Findings from our study illustrate that many substance use programs do not fit directly into a binary of “harm reduction” or “treatment.” Most of the participating programs in this study reported offering a spectrum of harm reduction and treatment services. Still, SSPs were most likely to offer harm reduction services, MOUD programs were most likely to offer treatment services, and those characterized as offering both MOUD & SSPs were most likely to offer the broadest services. Program clients also did not fit into the supposed binary of “active drug use” vs. “abstinence.” In fact, of the clients who attended MOUD only programs, nearly three quarters reported using non-prescribed drugs in the past week, and more than half reported injecting drugs in the past week; these rates were similar to those reported by clients who attended combined MOUD & SSP programs. Meanwhile, more than 40% of those who attended SSP only programs reported attending some type of drug treatment service in the past month.
Our results reveal some important incongruencies between services being offered by substance use programs and characteristics and behaviors reported by clients who attend such programs. For example, while three-quarters of MOUD program clients reported using non-prescribed drugs (one-quarter reported using opioids), only two-thirds of these programs offered overdose education or naloxone distribution and one-third offered fentanyl testing or test strips. This is highly concerning given the high prevalence of fentanyl in both the opioid and non-opioid illicit drug supplies [21] and may partly reflect the presence of policies that criminalize possession of fentanyl test strips in some of the sampled states [22]. Moreover, half of clients who attended MOUD programs without SSP or wound care actively injected drugs. While it is possible that these clients seek safe injection supplies elsewhere, a minority (14%) reported visiting an SSP in the past month.
There were also discrepancies in services offered by SSPs relative to client-reported service utilization. Of clients recruited from SSPs without MOUD, 22% indicated receiving methadone and 8% reported receiving buprenorphine in the past month. This implies clients are either seeking these medications via other service providers or acquiring them on the street, which has been reported to often be easier than enrolling in formal treatment [9, 23, 24]. Roughly half of MOUD programs offered same-day treatment initiation. Additionally, SSP programs were reaching the highest risk population that with the greatest rates of active drug use. Yet, on average, these programs reported having the smallest number of staff and the least available treatment or social services relative to the other programs types. The limited workforce and services offered may reflect the limited budgets often used to operate these programs. Many harm reduction services operate independently from the medical system and are not eligible for insurance reimbursement. Additionally, programs have been historically banned from accessing federal and local funds for SSPs; programs have had to depend on scarce funds acquired a combination of small grants, individual donations, and charitable foundations [4, 25]. The Biden Administration’s 2021 American Rescue Act was the first federal action to allocate targeted funding toward harm reduction services and SSPs [25, 26]. While this was an important step to potentially help scale up these services, local and national resistance and stigma to these programs remains persistent (highlighted by the recent resistance to federal funding sterile pipes [27]). Continued efforts to combat ongoing stigma and political resistance to these programs are needed [25].
Findings from this study demonstrate that in many ways, existing programs are not adequately meeting the service needs of or catering to the realities of PWUD. Creating a substance use service system that is truly person-centered and successful at improving health and dignity will necessitate moving away from the binary mentality of harm reduction vs. treatment to one which is better tailored to individual clients. This includes offering a continuum of co-located treatment, harm reduction, and social services that can meet individuals where they are. This would help facilitate access to life-saving services and greater socioeconomic stability [28, 29]. This may be particularly important for individuals with multiple vulnerabilities, as well as during emergencies—such as the COVID-19 pandemic—when minimizing travel and co-locating access to multiple health and social services is key [30]. In our study, programs that included both MOUD & SSP offered the greatest range of treatment and harm reduction services, including naloxone distribution, overdose prevention education, same-day treatment initiation, drop-in spaces, peer services/street outreach, and counseling services. However, these programs were the rarest in our sample of providers and remain largely under-resourced and at the periphery of the substance use service system. Moreover, such integrated models have been made possible by the ability to prescribe buprenorphine in non-traditional treatment settings [31]. Methadone, which may be the most effective and desirable MOUD option for some individuals, and used by many participants in our study, is still largely restricted to the opioid treatment program system bound by regulations on staffing, zoning, and hefty requirements for patients such as frequent urine drug screening [32, 33]. While there are some successful models of lower threshold methadone in other countries[34], scaling up methadone to meet needs of PWUD in the USA will require rethinking some of the core federal and state regulations, including expanding methadone availability beyond the opioid treatment program system [35]. It is important to note that most participating clients reported using drugs other than opioids; thus, integrating interventions for stimulant and other drug use should be central to efforts to better align programs with client behaviors.
Finally, across all program types, we identified important gaps in social and auxiliary services available relative to the socioeconomic circumstances of clients. While most programs offered on-site or referral to case management and social services, only a minority offered any direct housing support despite nearly half of clients being unstably housed. Education and job training were even less available, though nearly half of clients reported being unemployed. Moreover, roughly half of clients identified as female, and many were of parenting age. Yet, only one-third of programs offered any parenting, childcare, or pregnancy services. Lack of integration of these services highlights a missed opportunity to address social determinants of health that strongly influence overdose risk and overall health and stability among this highly vulnerable population[36, 37]. Increasing grant funding for wrap-around services, as was done via the Ryan White HIV/AIDS Program [38], improving insurance coverage of social services via bundled payments [39], and leveraging flexible funding streams, such as those allocated to states in the aftermath of opioid litigation, [40] may be avenues to assist programs in integrating client social services.
The current study is subject to several limitations. First, our sample of programs and clients may not be generalizable; we recruited the sample from Bloomberg Overdose Initiative states via convenience sampling of providers with preexisting relationships with initiative partners. Thus, it is likely that participating programs more likely represent non-for profit and harm-reduction-oriented service providers and that clients are not representative of the broader sociodemographic or behavioral characteristics of PWUD nationwide. For example, 100% of included MOUD only programs were non-for-profit organizations, while less than 40% of US opioid treatment programs that deliver all three types of MOUD are non-for-profit organizations [41]. Relatedly, clients who participated in this survey may be distinct from treatment and harm reduction clients more broadly and differ characteristically from those who did not choose to participate in the study. Indeed, the majority of clients recruited from SSPs were white, which may reflect the unique geography/demographics of the regions from which programs were recruited, but could also be indicative of greater barriers to accessing harm reduction services among Black and other minoritized groups [42], which should be a subject of future research. Moreover, client survey questions that inquired about treatment and harm reduction service utilization did not distinguish between services accessed at the program from which clients were recruited from versus other service providers and did not explicitly ask clients about their service utilization or treatment goals. Data are also based on cross-sectional surveys conducted during the early months of the COVID-19 pandemic and may not represent typical service provision or utilization and characteristics of clients at other times. Finally, proportion comparisons and p-values across provider characteristics should be interpreted with caution and be considered exploratory due to small sample and cell sizes.
