish, given the fact that a life is on the line, but I would als—I’d be fearful that if I was using that the emergency responders and police would charge me with something” (123, PWUD)

n = 10 HRs

n = 18 PWUD

n = 9 ERs

Harm Reduction Organizations not Reaching Entire Community of PWUD

Minority groups are likely not being reached by harm reduction organizations; lack of equitable distribution of services

FRs noted certain subpopulations of PWUD will not call 911/EMS for overdose due to EMS’ perception that certain groups (i.e. unhoused) don’t want help or have naloxone at home

HRs also noted certain subgroups of the unhoused populations (i.e., veterans, groups living further in the woods), gender minorities, racial ethnic minorities (i.e., Black, Native American), and rural areas aren’t being served sufficiently

PWUD also noted certain subgroups of the unhoused population aren’t being served sufficiently

"But we can pretty much assume that the vast majority of people who meet the criteria for receiving these services and who could benefit from interaction around drug poisoning risk, around drug poisoning prevalence are just outside of the whole milieu altogether” (102, Harm Reductionist)

"I mean people of color are wildly, um, you know, underrepresented in the population we serve. Uh, we see a disproportionately large number of men. I think the sex work community could benefit from our services and don’t…while we’ve reached into certain communities, there’s still some that we haven’t quite touched” (103, Harm Reductionist)

n = 13 HRs

n = 3 PWUD

n = 3 ERs

“Abstinence-Only” Philosophy Prevails over Harm Reduction in Texas

Harm reduction practices are neglected in “abstinence-only” models and collaboration between harm reduction organizations and healthcare providers are scarce

FRs noted that general knowledge and willingness to promote harm reduction programs embedded in EMS is not present in healthcare settings, with those settings more abstinence-based; lack of ability for EMS to follow-up with patient interaction when transferred to ED

HRs noted prevalence of abstinence-only philosophy in SUD recovery and treatment settings leads to a neglection of harm reduction practice, which leads to ineffective outcomes for PWUD seeking services and potentially increases risk of mortality for PWUD (i.e. not talking about naloxone in these settings); partnerships with testing services, wound care services, MAT clinics, EMS providers are scarce

PWUD noted abstinence-only philosophy in SUD treatment, recovery, and otherwise behavioral health settings and the potential consequences of sharing substance use/OD info to these professionals leads to PWUD not disclosing information in these settings; not receiving medication for pain

"So in addiction treatment as a whole, the industry itself is implicated in denying people treatment, discharging people from treatment, and mistreating people for continuing to use substances” (102, Harm Reductionist)

“…we were collaborating with [Local HIV Prevention Program]. But it was a struggle. It was a huge struggle. There was institutionalized stigma. You know, our clients were being treated poorly, and so it was just horrific until I got fed up and decided to just, you know, move offices…” (107, Harm Reductionist)

"…this abstinence-based-only mentality that, um—that a lot of people here have, um, you know, permeates out into the larger community. And, um, you know, as unsuccessful as that has been at treatin' people with, uh, this disorder, it doesn't matter. It, um—it's what they continue to go with” (108, Harm Reductionist)

n = 7 HRs

n = 6 PWUD

n = 3 ERs

Funding for Harm Reduction in Texas as Inadequate

Harm reduction organizations are not adequately funded to serve PWUD communities nor keep relevant information on them

FRs highlighted insufficient funding of behavioral health and EMS services generally in Texas

HRs noted inadequate funding for operations with regard to staff, frequency of outreach, and capacity to collect data related to overdose

PWUD expressed concerns that certain programs have unstable funding to deliver harm reduction services

"So we've hit a funding issue. Um, and it sounds like we might end up getting subsumed into THRA (Texas Harm Reduction Alliance). It's uncertain. Um, so, uh, I feel like if we're not well staffed, then, yeah, things—it's just a matter of kind of survival at that point 'cause we have so many people to see” (101, Harm Reductionist)

"I feel that um, what needs to be done is we need more funding, so that we can be out there longer. Um, so that we can create a um—we just need to be out there longer. We need to be doing the work longer…” (116, Harm Reductionist)

“I think that, uh, you know, to—funding for someone to report all that information would be key. You know? So that its accurate, we have one person or, you know? Because data, you know, data is really important.” (109, Harm Reductionist)

n = 9 HRs

n = 6 PWUD

n = 3 ERs

Absence of a Good Samaritan Law in Texas

Lack of a Good Samaritan Law (GSL) is a huge deterrent for calling 911 during an overdose

FRs noted lack of a GSL discourages PWUD for calling for help during an overdose

HRs also noted lack of a GSL discourages PWUD for calling for help during an overdose, creates gaps in overdose information and the perception that leadership at the state level does not want to reduce overdose fatalities

PWUD expressed uncertainty around the GSL and stated the current protections discourages PWUD from seeking care during an overdose; leads to incarcerations and PWUD not receiving necessary care during OD

" the war on drugs is like, oh, you have drugs or you-you have a, you know, a diagnosis, I’m going to put you in jail for it. You know, um, so a-and the fact that we don’t have amnesty or-or the good Samaritan law, you know, um— That’s a big impact. " (146, Emergency Responder)

“ Uh, but the bottom line is, like, you know, with or without a good Samaritan law, some people are gonna call 911, some people are just not, no matter what” (112, Harm Reductionist)

“I feel like if people knew that they weren’t going to get in trouble for calling 9-1-1 and having, you know, EMS come and pick somebody up or dropping somebody off at the hospital or whatever… I think it’d be different… the Good Samaritan law is…not real” (129, PWUD)

n = 6 HRs

n = 4 PWUD

n = 1 ERs

Paraphernalia Law limits Harm Reduction Organizations from Offering Empirically-supported Services

Fentanyl testing strips and syringe service programs (SSPs) are not offered by harm reduction organizations

HRs noted SSP are not legal and prevents service provision (i.e., not being able to use federal grant funding for SSP); concerns that clients are concerned about fear of accessing their services, spreading of HIV/HCV, clients reusing needles, and challenges around advocating for SSP through collecting information from clients

PWUD perceived that SSPs are illegal which leads to clients being hesitant or resistant to accessing HR outreach services; difficult to obtain clean syringes; means for drug testing not accessible

"Like, we have people who come to us from Killeen, um, and they say that, you know, if they ever get stopped and the police see syringes, even if they're unopened they destroy them. If they see Narcan, they take it and confiscate it. So this happens a lot." (101, Harm Reductionist)

"…syringe exchange is not legal in Texas, and that’s really um stopping us from meeting then what we need to do—the people that we need to meet and the demand that we need to meet. We are very—we’re-we’re not doing it, we’re just not—we’re not doin’ it.” (116, Harm Reductionist)

n = 10 HRs

n = 4 PWUD

n = 0 ERs