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Federal government websites often end in. The site is secure. Preview improvements coming to the PMC website in October Learn More or Try it out now. Opioid use disorder OUD is increasingly recognized as a chronic, relapsing brain disease whose treatment should be integrated into primary care settings alongside other chronic conditions. However, abstinence from all non-prescribed substance use continues to be prioritized as the only desired goal in many outpatient, primary care—based treatment programs. This presents a barrier to engagement for patients who continue to use substances and who may be at high risk for complications of ongoing substance use such as human immunodeficiency virus HIV , hepatitis C virus HCV , superficial and deep tissue infections, and overdose. Harm reduction aims to reduce the negative consequences of substance use and offers an alternative to abstinence as a singular goal. Incorporating harm reduction principles into primary care treatment settings can support programs in engaging patients with ongoing substance use and facilitate the delivery of evidence-based screening and prevention services. The objective of this narrative review is to describe strategies for the integration of evidence-based harm reduction principles and interventions into outpatient, primary care—based OUD treatment settings. We will offer specific tools for providers and programs including strategies to support safer injection practices, assess the risks and benefits of continuing medications for opioid use disorder in the setting of ongoing substance use, promote a non-stigmatizing program culture, and address the needs of special populations with ongoing substance use including adolescents, parents, and families. The online version contains supplementary material available at A year-old woman presents to an office-based addiction treatment program embedded within her primary care practice. She reports that she started using prescription opioids when she was 16 and transitioned to injecting heroin at age She also uses smoked and intravenous cocaine. She has tried going to inpatient medically managed withdrawal i. She has had three opioid overdoses in the past month and wants to stop using heroin. She has tried diverted buprenorphine, which helped manage opioid withdrawal temporarily, and she thinks that it would be easier and safer to have a prescription. However, she wonders if buprenorphine will control her opioid cravings and she is not ready to stop using cocaine. The patient felt anxious coming to her primary care doctor, having experienced stigma when she has sought medical care in the past. Patients in her situation often face barriers to engagement in outpatient opioid use disorder treatment settings. In the review below, we outline strategies to integrate harm reduction principles and interventions into primary care—based programs in order to optimize the care of patients who continue to use substances. For many years, opioid use disorder OUD and other substance use disorders SUD were erroneously viewed as a moral failing and not an illness. Even with the increasingly broad recognition of SUD as a chronic, relapsing brain disease, abstinence from all non-prescribed substance use continues to be prioritized as the only desired goal in many treatment settings, including in outpatient programs offering medications for opioid use disorder MOUD. Furthermore, harm reduction interventions have conclusively demonstrated a positive impact on patient and population-level outcomes. We offer specific tools that providers and programs can use to support safer injection practices, assess the risks and benefits of continuing MOUD in the setting of ongoing substance use, promote a non-stigmatizing program culture, and address the needs of special populations who continue to use substances including adolescents, parents, and families. Overdose education and naloxone distribution to people with OUD, family, friends, first responders, and other community members is a potent intervention that reduces opioid overdose fatalities. Additionally, the ability to provide naloxone in clinic is important for patients who experience barriers to picking it up at the pharmacy. Local departments of public health can advise on direct naloxone distribution and any local regulations allowing retroactive billing. In addition to providing intranasal naloxone, providers and team members should counsel patients on strategies to reduce the risk of overdose, including minimizing mixing of substances. Reverse motion detectors are a new tool that may help prevent overdose fatalities by alerting staff when someone enters a bathroom and becomes unresponsive. Although efficacy data on fatal overdose prevention are not yet available, reverse motion detectors have been implemented in several types of outpatient settings and are viewed as an acceptable tool by public safety. A multidisciplinary approach involving both providers and nurse care managers can promote access for patients with high needs. Teams may also be able to reduce visit burden by offering telemedicine appointments and by non-standard communication strategies e. Integrating harm reduction principles into treatment involves prioritizing patient perspective and choice around medication selection and dose using a shared decision-making framework. Where possible, OUD treatment programs should offer all FDA-approved MOUD, including sublingual buprenorphine, monthly injectable buprenorphine, monthly injectable naltrexone, and—if licensed as an opioid treatment program—methadone. Programs that are not licensed to dispense methadone should have the capacity to rapidly refer. If a lack of identification is expected to present barriers to prescription access at pharmacies, this should be addressed. Patients initiating buprenorphine should be offered the option of doing their induction in the office or in the community, depending on their preference. Handouts that walk patients through the community induction protocol may help facilitate buprenorphine initiation outside the office. New induction protocols, including microdosing and higher initial buprenorphine doses, may also be effective in mitigating the risk of precipitated withdrawal due to protracted fentanyl washout periods. Central to a harm reduction approach is to not require abstinence from other substances, including benzodiazepines, to continue OUD treatment. Instead of requirements that patients avoid other substances, teams should work with them to address other substance use disorders and risky substance use over time. This includes offering outpatient medically managed withdrawal for alcohol and benzodiazepines for eligible patients with barriers to inpatient treatment. In addition to regulatory concerns, when patients divert prescribed buprenorphine, they do not accrue the overdose prevention or OUD stabilization benefits of the medication, thus warranting a change in treatment approach, which may include shorter prescriptions, daily observed dosing, or referral to an opioid treatment program. Additionally, teams should offer FDA-approved medications for alcohol use disorder including naltrexone n. For patients with severe stimulant use disorder, contingency management is an evidence-based intervention and can be accomplished outside of formal programs by offering small rewards for recovery-focused behaviors, including attending appointments and providing expected UDT. Anecdotally, this has not impacted engagement in care. When checking a UDT, it is recommended to ask the patient—prior to the test—what substances they expect to appear in the result. Reflex testing for fentanyl and norfentanyl levels can also help with interpretation of a positive screen. Recent data suggest that renal clearance of fentanyl may take longer than 2—4 days, this has implications for provider and patient expectations for when a UDT will revert to negative. Taking an accurate, non-judgmental history is integral to incorporating harm reduction principles. Address both injection-related and sexual risk behaviors, asking about sexual practices and partners in a way that does not assume heterosexuality or binary gender identity. Electronic medical record templates that standardize assessment for overdose and HIV risk may support providers in incorporating these conversations consistently during visits see Supplement 1 for sample template. Additionally, if prepared to offer resources, we suggest screening patients for intimate partner violence and trafficking. Primary care OUD treatment settings can fill significant gaps in infection screening, prevention, and treatment services for PWID and other people who use substance who are at high risk of HIV, viral hepatitis, sexually transmitted infections, and bacterial superficial and deep tissue infections. Also consider screening for trichomonas in patients at risk A growing body of evidence supports the success of hepatitis C virus HCV treatment in primary care and OUD treatment settings, including among patients with ongoing injection drug use. Rapid HIV tests should be made available for patients who cannot or will not undergo phlebotomy, and for those who benefit from receiving results during a visit e. Local departments of public health may be able to provide free condoms to treatment settings or direct programs to resources. Primary care providers are well-positioned to deliver PrEP alongside other preventive health resources. Finally, people with ongoing substance use benefit from the availability of basic wound care services, including incision and drainage of simple abscesses, to address superficial bacterial complications of injection and mitigate the high burden of preventable Emergency Department visits as well as more serious systemic infections. An additional strategy that OUD treatment programs can employ to reduce infectious complications of injection is to provide injection equipment. Talk to patients about local regulations related to syringe access e. Providers living in an area with limited access to syringe service programs and over-the-counter syringes should consider writing prescriptions for syringes, alcohol swabs, and other supplies. Integral to supporting a harm reduction framework within primary care OUD treatment programs is offering counseling on ways to reduce the risks of ongoing substance use. Recognizing that people who use drugs have significant expertise in keeping themselves safe, providers should ask about the strategies they currently use to reduce the risk of infection and overdose. Once providers have an understanding of how patients use substances, they will be more empowered to discuss strategies to make behavior safer, which may include, for example, changing the way skin is cleaned prior to injection. Knowing and collaborating with local harm reduction specialists and syringe service programs can help providers develop their referral networks and provide patient-centered harm reduction resources. Creating a therapeutic treatment environment is critical to engaging patients with ongoing substance use, who have often experienced stigma, discrimination, and mistrust in primary care settings. Based on local resources, training could span a continuum from incorporating information about non-stigmatizing language and de-escalation strategies in the onboarding of new staff to organizing formal skills practice trainings for all team members. Programs may also consider offering hygiene kits, coffee, clean socks, a change of clothes, art supplies, or places to charge a cell phone to demonstrate awareness of the needs many people who use drugs face beyond their medical care. Importantly, patients who are Black, Indigenous, and People of Color BIPOC continue to experience significant disparities in OUD treatment access related to structural and interpersonal racism, including the application of criminal versus therapeutic medical approaches to SUD communities of color. Mutual support organizations, including Alcoholics Anonymous, Narcotics Anonymous, and SMART Recovery, recovery coaches, sober gyms, running groups, and step yoga may be helpful for some patients. Women with SUD have unmet contraception needs and experience high rates of unplanned pregnancy. Care should be taken to avoid coercion in contraception acceptance and method selection. Overall, the increasing integration of OUD treatment in primary care settings has improved access and, in many cases, reduced the stigma associated with SUD treatment. However, many outpatient OUD treatment programs continue to promote abstinence from non-prescribed substances as the only acceptable treatment goal, which risks alienating patients with ongoing substance use, a population with much to gain from primary and preventive services. Incorporating evidence-based harm reduction strategies into primary care—based OUD treatment settings will support programs in engaging patients earlier on the OUD care cascade—such as the patient in our vignette—and improving safety, respect, and autonomy for all patients with OUD. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. As a library, NLM provides access to scientific literature. J Gen Intern Med. Published online Jun Jessica L. Bagley , MD, MSc 1, 2, 7. Jessica R. Sarah M. Taylor, Email: ude. Corresponding author. Received Dec 11; Accepted Apr Abstract Opioid use disorder OUD is increasingly recognized as a chronic, relapsing brain disease whose treatment should be integrated into primary care settings alongside other chronic conditions. Supplementary Information The online version contains supplementary material available at Open in a separate window. Counsel on Other Overdose Prevention Strategies In addition to providing intranasal naloxone, providers and team members should counsel patients on strategies to reduce the risk of overdose, including minimizing mixing of substances. Table 2 Standard Intake Lab Panel. Provide Other Harm Reduction Supplies in the Clinic An additional strategy that OUD treatment programs can employ to reduce infectious complications of injection is to provide injection equipment. 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