Implementation and sustainability of hospital-based harm reduction delivery: a qualitative analysis

Patients with substance use disorders (SUD) face several challenges when hospitalized, including stigma, undertreated withdrawal and pain, and higher rates of self-directed discharge. Hospital-based harm reduction services can support patients with SUD, increase engagement, build trust, and catalyze culture change. Our hospital's Addiction Consult Team implemented a harm reduction program to provide education and substance use equipment to hospitalized patients whose SUD goals did not include abstinence. We conducted a qualitative evaluation of our harm reduction program to identify implementation and sustainability themes for long-term success.

This qualitative study consisted of semi-structured interviews conducted between October 2022 and March 2023 with hospitalized patients receiving harm reduction services and hospital staff at an urban safety-net hospital in San Francisco, California. Interviews were audio-recorded and transcribed with informed participant consent. Transcripts were deductively and inductively coded through an iterative process, and we used thematic analysis to identify themes.

We interviewed 20 patients and 20 staff participants with interviews ranging from 30-45 min. We identified three themes related to implementation and three related to sustainability. Implementation themes were: (1) Operational barriers, including time constraints, lack of clearly defined roles, and competing demands, challenged delivery of harm reduction kits; (2) Tension between generalized versus specialized harm reduction program ownership limited impact; and (3) Educational gaps impeded broader harm reduction uptake and reinforced stigma. Sustainability themes were: (1) Experiential learning reinforced harm reduction practice and culture change; (2) Interprofessional collaboration, especially involving SUD champions, supported the program; and (3) Sharing patient success stories helped overcome stigma and burnout and highlighted harm reduction effectiveness.

Harm reduction program implementation was challenged by resource constraints, complexity of program ownership, and lack of SUD knowledge. In contrast, experiential learning, interprofessional collaboration, and sharing patient successes sustained harm reduction efforts. Based on these findings, we recommend the following for long-term harm reduction program success: operationalize harm reduction workflow via hospital-wide interprofessional efforts; incorporate continuous, multimodal substance use training with all staff to ensure a baseline knowledge and drive culture change; and create feedback processes to share patient outcomes and narratives with staff.