Harm Reduction Framework PDF

Harm Reduction Framework Substance Abuse and Mental Health Services Administration Public Domain Notice All material appearing in this publication is in the public domain and may be reproduced or copied without permission from SAMHSA. Citation of the source is appreciated....

Harm Reduction Framework Substance Abuse and Mental Health Services Administration Public Domain Notice All material appearing in this publication is in the public domain and may be reproduced or copied without permission from SAMHSA. Citation of the source is appreciated. However, this publication may not be reproduced or distributed for a fee without the specific, written authorization of the Office of Communications, SAMHSA, HHS. Electronic Access and Copies Products may be downloaded at https://www.samhsa.gov/find-help/harm-reduction/ framework Recommended Citation Substance Abuse and Mental Health Services Administration: Harm Reduction Framework. Center for Substance Abuse Prevention, Substance Abuse and Mental Health Services Administration, 2023. Originating Office Center for Substance Abuse Prevention, Substance Abuse and Mental Health Services Administration, 5600 Fishers Lane, Rockville, MD 20857. Nondiscrimination Notice The Substance Abuse and Mental Health Services Administration (SAMHSA) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, religion, or sex (including pregnancy, sexual orientation, and gender identity). SAMHSA does not exclude people or treat them differently because of race, color, national origin, age, disability, religion, or sex (including pregnancy, sexual orientation, and gender identity). Contents Harm Reduction Framework for People Who Use Drugs (PWUD)....................................................... 4 Brief History and Background of Harm Reduction.........................................................................................5 Addressing Health Inequities.......................................................................................................................................... 6 Framework Overview........................................................................................................................................................... 6 Framing Harm Reduction.................................................................................................................................7 Pillars of Harm Reduction..................................................................................................................................8 Table 1. Six Pillars of Harm Reduction........................................................................................................8 Supporting Principles.........................................................................................................................................10 Table 2. Principles of Harm Reduction....................................................................................................10 Core Practice Areas.................................................................................................................................................. 12 Table 3. Core Practice Areas............................................................................................................................ 12 Community-Based Harm Reduction Programs (CHRPs).......................................................... 17 Conclusion............................................................................................................................................................................. 17 References.............................................................................................................................................................................18 Harm Reduction Steering Committee Members.......................................................................................... 25 Harm Reduction Framework 3  Harm Reduction Framework for People Who Use Drugs (PWUD) The Biden-Harris Administration has identified harm reduction as a federal drug policy priority. The White House Office of National Drug Control Policy (ONDCP), in the 2022 National Drug Control Strategy, notes that harm reduction is a public health approach designed to advance policies and programs in collaboration with people who use drugs (PWUD) and is supported by decades of evidence. Harm reduction strategies are shown to substantially reduce HIV and hepatitis C infection among people who inject drugs, reduce overdose risk, enhance health and safety, and increase by five-fold the likelihood of a person who injects drugs to initiate substance use disorder treatment.1, 2, 3 In line with this, harm reduction is one of the four strategic priorities of the U.S. Department of Health and Human Services (HHS) Overdose Prevention Strategy developed to address the overdose public health emergency.4 In December 2021, the Substance Abuse and Mental Health Services Administration (SAMHSA) convened the first-ever federal Harm Reduction Summit, in partnership with the Centers for Disease Control and Prevention (CDC) and ONDCP. The Summit brought together more than 100 experts representing prevention, treatment, recovery, and harm reduction perspectives. Most importantly, Summit attendees included people with lived experience with substance use to help inform SAMHSA’s policies, programs, and practices as they relate to harm reduction. Additional partners included community members, advocates, harm reductionists, providers, funders, and others who are affected by these issues. SAMHSA’s Harm Reduction Framework is one outcome of the Summit. This Framework is historic, as the first document to comprehensively outline harm reduction and discuss its role throughout HHS. The Framework was developed and written in partnership with the Harm Reduction Steering Committee, composed of harm reduction leaders in the field from across the country. This group represents a broad array of backgrounds and experience, with most having lived experience of drug use. The Steering Committee synthesized findings from the Summit ― including a definition of harm reduction, pillars and principles supporting that definition, and core practices that SAMHSA can support. The Framework is adapted from the Committee’s final report. This Framework will inform SAMHSA’s harm reduction activities moving forward, as well as related policies, programs, and practices. SAMHSA’s aim is to integrate harm reduction activities and approaches across its organizational Centers and initiatives, and to do so in a manner that draws on evidence-based practice and principles ― while also maintaining sustained dialogue with harm reductionists and people who use drugs (PWUD). The Framework will also inform SAMHSA’s thinking about opportunities to work with other federal, state, tribal, and local partners toward advancing harm reduction approaches, services, and programs. SAMHSA defines harm reduction as a practical and transformative approach that incorporates community-driven public health strategies — including prevention, risk reduction, and health promotion — to empower PWUD and their families with the choice to live healthier, self-directed, and purpose-filled lives. Harm reduction centers the lived and living experience of PWUD, especially those in underserved communities, in these strategies and the practices that flow from them. 4 Harm Reduction Framework Brief History and Background of Harm Reduction Harm reduction has a long history in the United States. The field itself and harm reduction practice emerged decades ago, as direct community action and mutual aid in response to effects of the “War on Drugs,” an early and incomplete scientific understanding of substance use and substance use disorders, and government inaction to swiftly respond to the growing HIV/AIDS epidemic.5 In 1982, CDC published findings that the human immunodeficiency virus (HIV) is transmissible through the intravenous use of drugs.6 By 1983, PWUD began the distribution of sterile syringes to limit the transmission of HIV/AIDS.7 After the 1988 restriction on federal funding for the purchase of syringes for needle and syringe exchange programs, PWUD and allies who operated syringe services programs (SSPs) across the country began to organize their work.8 In 1992, the first Harm Reduction Working Group meeting in the United States was held in San Francisco to create a unified definition of harm reduction. A major outcome of the group was the establishment of the National Harm Reduction Coalition.9 Since the first Harm Reduction Working Group meeting in 1992, harm reduction has grown in scope and in practice. PWUD have innovated and sustained the movement despite criminalization of many harm reduction interventions and lack of financial and social support. An important example is the advent of community naloxone distribution, which began in 1996.10 From 1996 through June 2014, 136 organizations reported distributing naloxone to 152,283 laypersons. Of the 109 organizations who collect reversal data, 26,463 overdose reversals were reported.11 Although the number of organizations distributing naloxone has doubled and since 2013 has included organizations other than SSPs, in 2014, SSPs still accounted for 80 percent of the distribution effort to PWUD, as well as 80 percent of overdose reversals.12 In 2019, SSPs distributed 702,232 doses of naloxone to 230,506 people in communities across the country.13 Studies have shown that communities may experience up to a 46 percent reduction in opioid overdose mortality when more than 100 people who are likely to observe or experience an overdose per 100,000 population are enrolled into an Overdose Education and Naloxone Distribution (OEND) program.14 In addition, SSPs are associated with an estimated 50 percent reduction in HIV and hepatitis C incidence.15,16 When combined with medications that treat opioid use disorder (also known as medications for opioid use disorder or MOUD), hepatitis C virus and HIV transmission is reduced by more than two-thirds.17 The last few decades have solidified the evidence-based practices and individuals have become specialized subject matter experts in the field of harm reduction. Harm Reduction Framework 5  Addressing Health Inequities In the spirit of Executive Order 13985,18 SAMHSA is in the process of reviewing its policies to examine the intended and unintended impacts of its programs, policies, and procedures; incorporating racial justice and health equity into its policy goals; and advancing equitable support for Black, Latino, American Indian and Alaskan Native persons, Asian Americans, Native Hawaiians, and Pacific Islanders, and other persons of color; members of religious minorities; lesbian, gay, bisexual, transgender, queer, intersex (LGBTQI+) persons; persons with disabilities; persons who live in rural areas; and persons otherwise adversely impacted by persistent poverty or inequality. This is proactively undertaken to address past and present inequities.18 Integrating harm reduction principles and approaches throughout the agency is one strategy for advancing that commitment. Deficient social determinants of health and structural inequalities contribute to and exacerbate substance use, substance use disorder, and mental illness, and can and do have a profound impact on some populations. Most notably, persons who have a history of familial, community or racial trauma may be particularly in need of compassionate services to support their pathways to improved health outcomes. Community practitioners and behavioral health providers must be culturally responsive and attentive to health equity to effectively improve individual and population level health. For this to be accomplished, community trust and buy-in must be earned, and that begins with truth and reconciliation of a community’s shared traumatic history and the structural racism that perpetuates inequities. On this foundation, trust and meaningful relationships can develop.19 “Formally acknowledging a community’s shared traumatic history is a fundamental step in preparing for and planning community engagement (CE) efforts that address health inequities.” 19 This work is undertaken in partnership with SAMHSA’s Office of Behavioral Health Equity, which describes the work as: “Advancing health equity involves ensuring that everyone has a fair and just opportunity to be as healthy as possible. This also applies not only to behavioral health, but in conjunction with quality services, this involves addressing social determinants, such as employment and housing stability, insurance status, proximity to services, culturally responsive care — all of which have an impact on behavioral health outcomes.”20 Framework Overview Harm reduction is practical in its understanding and acceptance that drug use and other behaviors that carry risk exist ― and responds in a compassionate and life-preserving manner. Harm reduction seeks to reduce the harmful impacts of stigma, mistreatment, discrimination, and harsh punishment of PWUD, especially those who are Black, Indigenous, and other People of Color.21 Building community partnerships with harm reduction organizations can positively shape beliefs and attitudes, reduce stigma, and ensure the well-being of the community at large.22 6 Harm Reduction Framework Harm reduction also accounts for the intersection of drug use, other stigmatized behaviors, and people’s health. Fundamentally, a harm reduction approach meets people where they are, engaging with them and providing support.23 Harm reduction opens the door to more options for PWUD, for whom traditional treatment approaches are inaccessible, ineffective, or inappropriate — and who want to make safer, healthier choices with their life and health. Access to harm reduction services is consistently shown to improve individual and community outcomes. By viewing substance use on a continuum, incremental change can be made, allowing for risk reduction to better suit a person’s own individual goals and motivations. Most importantly, harm reduction approaches save lives. The SAMHSA definition of harm reduction contains six pillars, 12 principles, and six core practice areas that give life to harm reduction approaches, initiatives, programs, and services. The pillars are essential building blocks that are the foundation of what makes harm reduction effective. The pillars are further divided into supporting principles that are the specific concepts and ideals supporting each pillar. The SAMHSA Framework also describes the core components of community-based harm reduction programs. Framing Harm Reduction SAMHSA conceptualizes harm reduction as being a set of services, an approach, and a type of organization. Harm reduction has, at times, been reduced to a singular service or group of services, when in fact, its application goes well beyond this. Harm reduction as an approach — with supporting principles and pillars that can be applied to a variety of contexts — includes the provision of evidence-based treatment. An organization or an individual healthcare practitioner may not consider themselves as primarily providing harm reduction services but may adopt and apply practices and principles outlined in this Framework ― to enhance the services they offer and engage with PWUD in a manner informed by these principles. Any organization who works with PWUD can benefit from the integration of harm reduction as an approach. Harm reduction is also part of the continuum of care and a comprehensive strategy that includes prevention, treatment, recovery, and health promotion. All of these elements are necessary — and people weigh them differently in different situations, at different points in their lives, and relative to a wide range of substances and behaviors. Prevention, in particular primary prevention, seeks to prevent problems before they start. That means preventing exposure to substances (or screening and intervening with early misuse), reducing risk factors, and strengthening protective factors at the individual, relationship, community, and society levels. Prevention also seeks to stop or delay the progression of substance use to a substance use disorder, as well as prevent other harms associated with substance use. Harm reduction recognizes the complex relationship people may have with substances, starting from first use, through the many possible intervention points from there. Harm reduction does not minimize the inherent harms associated with drug use and acknowledges that reducing harm can take different forms for different people at different points, including with the use of medications to treat substance use disorders. Harm reduction is also inclusive of abstinence as a chosen pathway but not inclusive of abstinence as a coerced pathway. Harm Reduction Framework 7  Harm reduction services must adhere to the harm reduction approach to maintain fidelity to the evidence base and lead to better outcomes. This is exemplified by the concept of Community-Based Harm Reduction Programs (CHRPs) described in this Framework. Pillars of Harm Reduction Table 1 summarizes the six pillars of harm reduction. Harm reduction initiatives, programs, or services should include these elements. Table 1. Six Pillars of Harm Reduction Harm Reduction... 1. Is led by people Work is led by PWUD and those with lived and living experience who use drugs of drug use. Harm reduction interventions that are evidence (PWUD) and based have been innovated and largely implemented by PWUD. with lived Through shared decision-making, people with lived experience experience of are empowered to take an active role in the engagement process drug use and have better outcomes.24 Put simply, the effectiveness of harm reduction programs is based on the buy-in and leadership of the people they seek to serve. Organizations providing harm reduction services should have a formal mechanism to meaningfully include the voices of people with lived experience in the design, implementation, and evaluation of those services.25 Adopting at least two of the following specific mechanisms of inclusion is mission critical: employment of people with lived experience in both intervention and administrative roles, advisory boards of PWUD, and the consultation of CHRPs or any other peer-led organizations. It is important to note that while people in recovery and people who formerly used drugs have valuable experience, centering the perspectives of people who currently use drugs (and the intersectionality with other historically marginalized individuals) and have a working understanding of the current, dynamic, and rapidly changing landscape of drug use in a particular community in which an organization is working, is essential to successful engagement and outcomes. This is exemplified in the provision of OEND Programs.26 2. Embraces the All individuals have inherent value and are treated with dignity, inherent value respect, and positive regard. of people Harm reduction initiatives, programs, and services are trauma informed, and never patronize nor pathologize PWUD, nor their communities. They acknowledge that substance use happens, and the reasons a person uses drugs are nuanced and complex. This includes people who use drugs to alleviate symptoms of an existing medical condition. 8 Harm Reduction Framework Harm Reduction...(Cont.) 3. Commits All communities that are impacted by systemic harms are leading to deep and directing program planning, implementation, and evaluation. community engagement Funding agencies and funded programs support and sustain and community community cultural practices, and value community wisdom and building expertise. Agencies and programs develop through community- led initiatives focused on geographically specific, culturally based models that integrate language revitalization, cultural programming, and Indigenous care with dominant-society healthcare approaches. 4. Promotes All aspects of the work incorporate an awareness of (and actively equity, rights, work to eliminate) inequity related to race, class, language, sexual and reparative orientation, and gender-based power differentials. social justice Pro-health and pro-social practices that have worked well for specific cultural and/or geographic communities are aligned with organizing and mobilizing, providing direct services, and supporting mutual aid among PWUD. CHRPs are often the best-placed organizations to respond to communities or individuals on racial justice and health equity issues, and provide services for Black, Latino, American Indian and Alaska Native persons, Asian Americans, Native Hawaiians, and Pacific Islanders, and other persons of color; members of religious minorities; LGBTQI+ persons; persons with disabilities; persons who live in rural areas; and persons otherwise adversely impacted by persistent poverty or inequality. 5. Offers most All harm reduction services have the lowest requirements for access. accessible and noncoercive Participation in services is always voluntary, confidential (or support anonymous), self-directed, and free from threats, force, and the concept of compliance. Any data collection requires informed consent and participants should not be denied services for not providing information. This means using low-threshold evaluation and data collection systems to measure the effectiveness of harm reduction programs. 6. Focuses on any All harm reduction services are driven by person-centered positive positive change, change in the individual’s quality of life. as defined by the person Harm reduction initiatives, programs, and services recognize that positive change means moving towards more connectedness to the community, family, and a more healthful state, as the individual defines it. There are many pathways to wellness; substance use recovery is only one of them. Abstinence is neither required nor discouraged. Harm Reduction Framework 9  Supporting Principles The pillars are supported and reinforced by 12 core principles that guide the work. As with the pillars, the principles are vital. Programs that do not incorporate all 12 principles risk violating the spirit of harm reduction. Table 2. Principles of Harm Reduction Supporting Principle Description Principles Respect Each individual is different. It is important to meet people where autonomy they are, and for people to lead their own individual journey. Harm reduction approaches, initiatives, programs, and services value and support the dignity, personal freedom, autonomy, self-determination, voice, and decision making of PWUD. Practice Love, trust, and connection are important in harm reduction work. acceptance and Harm reduction approaches, initiatives, programs, and services hold hospitality space for people who are at greatest risk for marginalization and discrimination. These elements emphasize trusting relationships and meaningful connections and understand that this is an important way to motivate people to find personal success and to feel less isolated. Provide support Harm reduction approaches, initiatives, programs, and services provide information and support without judgment, in a manner that is non-punitive, compassionate, humanistic, and empathetic. Peer-led services enhance and support individual positive change and recovery; and peer-led leadership leads to better outcomes. Connect with Positive connections with community, including family members community (biological or chosen) are an important part of well-being. Community members often assist loved ones with safety, risk reduction, or overdose response. When possible, harm reduction initiatives, programs, and services support families in expanding and deepening their strategies for love and support; and include families in services, with the explicit permission of the individual. Provide many Harm reduction can and should happen across the full continuum pathways to of health and social care, meeting whole-person health and social well-being across needs. In networking with other providers, harm reduction initiatives, the continuum of programs, and services work to build relationships and trust with health and social health and social care partners that embrace supporting principles. care To help achieve this, organizations practicing harm reduction utilize education and encourage policies that facilitate interconnectedness between all parties. 10 Harm Reduction Framework Supporting Principle Description...(Cont.) Principles Value practice- Structural racism and other forms of discrimination have limited the based evidence development and inclusion of research on what works in underserved and on- communities. Harm reduction initiatives, programs, and services the-ground understand these limitations and use community wisdom and experience practice-based evidence as additional sources of knowledge. Cultivate Relationships are of central importance to harm reduction. Harm relationships reduction approaches, initiatives, programs, and services are relational, not transactional, and work to establish and support quality relationships between individuals, families, and communities. Assist, not direct Harm reduction approaches, initiatives, programs, and services support people on their journey towards positive change, as they define it. Support is based on what PWUD identify as their needs and goals (not what programs think they need), offering people tools to thrive. Promote safety Harm reduction approaches, initiatives, programs, and services actively promote safety as defined by the people they serve. These efforts also acknowledge the impact that law enforcement can have on PWUD (particularly in historically criminalized and marginalized communities) and provide services accordingly. Engage first Each community has different cultural strengths, resources, challenges, and needs. Harm reduction approaches, initiatives, programs, and services are grounded in the most impacted and marginalized communities. It is important that meaningful engagement and shared decision making begins in the design phase of programming. Equally important is bringing to the table as many individuals and organizations as possible who understand harm reduction and who have meaningful relationships with the affected communities. Prioritize Each community has its own unique story that can be the foundation listening for harm reduction work. When we listen deeply, we learn what matters. Harm reductionists engage in active listening ― the act of inviting people to express themselves completely, recognizing the listener’s inherent biases, with the intent to fully absorb and process what the speaker is saying. Work toward Harm reduction approaches, initiatives, programs, and services systems change recognize that trauma; social determinants of health, such as access to healthcare, housing, and employment; inequitable policies; lack of prevention and early intervention strategies; and social support have all had a responsibility in systemic harm. Harm Reduction Framework 11  Core Practice Areas Core practices are effective methods for harm reduction that reflect community understanding, experience, strengths, and needs. There are six core practice areas: (1) safer practices; (2) safer settings; (3) safer access to healthcare; (4) safer transitions to care; (5) sustainable workforce and field; and (6) sustainable infrastructure. While not an exhaustive list, Table 3 provides key strategies and links to resources. Anyone in the United States can access free, direct technical assistance (in any of the core practice areas) from SAMHSA and CDC. SAMHSA’s harm reduction webpage offers resources, including allowable expenses for its grants that support harm reduction activities. Table 3. Core Practice Areas Supporting Resources and Evidence Examples of Practices (Research- and Practice-based) Safer Practices: Education and support describing how to reduce risk; provision of risk reduction supplies and materials Needs Based Syringe Services CDC Syringe Services Programs Technical Package Programs (SSPs) — also referred to as syringe exchange programs SAMHSA TIP 33 Treatment for Stimulant Use Disorders (SEPs) and needle exchange SAMHSA TIP 63 Medications for Opioid Use Disorder programs (NEPs),* including secondary exchange.1,17,19,22,26,27,28,29 Safer smoking supplies/ CDC Stimulant Guide distribution to reduce infectious disease transmission.* 29,30,31 *As permitted by law. No federal funding is used directly or through subsequent reimbursement of grantees to purchase pipes. Grants include explicit prohibitions of federal funds to be used to purchase drug paraphernalia. Overdose education, overdose CDC Lifesaving Naloxone Guide detection services, and naloxone distribution.10,13,26,29,32 SAMHSA What is Naloxone? SAMHSA TIP 63 Medications for Opioid Use Disorder SAMHSA Opioid-Overdose Reduction Continuum of Care Approach (ORCCA) Practice Guide 2023 Engaging Community Coalitions to Decrease Opioid Overdose Deaths Practice Guide 2023 12 Harm Reduction Framework  Supporting Resources and Evidence Examples of Practices (Research- and Practice-based)...(Cont.) Drug-checking education, CDC MMWR: Rapid Analysis of Drugs: A Pilot fentanyl test strips, xylazine Surveillance System to Detect Changes in the Illicit test strips and other assay test Drug Supply to Guide Timely Harm Reduction strips, FTIR spectrometers, and Responses other drug-checking technology at community drug-checking Overdose Data to Action: Surveillance Strategies | sites.33,34 Drug Overdose | CDC Injury Center SAMHSA Federal Grantees May Now Use Funds to Purchase Fentanyl Test Strips Integrated reproductive health SAMHSA TIP 33 Treatment for Stimulant Use Disorders education, services and supplies, and sexually transmitted infection screening, prevention, and treatment.35,36,37,38 Onsite access or immediate Wound Care & Medical Triage for People Who Use accessible referral to basic wound Drugs and the Programs That Serve Them | NASTAD care supplies and services in the community.38 CDC Syringe Services Program Technical Package Safer Settings: Access to safe environments to live, find respite, practice safer use, and receive supports that are trauma-informed and stigma-free Day centers and social spaces SAMHSA Peer Support Services in Crisis Care that offer harm reduction services, are low barrier, and are led and maintained by the communities they serve.39 Access to safe and secure SAMHSA Homeless & Housing Resource Center housing.33,40 Public health programs as SAMHSA Criminal and Juvenile Justice Resources alternatives to arrest and any legal system involvement.20,41 Hybrid recovery community Peer Recovery Center of Excellence organizations providing peer- delivered harm reduction and recovery support services.42 Harm Reduction Framework 13  Supporting Resources and Evidence Examples of Practices (Research- and Practice-based)...(Cont.) Safer Access to Healthcare: Ensuring access to person-centered and non-stigmatizing healthcare that is trauma informed, including FDA-approved medications Low-barrier treatment services SAMHSA Practical Tools for Prescribing and Promoting that offer a whole-person Buprenorphine in Primary Care Settings approach and rapid re-initiation, if needed.43 Flexible provision of services SAMHSA Practical Tools for Prescribing and Promoting that offer medication starts at Buprenorphine in Primary Care Settings first visit or at home, choice of medications, and individualized dosages.44 Healthcare settings and providers SAMHSA Engaging Community Coalitions to Decrease are directly informed by harm Opioid Overdose Deaths Practice Guide 2023 reduction principles, pillars, and the people they serve.45,46,47 Nonpunitive care that Overcoming Stigma, Ending Discrimination consistently offers the standard of care in a nonstigmatizing, nonjudgmental manner and does not refuse healthcare based on stigma or personal beliefs about PWUD.48 Mobile access and take-home SAMHSA Methadone Take-Home Flexibilities methadone medication.49,50,51,52 Extension Guidance Mobile buprenorphine services, SAMHSA The Physical Evaluation of Patients Who Will including telehealth options Be Treated with Buprenorphine at Opioid Treatment for initiation and continuity of Programs care.53,54,55,56 Access to new paradigms of care, SAMHSA Treating Concurrent Substance Use Among including treatment specific to Adults the use of all drugs and/or each drug.57,58 Onsite or quick referral, low- Oral Health, Mental Health and Substance Use barrier oral health services that Treatment are informed by lived experience of substance use.59 14 Harm Reduction Framework  Supporting Resources and Evidence Examples of Practices (Research- and Practice-based)...(Cont.) Safer Transitions to Care: Connections and access to harm-reduction-informed and trauma-informed care and services Health hubs for PWUD/ integrated Center of Excellence for Integrated Health Solutions HIV, viral hepatitis, and healthcare services.26,38,60,61,62,63,64 CDC HIV Risk Reduction Tool Expand telehealth, while also SAMHSA Telehealth for the Treatment of Serious addressing low technology Mental Illness and Substance Use Disorders literacy and enhancing access in languages other than English.54 SAMHSA Culturally Competent LEP and Low-literacy Services Warm hand-off to and from SAMHSA Connecting Communities to Substance Use emergency department programs Services: Practical Tools for First Responders ― with low-barrier MOUD initiation and post- overdose ACA Expanding Access to Medications for Opioid Use services.38,65 Disorder in Corrections and Community Settings Medication access and treatment SAMHSA Practical Tools for Prescribing and on-demand (abstinence not Promoting Buprenorphine in Primary Care Settings required).26,66,67,68 CDC Linking People with Opioid Use Disorder to Medication Treatment Onsite or immediate referral to SAMHSA Homeless & Housing Resource Center accessible nutritional assistance, clothing, temporary shelter, and SAMHSA Expanding Access to and Use of housing.65 Behavioral Health Services for People Experiencing Homelessness Seamless coordination of care SAMHSA GAINS Center for individuals leaving carceral settings and treatment settings ACA Expanding Access to Medications for Opioid Use that do not offer medications, Disorder in Corrections and Community Settings because people are at greatly SAMHSA Best Practices for Successful Reentry from heightened risk for overdose Criminal Justice Settings for People Living With fatality when back in the Mental Health Conditions and/or Substance Use community.65 Disorders Harm Reduction Framework 15  Supporting Resources and Evidence Examples of Practices (Research- and Practice-based)...(Cont.) Sustainable Workforce and Field: Resources for maintaining a skilled, well-supported, and appropriately managed workforce and for sustaining community-based programs Organizational leadership from ASPE Methods and Emerging Strategies to Engage people with living and lived People with Lived Experience experience.26 SAMHSA Participation Guidelines for Individuals with Lived Experience and Family NHRC Peer Delivered Syringe Exchange (PDSE) Toolkit SAMHSA TIP 64: Incorporating Peer Support into Substance Use Disorder Treatment Services Living wages and essential SAMHSA National Model Standards for Peer Support benefits for harm reduction Certification workers.69,70 Wellness services and support SAMHSA National Model Standards for Peer Support for harm reduction staff and Certification volunteers without mandated abstinence.39,71 Training and technical assistance SAMHSA Practitioner Training for community-based providers.38 Include harm reduction expertise SAMHSA Grant Review Process and lived expertise in the selection process of reviewers for harm reduction grants and other competitive processes.72 Sustainable Infrastructure: Resources for building and maintaining a revitalized and community-led infrastructure to support harm reduction best practices and the needs of PWUD Hire and appropriately compensate SAMHSA National Model Standards for Peer Support PWUD to inform policy at agencies Certification that serve PWUD.73 Co-leadership of PWUD in SAMHSA National Model Standards for Peer Support organizational partnership in Certification research.74 Promote education on the value of CDC/SAMHSA National Harm Reduction Technical harm reduction services.26,75, 76,77,78,79 Assistance Center SAMHSA Harm Reduction SAMHSA National Model Standards for Peer Support Certification 16 Harm Reduction Framework Community-Based Harm Reduction Programs (CHRPs) While integrating harm reduction (as an approach and as services) into a wide variety of settings is beneficial to the people who are served and impacted by them, SAMHSA is committed to supporting harm reduction organizations that are by and for their community ― as they are mission critical for connecting to our communities’ most marginalized individuals. CHRPs describe harm reduction organizations where people with lived and living experience lead the planning and oversight, program development and evaluation, and resource/funding allocation for an organization’s harm reduction initiatives, programs, and services. CHRPs also offer the core practice areas, as permitted by law. Harm reduction activities may be integrated into a comprehensive, person-centered program of care that includes treatment services that meet the specific needs of the community in which the program is housed. In addition to programs being consistent with all aforementioned principles and pillars, CHRPs should include people with lived experience as co-investigators in any research project. Boards, staff, and team members should be at least 51 percent those with lived experience. CHRPs demonstrate meaningful connection to PWUD in their community, especially to communities most marginalized, and provide lowest-barrier, core harm reduction practices. Conclusion The Harm Reduction Summit was a groundbreaking event that engaged a diversity of perspectives across the fields of prevention, treatment, recovery, and harm reduction. More than 100 participants attended the Summit, representing the private sector, community- based organizations, health care, faith-based organizations, academia, researchers, funders, law enforcement, and leaders from federal, state, local, and tribal governments. The subsequent Steering Committee synthesized and refined the Summit findings, providing guidance for this Framework. Moving forward, this Framework will inform SAMHSA’s harm reduction activities, as well as related policies, programs, and practices. SAMHSA’s aim is to integrate harm reduction activities and approaches across its organizational Centers and initiatives, and to do so in a manner that draws on evidence- based practice and principles — while also maintaining sustained dialog with harm reductionists and PWUD. SAMHSA is committed to continued collaboration with PWUD and the field to put this Framework into practice, support and expand harm reduction approaches and services, and ultimately save lives. Harm Reduction Framework 17  References 1 Abdul-Quader, A.S., Feelemyer, J., Modi, S., & Des Jarlais, D.C. (2013). Effectiveness of structural- level needle/syringe programs to reduce HCV and HIV infection among people who inject drugs: a systematic review. AIDS Behavior, 17, 2878–2892. https://doi.org/10.1007/s10461-013- 0593-y 2 Office of National Drug Control Policy. (2022). National Drug Control Strategy. https://www. whitehouse.gov/ondcp/the-administrations-strategy/national-drug-control-strategy/ 3 Hagan, H., McGough, J.P., Thiede, H., Hopkins, S., Duchin, J., & Alexander, E.R. (2000). Reduced injection frequency and increased entry and retention in drug treatment associated with needle exchange participation in Seattle drug injectors. Journal of Substance Abuse Treatment, 19(3), 247-252. https://doi.org/10.1016/S0740-5472(00)00104-5 4 Haffajee, R.L., Sherry, T.B., Dubenitz, J.M., White, J.O., Schwartz, D., Stoller, B., & Bagalman, E. (2021). U.S. Department of Health and Human Services Overdose Prevention Strategy (Issue Brief). U.S. Department of Health and Human Services. https://aspe.hhs.gov/sites/default/files/ documents/101936da95b69acb8446a4bad9179cc0/overdose-prevention-strategy.pdf 5 Des Jarlais, D.C. (2017). Harm reduction in the USA: the research perspective and an archive to David Purchase. Harm Reduction Journal, 14, Article 51. https://doi.org/10.1186/s12954-017-0178-6 6 Centers for Disease Control. (1982). Acquired immune deficiency syndrome (AIDS): precautions for clinical and laboratory staffs. MMWR, 31(43), 577–580. https://www.cdc.gov/mmwr/preview/ mmwrhtml/00001183.htm 7 McLean K. (2011). The biopolitics of needle exchange in the United States. Critical Public Health, 21(1), 71–79. https://doi.org/10.1080/09581591003653124 8 The Public Health and Welfare Act, 42 U.S.C. § 300ee-5. (2009). Use of funds to supply hypodermic needles or syringes for illegal drug use; prohibition. https://www.govinfo.gov/ content/pkg/USCODE-2009-title42/pdf/USCODE-2009-title42-chap6A-subchapXXIII-partA- sec300ee-11.pdf 9 National Harm Reduction Coalition. (2021). Who we are. https://harmreduction.org/about-us/ 10 Wheeler, E., Jones, T.S., Gilbert, M.K., Davidson, P.J., & Centers for Disease Control and Prevention (CDC). (2015). Opioid overdose prevention programs providing naloxone to laypersons—United States, 2014. MMWR, 64(23), 631–635. https://www.cdc.gov/mmwr/preview/ mmwrhtml/mm6423a2.htm 11 Ibid. 12 Ibid. 13 Lambdin, B.H., Bluthenthal, R.N., Wenger, L.D., Wheeler, E., Garner, B., Lakosky, P., & Kral, A.H. (2020). Overdose education and naloxone distribution within syringe service programs— United States, 2019. MMWR, 69(33), 1117–1121. https://www.cdc.gov/mmwr/volumes/69/wr/ mm6933a2.htm 14 Mueller, S.R., Walley, A.Y., Calcaterra, S.L., Glanz, J.M., & Binswanger, I.A. (2015). A review of opioid overdose prevention and naloxone prescribing: implications for translating community programming into clinical practice. Substance Abuse, 36(2), 240–253. https://doi.org/10.1080/08 897077.2015.1010032 18 Harm Reduction Framework 15 Aspinall, E.J., Nambiar, D., Goldberg, D.J., Hickman, M., Weir, A., Van Velzen, E., & Hutchinson, S.J. (2014). Are needle and syringe programmes associated with a reduction in HIV transmission among people who inject drugs: a systematic review and meta-analysis. International Journal Epidemiology, 43(1), 235–248. https://pubmed.ncbi.nlm.nih.gov/24374889/ 16 van Santen, D.K., Lodi, S., Dietze, P., van den Boom, W., Hayashi, K., Dong, H., & Prins, M. (2023). Comprehensive needle and syringe program and opioid agonist therapy reduce HIV and hepatitis C virus acquisition among people who inject drugs in different settings: a pooled analysis of emulated trials. Addiction, 118(6), 1116–1126. https://pubmed.ncbi.nlm.nih. gov/36710474/ 17 Centers for Disease Control and Prevention. (2019). Summary of Information on the safety and effectiveness of Syringe Services Programs (SSPs). https://www.cdc.gov/ssp/syringe-services- programs-summary.html 18 Executive Order No. 13985, 86 Fed. Reg. 7009 (January 20, 2021). Advancing racial equity and support for underserved communities through the federal government. Federal Register. https://www.federalregister.gov/documents/2021/01/25/2021-01753/advancing-racial-equity- and-support-for-underserved-communities-through-the-federal-government 19 Substance Abuse and Mental Health Services Administration (SAMHSA). (2022). Community engagement: an essential component of an effective and equitable substance use prevention system. SAMHSA. https://store.samhsa.gov/product/community-engagement- essential-component-substance-use-prevention-system/pep22-06-01-005 20 Substance Abuse and Mental Health Services Administration (SAMHSA). (2022). Behavioral health equity. SAMHSA. https://www.samhsa.gov/behavioral-health-equity 21 Substance Abuse and Mental Health Services Administration (SAMHSA). (2020). The opioid crisis and the Black/African American population: an urgent issue. SAMHSA. https://store. samhsa.gov/product/The-Opioid-Crisis-and-the-Black-African-American-Population-An- Urgent-Issue/PEP20-05-02-001 22 Zulqarnain, J., Burk, K., Facente, S., Pegram, L., Ali, A., & Asher, A. (2020). Syringe services program: a technical package of effective strategies and approaches for planning, design, and implementation. Centers for Disease Control and Prevention. https://stacks.cdc.gov/view/ cdc/105304 23 Ditmore, M.H. (2013). When sex work and drug use overlap: considerations for advocacy and practice. Harm Reduction International. https://www.hri.global/files/2014/08/06/Sex_ work_ report_%C6%924_WEB.pdf 24 Substance Abuse and Mental Health Services Administration (SAMHSA). (2010). Shared decision- making in mental health care: practice, research, and future directions. SAMHSA. https://store. samhsa.gov/product/Shared-Decision-Making-in-Mental-Health-Care/SMA09-4371 25 Ti, L., Tzemis, D., & Buxton, J.A. (2012). Engaging people who use drugs in policy and program development: A review of the literature. Substance Abuse Treatment, Prevention, and Policy, 7(1), 47–47. https://doi.org/10.1186/1747-597X-7-47 26 Broz, D., Carnes, N., Chapin-Bardales, J., Des Jarlais, D.C., Jones, C.M., McClung, R.P., & Asher, A.K. (2021). Syringe services programs’ role in ending the HIV epidemic in the U.S.: why we cannot do it without them. American Journal of Preventive Medicine, 61(5, Suppl. 1), S118-S129. https://doi.org/10.1016/j.amepre.2021.05.044 Harm Reduction Framework 19  27 National Institute on Drug Abuse. (2022). Syringe services programs. https://nida.nih.gov/drug- topics/syringe-services-programs 28 Centers for Disease Control and Prevention. (2021). HIV prevention in the United States: mobilizing to end the epidemic. https://stacks.cdc.gov/view/cdc/103438 29 Kral, A.H., Lambdin, B.H., Browne, E.N., Wenger, L.D., Bluthenthal, R.N., Zibbell, J.E., & Davidson, P.J. (2021). Transition from injecting opioids to smoking fentanyl in San Francisco, California. Drug and Alcohol Dependence, 227, 109003. https://pubmed.ncbi.nlm.nih.gov/34482046 30 Strike, C., & Watson, T.M. (2017). Education and equipment for people who smoke crack cocaine in Canada: progress and limits. Harm Reduction Journal, 14(17). https:// harmreductionjournal.biomedcentral.com/articles/10.1186/s12954-017-0144-3 31 Centers for Disease Control and Prevention (CDC). (2023). CDC Stimulant Guide. CDC. https:// www.cdc.gov/drugoverdose/featured-topics/stimulant-guide.html#q10 32 Weiner, J., Murphy, S.M., & Behrends, C. (2019). Expanding access to naloxone: a review of distribution strategies. Leonard Davis Institute of Health Economics, Center for Health Economics of Treatment Interventions for Substance Use Disorder, HCV, and HIV. https:// ldi.upenn.edu/our-work/research-updates/expanding-access-to-naloxone-a-review-of- distribution-strategies/ 33 Park, J.N., Frankel, S., Morris, M., Dieni, O., Fahey-Morrison, L., Luta, M., & Sherman, S. (2021). Evaluation of fentanyl test strip distribution in two Mid-Atlantic syringe services programs. International Journal of Drug Policy, 94, 103196. https://pubmed.ncbi.nlm.nih.gov/33713964 34 Peiper, N.C., Clarke, S.D., Vincent, L., Ciccarone, D., Kral, A.H., & Zibbell, J.E. (2019). Fentanyl test strips as an opioid overdose prevention strategy: Findings from a syringe services program in the Southeastern United States. International Journal of Drug Policy, 63, 122–128. https:// pubmed.ncbi.nlm.nih.gov/30292493 35 Owens, L., Gilmore, K., Terplan, M., Prager, S., & Micks, S. (2020). Providing reproductive health services for women who inject drugs: a pilot program. Harm Reduction Journal, 17(47). https:// harmreductionjournal.biomedcentral.com/articles/10.1186/s12954-020-00395-y 36 Burr, C.K., Storm, D.S., Hoyt, M.J., Dutton, L., Berezny, L., Allread, V., & Paul, S. (2014). Integrating health and prevention services in syringe access programs: a strategy to address unmet needs in a high-risk population. Public Health Reports, 129(1), 26–32. https://www.ncbi.nlm.nih. gov/pmc/articles/PMC3862985 37 Centers for Disease Control and Prevention. (2022). HIV risk among persons who exchange sex for money or nonmonetary items. https://www.cdc.gov/hiv/group/sexworkers.html 38 Centers for Disease Control and Prevention. (2016). Program guidance for implementing certain components of syringe services programs. https://www.cdc.gov/hiv/pdf/risk/cdc-hiv- syringe-exchange-services.pdf 39 Olding, M., Ivsins, A., Mayer, S., Betsos, A., Boyd, J., Sutherland, C., & McNeil, R. (2020). A low- barrier and comprehensive community-based harm-reduction site in Vancouver, Canada. American Journal of Public Health, 110(6), 833–835. https://pubmed.ncbi.nlm.nih.gov/32298171/ 20 Harm Reduction Framework 40 Watson, D.P., Shuman, V., Kowalsky, J., Golembiewski, E., & Brown, M. (2017). Housing first and harm reduction: a rapid review and document analysis of the US and Canadian open access literature. Harm Reduction Journal, 14(30). https://harmreductionjournal.biomedcentral.com/ articles/10.1186/s12954-017-0158-x 41 Volkow, N.D., Poznyak, V., Saxena, S., Gerra, G., & UNODC-WHO Informal International Scientific Network (2017). Drug use disorders: impact of a public health rather than a criminal justice approach. World Psychiatry, 16(2), 213–214. https://doi.org/10.1002/wps.20428 42 Ashford, R.D., Brown, A.M., McDaniel, J., Neasbitt, J., Sobora, C., Riley, R., & Curtis, B. (2019). Responding to the opioid and overdose crisis with innovative services: the Recovery Community Center Office-Based Opioid Treatment (RCC-OBOT) model. Addictive Behaviors, 98, 106031. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7286074/ 43 Aronowitz, S.V., Navos Behrends, C., Lowenstein, M., Schackman, B.R., & Weiner, J. (2022). Lowering the barriers to medication treatment for people with opioid use disorder. Leonard Davis Institute of Health Economics, Center for Health Economics of Treatment Interventions for Substance Use Disorder, HCV, and HIV. https://ldi.upenn.edu/wp-content/uploads/2022/01/ Penn-LDI.CHERISH-Issue-Brief.January-2022.pdf 44 Jakubowski A., & Fox A. (2020). Defining low-threshold buprenorphine treatment. Journal of Addiction Medicine, 14(2), 95–98. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7075734/ 45 Hawk, M., Coulter, R.W., Egan, J.E., Fisk, S., Reuel Friedman, M., Tula, M., & Kinsky, S. (2017). Harm reduction principles for healthcare settings. Harm Reduction Journal, 14, Article 70. https://harmreductionjournal.biomedcentral.com/articles/10.1186/s12954-017-0196-4 46 Khan, G.K., Harvey, L., Johnson, S., Long, P., Kimmel, S., Pierre, C., & Drainoni, M.-L. (2022). Integration of a community-based harm reduction program into a Safety Net Hospital: A qualitative study. Harm Reduction Journal, 19, Article 35. https://harmreductionjournal. biomedcentral.com/articles/10.1186/s12954-022-00622-8 47 Krawczyk, N., Allen, S.T., Schneider, K.E., Solomon, K., Shah, H., Morris, M., & Saloner, B. (2022). Intersecting substance use treatment and harm reduction services: exploring the characteristics and service needs of a community-based sample of people who use drugs. Harm Reduction Journal, 19, Article 95. https://pubmed.ncbi.nlm.nih.gov/36002850/ 48 Muncan, B., Walters, S.M., Ezell, J., & Ompad, D.C. (2020). “They look at us like junkies”: Influences of drug use stigma on the healthcare engagement of people who inject drugs in New York City. Harm Reduction Journal, 17, Article 53. https://doi.org/10.1186/s12954-020- 00399-8 49 Chan, B., Hoffman, K.A., Bougatsos, C., Grusing, S., & Chou, R. (2021). Mobile methadone medication units: A brief history, scoping review and research opportunity. Journal of Substance Abuse Treatment, 129, Article 108483. https://pubmed.ncbi.nlm.nih.gov/34080541/ 50 Greenfield, L., Brady, J.V., Besteman, K.J., & De Smet, A. (1996). Patient retention in mobile and fixed-site methadone maintenance treatment. Alcohol and Drug Dependence, 42, 125–131. https://pubmed.ncbi.nlm.nih.gov/8889411/ 51 Frank, D. Mateu-Gelabert, P., Perlman, D.C., Walters, S.M., Curran, L., & Guarino, H. (2021). “It’s like ‘liquid handcuffs’”: The effect of take-home dosing policies on methadone maintenance treatment (MMT) patients’ lives. Harm Reduction Journal, 18, Article 88. https://doi.org/10.1186/ s12954-021-00535-y Harm Reduction Framework 21  52 Amram, O., Amiri, S., Panwala, V., Lutz, R., Joudrey, P.J. & Socias, E. (2021). The impact of relaxation of methadone take-home protocols on treatment outcomes in the COVID-19 era. American Journal of Drug and Alcohol Abuse, 47(6), 722–729. https://www.tandfonline.com/ doi/abs/10.1080/00952990.2021.1979991?journalCode=iada20 53 Rosecrans, A., Harris, R., Saxton, R.E., Cotterell, M., Zoltick, M., Willman, C., & Page, K.R. (2022). Mobile low- threshold buprenorphine integrated with infectious disease services. Journal of Substance Abuse Treatment, 133, Article 108553. https://doi.org/10.1016/j.jsat.2021.108553 54 Inheanacho, T., Payne, K., & Tsai, J. (2020). Mobile, community-based buprenorphine treatment for veterans experiencing homelessness with opioid use disorder: a pilot, feasibility study. American Journal of Addiction, 29(6), 485–491. https://pubmed.ncbi.nlm.nih.gov/32367557/ 55 Krawczyk, N., Buresh, M., Gordon, M.S., Blue, T.R., Fingerhood, M.I., & Agus, D. (2019). Expanding low-threshold buprenorphine to justice-involved individuals through mobile treatment: Addressing a critical care gap. Journal of Substance Abuse Treatment, 103, 1–8. https:// pubmed.ncbi.nlm.nih.gov/31229187 56 Gibson, B.A., Morano, J.P., Walton, M.R., Marcus, R., Zelenev, A., Bruce, R.D., & Altice, F.L. (2017). Innovative program delivery and determinants of frequent visitation to a mobile medical clinic in an urban setting. Journal of Health Care for the Poor and Underserved, 28(2), 643– 662. https://pubmed.ncbi.nlm.nih.gov/28529215 57. Robbins, J.L., Englander, H., & Gregg, J. (2021). Buprenorphine microdose induction for the management of prescription opioid dependence. Journal of the American Board of Family Medicine, 34, S141–S146. https://pubmed.ncbi.nlm.nih.gov/33622829/ 58 Randhawa, P.A., Brar, R., & Nolan, S. (2020). Buprenorphine-naloxone “microdosing”: an alternative induction approach for the treatment of opioid use disorder in the wake of North America’s increasingly potent illicit drug market. Canadian Medical Association Journal, 192(3). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6970598/#:~:text=Officially%20 recognized%20as%20the%20Bernese,over%20time%20(Box%201). 59 National Council for Mental Wellbeing. (2021). Oral health, mental health and substance use treatment. https://www.thenationalcouncil.org/wp-content/uploads/2021/09/NC_CoE_ OralhealthMentalHealthSubstanceUseChallenges_Toolkit.pdf?daf=375ateTbd56&sc_cid=SG_ Refer_blog_mouth-body-connection_link-between-mental-health-and-oral-health 60 Palmateer, N., Hamill, V., Bergenstrom, A., Bloomfield, H., Gordon, L., Stone, & Hutchinson, S. (2022). Interventions to prevent HIV and hepatitis C among people who inject drugs: latest evidence of effectiveness from a systematic review (2011 to 2020). International Journal of Drug Policy, 109, Article 103872. https://doi.org/10.1016/j.drugpo.2022.103872 61 Rich, K.M., Bia, J., Altice, F.L. et al. (2018). Integrated models of care for individuals with opioid use disorder: how do we prevent HIV and HCV?. Current HIV/AIDS Reports, 15, 266–275. https:// doi.org/10.1007/s11904-018-0396-x 62 Mette, E. (2020). Q&A: A deep dive into New York’s Drug User Health Hubs with New York’s Allan Clear. National Academy for State Health Policy. https://www.nashp.org/qa-a-deep-dive- into-new-yorks-drug-user-health-hubs-with-new-yorks-allan-clear/ 22 Harm Reduction Framework 63 Eckhardt, B., Mateu-Gelabert, P., Aponte-Melendez, Y., Fong, C., Kapadia, S., Smith, M., Edlin, B. R., & Marks, K.M. (2022). Accessible hepatitis C care for people who inject drugs: a randomized clinical trial. JAMA Internal Medicine, 182(5), 494–502. https://jamanetwork.com/ journals/jamainternalmedicine/fullarticle/2790054 64 Bartholomew, T.S., Tookes, H.E., Serota, D.P., Behrends, C.N., Forrest, D.W., & Feaster, D.J. (2020). Impact of routine opt-out HIV/HCV screening on testing uptake at a syringe services program: an interrupted time series analysis. International Journal of Drug Policy, 84, Article 102875. https://pubmed.ncbi.nlm.nih.gov/32731112 65 Substance Abuse and Mental Health Services Administration (SAMHSA). (2022). Harm Reduction. SAMHSA. https://www.samhsa.gov/find-help/harm-reduction 66 Platt, L., Minozzi, S., Reed, J., Vickerman, P., Hagan, H., French, C., & Hickman, M. (2017). Needle syringe programmes and opioid substitution therapy for preventing hepatitis C transmission in people who inject drugs. Cochrane Database of Systematic Reviews, 9, CD012021. https:// pubmed.ncbi.nlm.nih.gov/28922449/ 67 Weinstein, Z.M., Cheng, D.M., D’Amico, M.J., Forman, L.S., Regan, D., Yurkovic, A., Samet, J.H., & Walley, A.Y. (2020). Inpatient addiction consultation and post-discharge 30-day acute care utilization. Drug and Alcohol Dependence, 213, 108081. https://doi.org/10.1016/j. drugalcdep.2020.108081 68 Payne, B.E., Klein, J.W., Simon, C.B., James, J.R., Jackson, S.L., Merrill, J.O., Zhuang, R., & Tsui, J.I. (2019). Effect of lowering initiation thresholds in a primary care-based buprenorphine treatment program. Drug and Alcohol Dependence, 200, 71–77. https://pubmed.ncbi.nlm.nih. gov/31103879/ 69 Olding, M., Barker, A., McNeil, R., & Boyd, J. (2021). Essential work, precarious labour: the need for safer and equitable harm reduction work in the era of COVID-19. International Journal of Drug Policy, 90, Article 103076. https://pubmed.ncbi.nlm.nih.gov/33321286/ 70 Greer, A., Bungay, V., Pauly, B., & Buxton, J. (2020). ‘Peer’ work as precarious: A qualitative study of work conditions and experiences of people who use drugs engaged in harm reduction work. International Journal of Drug Policy, 85, Article 102922. https://pubmed.ncbi.nlm.nih. gov/32911320/ 71 Shepard, B.C. (2013). Between harm reduction, loss and wellness: on the occupational hazards of work. Harm Reduction Journal, 10(5). https://harmreductionjournal.biomedcentral.com/ articles/10.1186/1477-7517-10-5 72 Rittenbach, K., Horne, C.G., O’Riordan, T., Bichel, A., Mitchell, N., Fernandez Parra, A.M., & MacMaster, F.P. (2019). Engaging people with lived experience in the grant review process. BMC Medical Ethics, 20, Article 95. https://doi.org/10.1186/s12910-019-0436-0 73 Marshall, Z., Dechman, M.K., Minichiello, A., Alcock, L., & Harris, G.E. (2015). Peering into the literature: A systematic review of the roles of people who inject drugs in harm reduction initiatives. Drug and Alcohol Dependence, 151, 1–14. https://pubmed.ncbi.nlm.nih. gov/25891234/ 74 Brown, G., Crawford, S., Perry, G.E., Byrne, J., Dunne, J., Reeders, D., & Jones, S. (2019). Achieving meaningful participation of people who use drugs and their peer organizations in a strategic research partnership. Harm Reduction Journal, 16(1), 37. https://harmreductionjournal. biomedcentral.com/articles/10.1186/s12954-019-0306-6 Harm Reduction Framework 23  75 Fernandez-Vina, M.H., Prood, N.E., Herpolsheimer, A., Waimber, J., & Burris, S. (2020). State laws governing syringe services programs and participant syringe possession, 2014–2019. Public Health Reports, 135(S1), 128S–137S. https://pubmed.ncbi.nlm.nih.gov/32735195/ 76 Davis, C.S., Burris, S., Kraut-Becher, J., Lynch, K.G., & Metzger, D. (2005). Effects of an intensive street-level police intervention on syringe exchange program use in Philadelphia, Pa. American Journal of Public Health, 95(2), 233–236. https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC1449157/ 77 Jones, C.M. (2019). Syringe services programs: An examination of legal, policy, and funding barriers in the midst of the evolving opioid crisis in the U.S. International Journal of Drug Policy, 70, 22–32. https://pubmed.ncbi.nlm.nih.gov/31059965/ 78 Cloud, D.H., Castillo, T., Brinkley-Rubinstein, L., Dubey, M., & Childs, R. (2018). Syringe decriminalization advocacy in red states: lessons from the North Carolina Harm Reduction Coalition. Current HIV/AIDS Reports, 15(3), 276–282. https://doi.org/10.1007/s11904-018-0397-9 79 Clark, P.A. & Fadus, M. (2010). Federal funding for needle exchange programs. Medical Science Monitor, 16(1). https://pubmed.ncbi.nlm.nih.gov/20037499/ 24 Harm Reduction Framework Harm Reduction Steering Committee Members Mark Jenkins Justine Waldman Founder and Executive Director Founder and Chief Executive Officer Connecticut Harm Reduction Alliance REACH Medical Hartford, CT Ithaca, NY Elizabeth Burden Rafael Rivera Senior Advisor Deputy Director National Council for Mental Wellbeing Bureau of Prevention Services, Illinois Phoenix, AZ Department of Human Services Chicago, IL Jessica Tilley Founder Louise Vincent HRH413 Executive Director Northampton, MA North Carolina Urban Survivors Union Greensboro, NC Hiawatha Collins Community and Capacity Building Manager Christine Rodriguez National Harm Reduction Coalition Senior Program Manager New York, NY AIDS United Washington, DC Sherrine Peyton State Opioid Settlement Administrator Philomena Kebec Illinois Department of Human Services Economic Development Coordinator Chicago, IL Bad River Tribe Odanah, WI Rafael A. Torruella Executive Director Caty Simon Intercambios Puerto Rico Leadership Team Member Fajardo, PR Urban Survivors Union Holyoke, MA Maya Doe-Simkins Co-Founder Stephanie Campbell Harm Reduction Michigan Behavioral Ombudsman Project Director Traverse City, MI New York State Office of Addiction Services and Supports Chad Sabora Albany, NY Vice President of Government and Public Relations Anthony D. Salandy Indiana Center for Recovery Interim Executive Director, Managing Director St. Louis, MO of Programs National Harm Reduction Coalition Marielle A. Reataza New York, NY Executive Director National Asian Pacific American Families Chase Holleman Against Substance Abuse Public Health Analyst Alhambra, CA Substance Abuse and Mental Health Services Administration (SAMHSA) Charles King Greensboro, NC Chief Executive Officer Housing Works Shannon Mace New York, NY Executive Director Legal Assistance Project: A Medical-Legal Partnership Philadelphia, PA Harm Reduction Framework 25 [This page is intentionally blank.] [This page is intentionally blank.]  Substance Abuse and Mental Health Services Administration SAMHSA’s mission is to lead public health and service delivery efforts that promote mental health, prevent substance misuse, and provide treatments and supports to foster recovery while ensuring equitable access and better outcomes. 1-877-SAMHSA-7 (726-4727) 1-800-487-4889 (TTY) www.samhsa.gov