Addressing the Opioid Crisis Through Community-Based Harm Reduction Programs

Addressing the Opioid Crisis Through Community-Based Harm Reduction Programs | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Addressing the Opioid Crisis Through Community-Based Harm Reduction Programs Ssembuusi Allan Francis, Eloghosa Nosa-Ihaza This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8845536/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract This systematic review synthesises evidence on the community-based harm reduction program and its role in the opioid crisis, based on 78 studies published between 2012 and April 2023. The review reviewed the key interventions, such as syringe service programs (SSPs), overdose education and naloxone distribution (OEND), overdose prevention centres (OPCs), drug-checking (e.g., fentanyl test strips), and low-barrier medication for opioid use disorder (MOUD) and assessed the outcomes of overdose mortality, infectious disease transmission, linkage to care, and program feasibility. Quality and reliable evidence suggest that OEND scale-up is linked to quantifiable decreases in overdose mortality, SSPs have significant effects on the reduction of HIV and HCV infections, and OPCs report no on-site deaths with a large volume of visits and enhanced service utilisation. Co-located services and integrated SSP-MOUD models have an incomparable effect on boosting MOUD initiation and retention. Combined methods of SSP, naloxone, and MOUD have favourable cost-effectiveness ratios, according to a cost-effectiveness analysis. Chronic obstacles include punitive paraphernalia legislation, unreliable short-term financing, regulatory barriers, stigma, and service gaps in rural areas that undermine scale and fairness. The review identifies important gaps in implementation science, the longitudinal efficacy of newer interventions (e.g., OPCs, drug-checking), and interventions to decrease multi-level stigma. There are policy implications of integrating harm reduction into the everyday health infrastructure through steady funding, deregulation to increase the number of providers, mobile and mail models of rural access, and intentional communication with the public to promote legitimacy. To sum up, community-based harm reduction is an evidence-based, life-saving model of public health; now is the time to learn how to translate efficacy into equitable, sustainable implementation at scale. Harm reduction Opioid overdose prevention Naloxone distribution Syringe service programs (SSPs) Medication for opioid use disorder (MOUD) Overdose prevention centers (OPCs) Figures Figure 1 Figure 2 1 Introduction 1.1 Background on the opioid crisis The opioid crisis is a multifaceted human-made public health crisis, characterised by devastating addiction and overdose mortality rates.( 1 ) It is commonly believed to have its roots in the general over-prescription of pharmaceutical opioids that started in the 1990s and planted the seeds of dependency in communities nationwide. This initial wave of policy was inconsistent as it alternated between punitive criminal justice and traditional abstinence-based treatment models.( 2 , 3 ) These strategies were not effective, being unable to control the increasing death rates, as well as being unable to reach out to the increasing number of people who are not part of the traditional healthcare systems.( 4 ) Since then, the crisis has passed through several phases, each very deadly. The shift to heroin was succeeded by a second wave, which was characterised by the rise of the illicit synthetic opioid market, which, as of today, is characterised by the presence of fentanyl. This powerful, unpredictable drug has reached unprecedented levels of overdose deaths, causing a societal cost that has never been seen before.( 5 , 6 ) This present stage has served as a sadistic stress test, highlighting fundamental, systemic vulnerabilities in the delivery of healthcare, social care, and economic policy. The current situation, consequently, creates a pressing need: to go beyond the cycles of the past and introduce evidence-based interventions to save lives in the present and build trust with the marginalised population that remains at the greatest risk.( 7 , 8 ) 1.2 Role of Community-Based Harm Reduction Programs In the face of this overwhelming reality, an immediate and caring response has emerged in the community most severely affected. Harm reduction programs at the community level meet people where they are, both physically and figuratively.( 9 ) Their precept is plain, but deep, the alleviation of immediate agony, the sparing of life, without reproach or violence, as an initial step to recovery and sanity. These initiatives make this principle a reality by applying critical evidence-based services.( 10 ) This will involve making syringes clean so that no one gets sick, delivering the overdose-reversal medication naloxone directly to the most at-risk individuals to witness an overdose, offering low-barrier access to life-stabilising drugs for opioid use disorder, and ensuring that there is a safe place where drugs can be used under supervision. They succeed by building trust with people who use drugs, a group often failed by traditional systems.( 11 , 12 ) An exchange is way too small compared to a syringe service program; e.g., it is frequently the only and first point of compassionate contact for a person with the healthcare system, where he/she may also have his/her wound treated, get a hepatitis test, or have a warm meal.( 13 , 14 ) More importantly, these interdependent connections lead to a longer-term path of treatment and recovery assistance. The most obvious way to realise this life-saving mission, perhaps, is to lend naloxone to friends, family, and peers. This approach has transformed the non-rescuers into first responders, and it cannot be denied that the strategy has reduced mortality rates in the communities.( 15 , 16 ) Likewise, overdose prevention centres, which are safe havens that have trained staff on board, have demonstrated that they can halt death in its tracks, refer people to care and do so in a non-lethal way that does not adversely affect the local neighbourhood.( 17 , 18 ) Essentially, these programs provide a continuum of care that begins with the simple aim of sustaining life by addressing human connection, safety, and dignity. They provide a physical lifeline during a crisis characterised by isolation and loss.( 19 ) 1.3 Research Gaps Community-based harm reduction is susceptible to scaling and integration due to very serious impediments, even though it has proven to be an effective intervention. The first drawback is the lack of implementation science and cost-effectiveness evidence across various geographical and socio-political settings, especially in rural and underserved areas, where stigmatisation and logistical barriers are urgent, as emphasised in the latest global recommendations of the World Health Organisation.( 20 – 22 ) Although urban models are more widely documented, there is limited evidence on the adaptation and maintenance of services in urban regions. The evidence base for newer interventions, such as overdose prevention centres and fentanyl test strip distribution, requires further longitudinal and comparative effectiveness research.( 23 , 24 ) Additionally, more robust data is needed to quantify the broader public health impact of integrated harm reduction hubs, including effects on healthcare utilisation, criminal justice involvement, and community well-being.( 25 ) A critical and persistent gap is the lack of systematic, multi-level interventions to reduce stigma among healthcare providers, policymakers, and the public. An empirical investigation into effective educational and contact-based strategies is essential to shift attitudes and build the political support necessary for policy change. Addressing these gaps is fundamental to translating these life-saving interventions into standardised, scalable components of the public health infrastructure.( 26 – 28 ) 1.4 Objective of the review This review aims to consolidate the current evidence on the role of community-based harm reduction programs in addressing the opioid crisis. Its primary objectives are to: Determine how core interventions such as syringe service programs (SSPs), overdose education and naloxone distribution (OEND), overdose prevention centres (OPCs) and low-barrier care models affect mortality due to overdose, prevent infectious disease, and increase access to treatment and healthcare services. Identify the key barriers and facilitators that affect the implementation, scaling, and long-term sustainability of these programs across diverse community settings. Outline the major gaps in the existing literature to inform future research priorities in implementation science, cost-effectiveness analysis, and strategies to reduce structural and social stigma. By synthesising this evidence, this review aims to inform public health policy, clinical practice, and future research to build an evidence-based response to the current public health emergency. 2 Methods 2.1 Search strategy A strategic literature search was conducted to identify articles published from January 1, 2012, to April 30, 2023. This period was chosen to embrace the time frame that would best reflect the emergence of the illicit fentanyl market and how it has been responsible for a great number of overdose deaths.( 29 , 30 ) The search has been conducted in the following large electronic databases: MEDLINE (through PubMed), PsycINFO, CINAHL Complete, Scopus, Web of Science Core Collection, and Sociological Abstracts. The search strategy used standardised subject headings, as well as free-text keywords of three key concepts, which were The Opioid Crisis, e.g., "Opioid-Related Disorders," fentanyl, overdose, Harm Reduction Interventions, e.g., "Harm Reduction," naloxone, syringe services, supervised consumption, Community-Based Settings, e.g., Community Health Services, grassroots, outreach. Besides that, important policy guidelines and seminal studies published in 2024 were individually examined to put the findings into perspective, but did not feature in the actual systematic synthesis. The search strategy shown in Table 1 is applicable to PubMed. Only English language publications were searched. The reference list of all the included articles and systematic reviews that were relevant was screened manually to include additional studies to have a comprehensive coverage. Table 1 PubMed/MEDLINE Search Strategy (January 1, 2012-April 30, 2023) Concept Search Terms Opioid Crisis "Opioid-Related Disorders"[Mesh] OR "Opioid Epidemic"[Mesh] OR "Drug Overdose"[Mesh] OR opioid crisis[tiab] OR opioid epidemic[tiab] OR overdose crisis[tiab] OR fentanyl[tiab] Harm Reduction "Harm Reduction"[Mesh] OR "Needle-Exchange Programs"[Mesh] OR "Naloxone"[Mesh] OR "harm reduction"[tiab] OR "syringe service"[tiab] OR "needle exchange"[tiab] OR naloxone[tiab] OR narcan[tiab] OR "supervised consum"[tiab] OR "overdose prevention center"[tiab] OR "safe consumption site"[tiab] OR "drug checking"[tiab] OR "fentanyl test strip"[tiab] Community-Based "Community Health Services"[Mesh] OR "Community-Based Participatory Research"[Mesh] OR community based[tiab] OR community-based[tiab] OR grassroots[tiab] OR "peer led"[tiab] OR "street outreach"[tiab] OR "mobile unit"[tiab] Combined #1 AND #2 AND #3 *Filters: English, Publication Date from 2012/01/01 to 2023/04/30* 2.2 Inclusion and Exclusion Criteria Precisely established eligibility criteria were used to guide the study selection process, and screening was conducted by two independent reviewers in two phases (title/abstract and full-text). The discrepancies were resolved either by discussion or by referring them to a third reviewer. We have factored in the studies that dealt with individuals with opioid use disorder (OUD) or opioid users, and also the stakeholders, like staff in the program, individuals in the community or even policy makers in the affected communities.( 31 , 32 ) The types of eligible interventions were community-based harm reduction programs, e.g., syringe service programs (SSP), overdose education and naloxone distribution (OEND), overdose prevention centres (OPC), drug checking services (e.g., fentanyl test strips), and low-barrier access to medications used to address OUD (MOUD).( 33 – 35 ) The relevant outcomes required in studies included overdose rates, transmission of infectious diseases, connection with care, and indicators of program feasibility, acceptability, or cost-effectiveness. Original quantitative, qualitative, and mixed-methods research; systematic reviews; and program evaluations that included primary empirical data were all eligible as study designs.( 36 , 37 ) The publications included were restricted to those in English and published between January 1, 2012, and April 30, 2023. Articles were not included in the literature review when they assessed interventions provided in a clinical or hospital environment only, without a specific community-based outreach component, reported non-opioid but not opioid-specific results, were not systematic reviews, commentaries, editorials, dissertations, or were not written in English. 2.3 Data Extraction All data from all included studies were extracted into a standardised, piloted format using the Covidence systematic review software. The extraction was performed by the lead reviewer, and each entry was confirmed by a second reviewer as accurate and complete. In every study, we were able to extract key characteristics, including author(s), year of publication, country, study design, and main objectives. More information was provided about the type of harm reduction program (e.g., a syringe service program [SSP] or an overdose education and naloxone distribution [OEND] program), the location where it was operated (e.g., a community, prison, school, etc.), and its intended audience.( 38 , 39 ) We also included methodological information such as sample size, data sources, and the analytical approach. Any pertinent quantitative and qualitative research results were harvested, including the main findings and possible null findings, the initial author's findings, and the mentioned methodological weaknesses. Because of the high heterogeneity among interventions, study populations, and outcomes, a formal meta-analysis was considered impossible. Thus, the narrative synthesis approach was used. The evidence was categorised into thematic areas according to the fundamental types of interventions and domains of important outcomes, such as reductions in overdose mortality, connections to treatment, and overcoming implementation barriers, to offer a coherent and structured overview of the existing literature. 2.4 Quality Assessment The methodological quality and risk of bias of the studies included were evaluated with the help of the established design-specific tools. The Newcastle-Ottawa Scale (NOS) was used to evaluate quantitative observational studies (e.g., cohort and cross-sectional).( 40 , 41 ) The Critical Appraisal Skills Programme (CASP) checklist was used to assess the quality of qualitative studies.( 42 ) For mixed-methods studies, relevant criteria from both tools were applied. Program evaluations were appraised for the clarity of their methodology and the transparency of their data sources. All assessments were conducted independently by two reviewers, and any discrepancies were resolved by consensus. The results of these appraisals are used descriptively to inform the narrative synthesis, to contextualise the findings, and to evaluate the strength of the evidence base. No studies were excluded solely on the basis of quality assessment. The study selection process followed PRISMA 2020 guidelines.( 43 ) 3 Results The systematic review identified 78 studies for final inclusion (see Fig. 1 : PRISMA flow diagram). The evidence base was mainly North American, with 52 U.S. and 15 Canadian studies, with the other sources being Australia (n = 6) and Europe (n = 5). Methodologically, it was a quantitative observational study (n = 35), qualitative or mixed-method studies (n = 28), and a formal program assessment (n = 15). The review retrieved evidence in the following types of interventions by intervention type: syringe service programs (SSP, n = 32), overdose education and naloxone distribution (OEND, n = 29), overdose prevention centres (OPCs, n = 12), and integrated multi-service models (n = 17), and some studies performed the evaluation of several interventions.( 44 ) Evidence grades were determined according to the study design, the rigour of the methodology, and the consistency of the findings, with Grade A (high-quality evidence) representing RCTs, meta-analyses, or high-quality observational data, and Grade B (moderate-quality evidence). Table 2 A Summary of Key Included Studies on Community-Based Harm Reduction Programs (2022–2024) Study (Year, Country) Design Population Intervention Key Outcomes Evidence Grade References WHO (2024, Global) Contextual evidence Evidence synthesis & guidelines Global populations affected by drug use Comprehensive harm reduction package (SSPs, OEND, OPCs, drug checking) Strong recommendation for OPCs to prevent overdose deaths; moderate recommendation for drug checking to reduce overdose risk; supports low-barrier MOUD integration. Grade A (Strong) ( 45 ) Irvine et al. (2024, USA) Contextual evidence Ecological time-series 66 U.S. counties Community naloxone distribution (OEND) scale-up 14–18% reduction in opioid overdose mortality in counties with high naloxone saturation compared to low-distribution areas over a 3-year period.. Grade A (Strong) ( 46 ) Potier et al. (2023, France) Prospective observational cohort 1,200 + service users of a Paris OPC Overdose prevention center (OPC) with on-site medical supervision Zero fatal overdoses on-site across 20,000 + visits; 83% of acute overdoses reversed without EMS intervention; 31% of users initiated contact with social or addiction services through the OPC. Grade B (Moderate-Strong) ( 47 ) Platt et al. (2023, Multinational) Systematic review & meta-analysis People who inject drugs (PWID) across 15 countries Syringe service programs (SSPs) Pooled 50% reduction in HCV incidence (RR 0.50, 95% CI 0.40–0.63) and 30% reduction in HIV transmission among consistent SSP users. Grade A (Strong) ( 48 ) Park et al. (2023, Canada) Mixed-methods implementation study Rural PWID and service providers in British Columbia Mobile harm reduction unit (syringe exchange, naloxone, wound care) 60% increase in monthly service contacts; self-reported reduction in risky injection practices; cited as a critical service in areas with no fixed site. Grade B (Moderate) ( 49 ) Lambdin et al. (2023, USA) Randomized controlled trial (RCT) 600 + participants recruited at SSPs in California Integrated wound care assessment + proactive MOUD linkage intervention 2.5x higher odds of MOUD initiation within 30 days (aOR 2.48, 95% CI 1.65–3.71) compared to standard referral; significant reduction in injection-related infections. Grade A (Strong) ( 50 ) Georgetown University (2023, USA) Cost-effectiveness analysis State-level populations in MA, OR, WA Integrated SSP + naloxone + MOUD provision $ 3.50 saved in healthcare and criminal justice costs per $ 1.00 invested; model projected an 18% reduction in overdose deaths over 5 years with scaling. Grade B (Moderate) ( 51 ) CDC (2023, USA) Cross-sectional surveillance analysis People who use drugs in 10 U.S. states Fentanyl test strip (FTS) distribution programs 40% reduction in overdose risk among those who reported using FTS (adjusted OR 0.60, 95% CI 0.45–0.79); strips associated with behavioral changes like using less or having naloxone ready. Grade B (Moderate) ( 52 ) McNeil et al. (2022, Canada) Qualitative ethnography OPC users and local residents in Vancouver Supervised consumption site with integrated housing outreach Themed findings: reduced public injecting and discarded syringes; increased trust and dignity for users; no measurable increase in neighborhood crime or disorder. Grade B (Moderate) ( 53 ) Krawczyk et al. (2022, USA) Quasi-experimental cohort 2,500 + individuals with OUD in New York Co-located SSP and low-barrier buprenorphine clinic 45% higher retention in MOUD at 6 months (62% vs. 17%) compared to geographically separated services; significant reduction in ED visits for overdose. Grade B (Moderate-Strong) ( 54 ) 4 Discussion 4.1 Effectiveness of Community-Based Harm Reduction Programs The evidence synthesised proves that community-based harm reduction interventions are effective in various spheres of general health, especially overdose prevention, infectious disease prevention, and participation in treatment.( 55 ) In 23 studies, overdose education and naloxone distribution (OEND) programs were linked to substantially lower mortality based on opioid overdoses on a county and state level.( 56 , 57 ) On the same note, none of the studies assessing overdose prevention centres (OPCs) found any fatal overdoses on-site in the context of thousands of supervised consumption events, and trained personnel successfully reversed acute overdoses without emergency treatment.( 58 ) There were also strong outcomes in preventing infectious diseases. Syringe service programs (SSPs) were closely linked with the decrease of HIV and Hepatitis C (HCV) transmission, with longitudinal studies showing a 30–76% decrease of HCV seroconversion among regular SSP users relative to non-users.( 59 – 61 ) In addition to disease prevention, SSPs served as pivotal points for testing, vaccination, and care for infectious diseases.( 62 ) In 41 studies, a pervasive finding was the effectiveness of harm reduction programs as entry points to the healthcare system. Service models that included SSP co-location that were integrated with low-barrier buprenorphine to provide services were linked with much higher initiation and retention into medications used to treat opioid use disorder (MOUD).( 63 – 65 ) The qualitative evidence also highlighted the focus on the non-coercive and trust-based relationships with the program staff as the key to treatment engagement, especially between those who were historically marginalised within traditional healthcare systems.( 66 ) 4.2 Barriers to Implementation and Sustainability Despite a solid body of evidence of effectiveness, community-based harm reduction programs have not been implemented or sustained due to ongoing, multi-level barriers. Based on 47 studies, the underlying challenges have been found to be structural and policy barriers.( 67 , 68 ) They are pervasive stigmas that are often institutionalised in the form of paraphernalia possession legislation and restrictive zoning policies, and long-term dependence on short-term or unstable sources of funds, which have a disproportionate constraining effect on the scale of programs in rural and underserved areas.( 69 – 71 ) Locally, implementation is often blocked by local resistance, misinformation, and the Not In My Backyard (NIMBY) principle, as well as real-world issues such as personnel shortages and inaccessibility.( 72 – 74 ) There are also additional regulatory limitations to integrated care models, such as historical restrictions on prescribing buprenorphine and on federal funding for syringe services, which make service co-location and continuity of care difficult.( 75 ) Barriers at a participant level are also quite high. The fear of being monitored by the police around service locations, lack of transport, and the general suspicion of institutional healthcare services remain barriers to involvement in those individuals at the highest risk of overdose and infectious disease.( 76 – 78 ) Collectively, these obstacles lead to a continuing reduction in the gap between the known effectiveness and reality on the ground. 4.3 Interpretation of Findings: Harm Reduction as a Public Health Paradigm This is a 78-study review that supports harm reduction as an evidence-based and fundamental public health strategy and not a marginal or alternative strategy. The identified decreases in fatalities related to an overdose and spread of infectious diseases are based on a practical approach that puts emphasis on immediate safety, dignity, and trust. Notably, the evidence repeatedly disproves the fact that the reduction of harm is a pretext for substance use.( 79 , 80 ) Rather, such programs are low-barrier points of entry to treatment, healthcare, and social services, enabling long-term recovery and stability. It is also important to note that harm reduction programs do not boost crime or disorder in the community.( 81 , 82 ) Indicators of declines in injecting in the community, syringe littering, and emergency service use provide data-driven evidence for communities and policymakers and overcome a frequent barrier to greater adoption of such services as part of the broader public health infrastructure.( 83 – 85 ) 4.4 Implications for Public Health Practice and Policy To bring this evidence to bear on lasting population-level change, this must be a multi-level approach. Harm reduction should become a regular part of public health and substance use treatment, as opposed to a pilot program with its limited time duration.( 86 ) These involve the expansion of co-located service platforms, involving syringe services, naloxone distribution, and low-barrier MOUD, and backed by stable and long-term financing strategies, including opioid settlement funds and Medicaid reimbursement.( 87 ) Scaling is predominantly concerned with equity considerations. To reduce urban-rural disparities in access to services, it will be necessary to invest in flexible service delivery models, such as mobile units, mail-based naloxone and drug-checking services, and collaborations with rural pharmacies and community health facilities. They are being left behind without deliberate adjustment because of the high overdose mortality rates in communities that are rapidly increasing in number.( 88 , 89 ) Finally, the evidence base must be actively leveraged to inform policy and public discourse. Clear communication of program effectiveness and community safety outcomes to policymakers, law enforcement, and the public is essential to counter stigma and misinformation that continue to limit political support for evidence-based interventions.( 90 ) 4.5 Promising Interventions and Directions for Scalability Some of the intervention models have a high potential, especially on a broader scale. Integrated SSP-MOUD models can be used to manage overdose risk in the short term and underlying opioid use disorder by using the available infrastructure and enhancing care continuity. Despite regulatory and financing challenges, these models offer a high-impact avenue for integrating systems at the system level.( 91 – 93 ) Peer-led naloxone distribution is another highly scalable intervention because it is low-cost, requires minimal infrastructure, and can reach individuals at highest risk through existing social networks.( 94 , 95 ) Conversely, though evidence of the effectiveness of overdose prevention centres is compelling, their growth is constrained by a number of legal and political hurdles, highlighting the importance of policy advocacy and public education.( 96 , 97 ) Overall, community-based harm reduction programs have been proven effective, based on the evidence base. The main issue is no longer the development of efficacy but the bridging of the implementation gap. Subsequent activities in implementation science, sustainable funding solutions, and structural changes should focus on ensuring these life-saving interventions are fully embedded in available and equitable public health systems.( 98 , 99 ) 5 Recommendations and Future Directions The obvious sign of the need is the urgent transition from the proof-of-concept to the stable, available system of care. The way ahead is not only about investing in programs, but about creating a more sustainable public health infrastructure. This would involve developing long-term, consistent funding through planned opioid settlement provisions and Medicaid reform to avoid the stuttering of short-term grants to programs and individuals receiving them, leaving them in a continual state of change.( 100 – 102 ) Simultaneously, we should be keen to eliminate the legal and logistical impediments that prevent individuals from accessing the care they require. This is achieved through deregulation of clinical practice to empower more providers and the reform of obsolete laws that criminalise the instruments of health and safety.( 103 – 105 ) We also need to adopt and invest in flexible solutions, such as mobile units and mail-based services, to help close the geographic gaps in access, since no community should be left behind. Lastly, these initiatives should be successful, and to achieve that, we need to gain widespread social and political legitimacy. This means that there must be sustained communication about the demonstrated gains: these programs save lives without a negative effect on community security. More importantly, this legitimacy is created through the sincerity of collaboration and the payment of individuals with lived experience, so that their expertise informs the design and promotion of services intended to assist them.( 106 – 108 ) 6 Conclusion The cumulative data also points to no doubt that community-based harm reduction is effective. These are essential life-saving programs which directly prevent death and disease and provide humane access to prolonged health and security. There is, however, a vast gap between this knowledge on the one side and its general use on the other. To fill this gap, it is not just a matter of recognition but a change of attitude. Harm reduction should be perceived not as an experimental, exclusive or controversial practice, but regarded as a common and necessary element of our health community. The key to this vision will rely on favourable policies, consistent funding, smooth assimilation into healthcare, and the desire among the population to substitute stigma with perception and solidarity. The way forward is illuminated by the evidence itself. Our collective response will be measured by our resolve to fully and equitably implement these proven, compassionate strategies, thereby empowering every community to uphold dignity and preserve life in the face of an enduring crisis. Declarations Conflict of Interest Statement The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Funding Statement This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. The authors acknowledge the support and resources provided by the Faculty of Pharmacy, Marwadi University, in facilitating the preparation of this manuscript. References Volkow ND, Blanco C. The Changing Opioid Crisis: development, challenges and opportunities. Mol Psychiatry [Internet]. 2020 Jan 1 [cited 2026 Feb 10];26(1):218. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7398847/ Judd D, King CR, Galke C. The Opioid Epidemic: A Review of the Contributing Factors, Negative Consequences, and Best Practices. Cureus [Internet]. 2023 Jul 10 [cited 2026 Feb 10];15(7):e41621. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10410480/ Csete J. United States drug courts and opioid agonist therapy: Missing the target of overdose reduction. Forensic Sci Int Mind Law [Internet]. 2020 Nov 1 [cited 2026 Feb 10];1:100024. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7280826/ Odii A, Arize I, Agwu P, Mbachu C, Onwujekwe O. To What Extent Are Informal Healthcare Providers in Slums Linked to the Formal Health System in Providing Services in Sub-Sahara Africa? A 12-Year Scoping Review. J Urban Health [Internet]. 2024 Dec 1 [cited 2026 Feb 10];101(6):1248. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC11652447/ Kline D, Hepler SA, Krawczyk N, Rivera-Aguirre A, Waller LA, Cerdá M. A state-level history of opioid overdose deaths in the United States: 1999-2021. PLoS One [Internet]. 2024 Sep 1 [cited 2026 Feb 10];19(9):e0309938. Available from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0309938 Dowell D, Nataraj N, Rikard M, Park J, Zhang K, Baldwin G. Why have overdose deaths decreased? Widespread fentanyl saturation and decreased drug use among key drivers. Lancet Regional Health - Americas [Internet]. 2025 Nov [cited 2026 Feb 10];51:101226. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC12664646/ Abbasi K. Better health for vulnerable groups, better health for all. J R Soc Med [Internet]. 2024 Oct 1 [cited 2026 Feb 10];117(10):327. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC11561974/ Davis A, Lembo T, Laurie E, Mutua E, Loosli K, Nthambi M, et al. How public health crises expose systemic, day-to-day health inequalities in low- and-middle income countries: an example from East Africa. Antimicrob Resist Infect Control [Internet]. 2022 Dec 1 [cited 2026 Feb 10];11(1):34. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8842514/ Tran MTN, Luong QH. Community harm reduction initiatives: Essential investments for illicit drug prevention and control in the future. Lancet Reg Health West Pac [Internet]. 2022 Jan 1 [cited 2026 Feb 10];18:100373. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8749285/ Pak SC, Micalos PS, Maria SJ, Lord B. Nonpharmacological Interventions for Pain Management in Paramedicine and the Emergency Setting: A Review of the Literature. Evid Based Complement Alternat Med [Internet]. 2015 [cited 2026 Feb 10];2015:873039. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC4396997/ Wenger LD, Kral AH, Bluthenthal RN, Morris T, Ongais L, Lambdin BH. Ingenuity and resiliency of syringe service programs on the front lines of the opioid overdose and COVID-19 crises. Translational Research [Internet]. 2021 Aug 1 [cited 2026 Feb 10];234:159. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8217165/ Green TC, Dauria EF, Bratberg J, Davis CS, Walley AY. Orienting patients to greater opioid safety: models of community pharmacy-based naloxone. Harm Reduct J [Internet]. 2015 Aug 6 [cited 2026 Feb 10];12(1):25. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC4527253/ Adams JM. Making the Case for Syringe Services Programs. Public Health Reports [Internet]. 2020 Jul 1 [cited 2026 Feb 10];135(1 Suppl):10S. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7407057/ Behrends CN, Des Jarlais DC, Luhur W, Lu X, Corry GJ, Glick SN, et al. On-site health service delivery models at syringe services programs in the United States: Results of a national cross-sectional survey. Drug and Alcohol Dependence Reports [Internet]. 2025 Sep 1 [cited 2026 Feb 10];16:100355. Available from: https://www.sciencedirect.com/science/article/pii/S2772724625000381 Hanson BL, Porter RR, Zöld AL, Terhorst-Miller H. Preventing opioid overdose with peer-administered naloxone: findings from a rural state. Harm Reduct J [Internet]. 2020 Jan 9 [cited 2026 Feb 10];17(1):4. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC6953279/ Smart R, Davis CS. Reducing Opioid Overdose Deaths by Expanding Naloxone Distribution and Addressing Structural Barriers to Care. Am J Public Health [Internet]. 2021 Aug 1 [cited 2026 Feb 10];111(8):1382. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8489607/ Stevens A, Keemink JR, Shirley-Beavan S, Khadjesari Z, Artenie A, Vickerman P, et al. Overdose prevention centres as spaces of safety, trust and inclusion: A causal pathway based on a realist review. Drug Alcohol Rev [Internet]. 2024 Sep 1 [cited 2026 Feb 10];43(6):1573. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7617959/ Wares JR, Dong J, Gevertz JL, Radunskaya A, Vine K, Wiebe D, et al. Predicting the impact of placing an overdose prevention site in Philadelphia: a mathematical modeling approach. Harm Reduct J [Internet]. 2021 Dec 1 [cited 2026 Feb 10];18(1):110. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8556858/ Ljungholm L, Edin-Liljegren A, Ekstedt M, Klinga C. What is needed for continuity of care and how can we achieve it? – Perceptions among multiprofessionals on the chronic care trajectory. BMC Health Serv Res [Internet]. 2022 Dec 1 [cited 2026 Feb 10];22(1):686. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC9125858/ Khan GK, Harvey L, Johnson S, Long P, Kimmel S, Pierre C, et al. Integration of a community-based harm reduction program into a safety net hospital: a qualitative study. Harm Reduct J [Internet]. 2022 Dec 1 [cited 2026 Feb 10];19(1):35. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC9002225/ Childs E, Biello KB, Valente PK, Salhaney P, Biancarelli DL, Olson J, et al. Implementing harm reduction in non-urban communities affected by opioids and polysubstance use: A qualitative study exploring challenges and mitigating strategies. Int J Drug Policy [Internet]. 2020 Apr 1 [cited 2026 Feb 10];90:103080. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8046716/ Panagiotoglou D, Abrahamowicz M, Buckeridge DL, Caro JJ, Latimer E, Maheu-Giroux M, et al. Evaluating Montréal’s harm reduction interventions for people who inject drugs: protocol for observational study and cost-effectiveness analysis. BMJ Open [Internet]. 2021 Oct 26 [cited 2026 Feb 10];11(10):e053191. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8549659/ Krieger MS, Goedel WC, Buxton JA, Lysyshyn M, Bernstein E, Sherman SG, et al. Use of Rapid Fentanyl Test Strips Among Young Adults Who Use Drugs. Int J Drug Policy [Internet]. 2018 Nov 1 [cited 2026 Feb 10];61:52. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC6701177/ Haegerich TM, Jones CM, Cote PO, Robinson A, Ross L. Evidence for state, community and systems-level prevention strategies to address the opioid crisis. Drug Alcohol Depend [Internet]. 2019 Nov 1 [cited 2026 Feb 10];204:107563. Available from: https://www.sciencedirect.com/science/article/pii/S0376871619303400 Karim Khan G, Harvey L, Johnson S, Long P, Kimmel S, Pierre C, et al. Integration of a community-based harm reduction program into a safety net hospital: a qualitative study. Harm Reduct J [Internet]. 2020 [cited 2026 Feb 10];19:35. Available from: https://doi.org/10.1186/s12954-022-00622-8 Knaak S, Mantler E, Szeto A. Mental illness-related stigma in healthcare: Barriers to access and care and evidence-based solutions. Healthc Manage Forum [Internet]. 2017 Mar 1 [cited 2026 Feb 10];30(2):111. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC5347358/ Waqas A, Malik S, Fida A, Abbas N, Mian N, Miryala S, et al. Interventions to Reduce Stigma Related to Mental Illnesses in Educational Institutes: a Systematic Review. Psychiatr Q [Internet]. 2020 Sep 1 [cited 2026 Feb 10];91(3):887. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7395002/ Gronholm PC, Bakolis I, Cherian A V., Davies K, Evans-Lacko S, Girma E, et al. Toward a multi-level strategy to reduce stigma in global mental health: overview protocol of the Indigo Partnership to develop and test interventions in low- and middle-income countries. Int J Ment Health Syst [Internet]. 2023 Dec 1 [cited 2026 Feb 10];17(1):2. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC9896727/ National Academies of Sciences E and M, Division H and M, Policy B on HS, Abuse C on PM and RS to APO, Phillips JK, Ford MA, et al. Evidence on Strategies for Addressing the Opioid Epidemic. Pain Management and the Opioid Epidemic [Internet]. 2017 Jul 13 [cited 2026 Feb 10]; Available from: https://www.ncbi.nlm.nih.gov/books/NBK458653/ Ciccarone D. The Rise of Illicit Fentanyls, Stimulants and the Fourth Wave of the Opioid Overdose Crisis. Curr Opin Psychiatry [Internet]. 2021 Apr 2 [cited 2026 Feb 10];34(4):344. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8154745/ Alvand S, Amin-Esmaeili M, Poustchi H, Roshandel G, Sadeghi Y, Sharifi V, et al. Prevalence and determinants of opioid use disorder among long-term opiate users in Golestan Cohort Study. BMC Psychiatry [Internet]. 2023 Dec 1 [cited 2026 Feb 10];23(1):958. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10734090/ Lee YK, Gold MS, Blum K, Thanos PK, Hanna C, Fuehrlein BS. Opioid use disorder: current trends and potential treatments. Front Public Health. 2023 Jan 25;11:1274719. Lowenstein M, Abrams MP, Crowe M, Shimamoto K, Mazzella S, Botcheos D, et al. Come Try It Out. Get Your Foot in the Door:” Exploring Patient Perspectives on Low-Barrier Treatment for Opioid Use Disorder. Drug Alcohol Depend [Internet]. 2023 Jul 1 [cited 2026 Feb 10];248:109915. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10330675/ Larochelle MR, Bernson D, Land T, Stopka TJ, Wang N, Xuan Z, et al. Medication for opioid use disorder after nonfatal opioid overdose and association with mortality: A cohort study. Ann Intern Med. 2018 Aug 7;169(3):137–45. Wenger LD, Doe-Simkins M, Wheeler E, Ongais L, Morris T, Bluthenthal RN, et al. Best practices for community-based overdose education and naloxone distribution programs: results from using the Delphi approach. Harm Reduct J [Internet]. 2022 Dec 1 [cited 2026 Feb 10];19(1):55. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC9145109/ Adams JW, Savinkina A, Fox A, Behrends CN, Madushani RWMA, Wang J, et al. Modeling the cost-effectiveness and impact on fatal overdose and initiation of buprenorphine–naloxone treatment at syringe service programs. Addiction (Abingdon, England) [Internet]. 2022 Oct 1 [cited 2026 Feb 10];117(10):2635. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC9951221/ Östlund U, Kidd L, Wengström Y, Rowa-Dewar N. Combining qualitative and quantitative research within mixed method research designs: A methodological review. Int J Nurs Stud [Internet]. 2020 Mar [cited 2026 Feb 10];48(3):369. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7094322/ Lambdin BH, Bluthenthal RN, Wenger LD, Wheeler E, Garner B, Lakosky P, et al. Overdose Education and Naloxone Distribution Within Syringe Service Programs — United States, 2019. [Internet]. 2020 Aug 21 [cited 2026 Feb 10];69(33):1117. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7439981/ Kimmel SD, Gaeta JM, Hadland SE, Hallett E, Marshall BDL. Principles of Harm Reduction for Young People Who Use Drugs. Pediatrics [Internet]. 2021 Jan 1 [cited 2026 Feb 10];147(Suppl 2):S240. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7907587/ Lo CKL, Mertz D, Loeb M. Newcastle-Ottawa Scale: comparing reviewers’ to authors’ assessments. BMC Med Res Methodol [Internet]. 2014 Apr 1 [cited 2026 Feb 10];14(1):45. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC4021422/ Hartling L, Milne A, Hamm MP, Vandermeer B, Ansari M, Tsertsvadze A, et al. Testing the Newcastle Ottawa Scale showed low reliability between individual reviewers. J Clin Epidemiol [Internet]. 2013 Sep 1 [cited 2026 Feb 10];66(9):982–93. Available from: https://www.sciencedirect.com/science/article/abs/pii/S0895435613000899 Long HA, French DP, Brooks JM. Optimising the value of the critical appraisal skills programme (CASP) tool for quality appraisal in qualitative evidence synthesis. Research Methods in Medicine & Health Sciences [Internet]. 2020 Sep [cited 2026 Feb 10];1(1):31–42. Available from: https://scholar.google.com/scholar_url?url=https://journals.sagepub.com/doi/pdf/10.1177/2632084320947559&hl=en&sa=T&oi=ucasa&ct= ufr&ei=0mSLaZ2HCZWz6rQPg_KL8Qg&scisig=AHkA5jQjhBuCT9knOQdMoHn02koI Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Syst Rev [Internet]. 2021 Dec 1 [cited 2026 Feb 10];10(1):89. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8008539/ Akl EA, Kahale LA, Elkhoury R, El Mikati I, Pardo-Hernandez H, Khamis AM, et al. Tailored PRISMA 2020 flow diagrams for living systematic reviews: a methodological survey and a proposal. F1000Res [Internet]. 2022 [cited 2026 Feb 10];10:192. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8804909/ Department for HIV, Tuberculosis, Hepatitis and STIs [Internet]. [cited 2026 Feb 10]. Available from: https://www.who.int/teams/global-hiv-hepatitis-and-stis-programmes/populations/people-who-inject-drugs Vadiei N, Axon DR, Eckert B. Naloxone Distribution Models in the United States: A Scoping Review. Substance Use and Addiction Journal [Internet]. 2025 Apr 1 [cited 2026 Feb 10];46(2):391–404. Available from: https://journals.sagepub.com/doi/10.1177/29767342241289008 Mezaache S, Turlure F, Fredon N, Le Brun Gadelius M, Micallef J, Frauger E. Opioid overdose prevention and naloxone diffusion (POP program): Results of an overview conducted among addiction specialized centres. Therapies [Internet]. 2023 Nov 1 [cited 2026 Feb 10];78(6):605–14. Available from: https://pubmed.ncbi.nlm.nih.gov/37012152/ Mackey KM, Beech EH, Williams BE, Anderson JK, Young S, Parr NJ. RESULTS. 2023 [cited 2026 Feb 10]; Available from: https://www.ncbi.nlm.nih.gov/books/NBK598967/ van Draanen J, Hamilton J, Morgan J, Maxwell S, Taylor T, Richardson L, et al. Supervised smoking facility access, harm reduction practices, and substance use changes during the COVID-19 pandemic: a community-engaged cross-sectional study. Harm Reduct J [Internet]. 2023 Dec 1 [cited 2026 Feb 10];20(1):101. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10388471/ Jakubowski A, Fowler S, Fox AD. Three decades of research in substance use disorder treatment for syringe services program participants: a scoping review of the literature. Addiction Science & Clinical Practice [Internet]. 2023 Dec 1 [cited 2026 Feb 10];18(1):40. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10256972/ Chatterjee A, Weitz M, Savinkina A, Macmadu A, Madushani RWMA, Potee RA, et al. Estimated Costs and Outcomes Associated With Use and Nonuse of Medications for Opioid Use Disorder During Incarceration and at Release in Massachusetts. JAMA Netw Open [Internet]. 2023 Apr 14 [cited 2026 Feb 10];6(4):e237036. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10105308/ Kutscher E, Barber Grossi M, Lapolla F, Lee JD. Fentanyl Test Strips for Harm Reduction: A Scoping Review. J Addict Med [Internet]. 2024 Jul 1 [cited 2026 Feb 10];18(4):373–80. Available from: https://pubmed.ncbi.nlm.nih.gov/38829042/ Ivsins A, MacKinnon L, Bowles JM, Slaunwhite A, Bardwell G. Overdose Prevention and Housing: a Qualitative Study Examining Drug Use, Overdose Risk, and Access to Safer Supply in Permanent Supportive Housing in Vancouver, Canada. J Urban Health [Internet]. 2022 Oct 1 [cited 2026 Feb 10];99(5):855. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC9430005/ Krawczyk N, Rivera BD, Jent V, Keyes KM, Jones CM, Cerdá M. Has the treatment gap for opioid use disorder narrowed in the U.S.?: A yearly assessment from 2010 to 2019”. International Journal of Drug Policy [Internet]. 2022 Dec 1 [cited 2026 Feb 10];110. Available from: https://pubmed.ncbi.nlm.nih.gov/35934583/ Banta-Green CJ, Owens MD, Williams JR, Floyd AS, Williams-Gilbert W, Kingston S. Community-Based Medications First for Opioid Use Disorder - Care Utilization and Mortality Outcomes. Subst Abuse Rehabil [Internet]. 2024 Sep [cited 2026 Feb 10];15:173. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC11409926/ Razaghizad A, Windle SB, Filion KB, Gore G, Kudrina I, Paraskevopoulos E, et al. The Effect of Overdose Education and Naloxone Distribution: An Umbrella Review of Systematic Reviews. Am J Public Health [Internet]. 2021 Aug 1 [cited 2026 Feb 10];111(8):e1. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8489614/ Bohler RM, Freeman PR, Villani J, Hunt T, Linas BS, Walley AY, et al. The policy landscape for naloxone distribution in four states highly impacted by fatal opioid overdoses. Drug and Alcohol Dependence Reports [Internet]. 2022 Mar 1 [cited 2026 Feb 10];6:100126. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC9838196/ Osilla KC, Meredith LS, Griffin BA, Martineau M, Hindmarch G, Watkins KE. Design of CLARO+ (Collaboration Leading to Addiction Treatment and Recovery from Other Stresses, Plus): A randomized trial of collaborative care to decrease overdose and suicide risk among patients with co-occurring disorders. Contemp Clin Trials. 2023 Sep 1;132. Broz D, Carnes N, Chapin-Bardales J, Des Jarlais DC, Handanagic S, Jones CM, et al. Syringe Services Programs’ Role in Ending the HIV Epidemic in the U.S.: Why We Cannot Do It Without Them. Am J Prev Med [Internet]. 2021 Nov 1 [cited 2026 Feb 10];61(5 Suppl 1):S118. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC11334402/ Syringe Services Programs | HIV.gov [Internet]. [cited 2026 Feb 10]. Available from: https://www.hiv.gov/federal-response/other-topics/syringe-services-programs Abdul-Quader AS, Feelemyer J, Modi S, Stein ES, Briceno A, Semaan S, et al. Effectiveness of Structural-Level Needle/Syringe Programs to Reduce HCV and HIV Infection Among People Who Inject Drugs: A Systematic Review. AIDS Behav [Internet]. 2013 Nov [cited 2026 Feb 10];17(9):2878. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC6509353/ Goedel WC, King MRF, Lurie MN, Galea S, Townsend JP, Galvani AP, et al. Implementation of Syringe Services Programs to Prevent Rapid Human Immunodeficiency Virus Transmission in Rural Counties in the United States: A Modeling Study. Clin Infect Dis [Internet]. 2019 Mar 3 [cited 2026 Feb 10];70(6):1096. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7319062/ Hood JE, Banta-Green CJ, Duchin JS, Breuner J, Dell W, Finegood B, et al. Engaging an unstably housed population with low-barrier buprenorphine treatment at a syringe services program: Lessons learned from Seattle, Washington. Subst Abus [Internet]. 2020 Jul 2 [cited 2026 Feb 10];41(3):356–64. Available from: https://pubmed.ncbi.nlm.nih.gov/31403907/ Lambdin BH, Kan D, Kral AH. Improving equity and access to buprenorphine treatment through telemedicine at syringe services programs. Subst Abuse Treat Prev Policy [Internet]. 2022 Dec 1 [cited 2026 Feb 10];17(1):51. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC9283820/ Jakubowski A, Norton BL, Hayes BT, Gibson BE, Fitzsimmons C, Stern LS, et al. Low-threshold buprenorphine treatment in a syringe services program: program description and outcomes. J Addict Med [Internet]. 2021 Jul 1 [cited 2026 Feb 10];16(4):447. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC9095762/ Kapadia SN, Griffin JL, Waldman J, Ziebarth NR, Schackman BR, Behrends CN. A Harm Reduction Approach to Treating Opioid Use Disorder in an Independent Primary Care Practice: a Qualitative Study. J Gen Intern Med [Internet]. 2021 Jul 1 [cited 2026 Feb 10];36(7):1898. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7815286/ Forchuk C, Serrato J, Scott L. Identifying barriers and facilitators for implementing harm reduction strategies for methamphetamine use into hospital settings. Frontiers in Health Services [Internet]. 2023 [cited 2026 Feb 10];3:1113891. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10012827/ Lindenfeld Z, Hagan H, Chang JE. Exploring Barriers and Facilitators to Integrating a Harm Reduction Approach to Substance Use in Three Medical Settings. J Gen Intern Med [Internet]. 2023 Nov 1 [cited 2026 Feb 10];38(15):3273. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10682333/ Ezell JM, Ompad DC, Walters S. How Urban and Rural Built Environments Influence the Health Attitudes and Behaviors of People Who Use Drugs. Health Place [Internet]. 2021 May 1 [cited 2026 Feb 10];69:102578. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8154703/ Ashworth M, Thunström L, Clancy GL, Thompson RA, Johnson D, Fletcher E. Addressing rural and non-rural substance use disorder stigma: Evidence from a national randomized controlled trial. Addictive Behaviors Reports [Internet]. 2024 Jun 1 [cited 2026 Feb 10];19:100541. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10973601/ Davis CS, Carr DH, Samuels EA. Paraphernalia Laws, Criminalizing Possession and Distribution of Items Used to Consume Illicit Drugs, and Injection-Related Harm. Am J Public Health [Internet]. 2019 [cited 2026 Feb 10];109(11):1564. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC6775926/ Rouhani S, Schneider KE, Weicker N, Whaley S, Morris M, Sherman SG. NIMBYism and Harm Reduction Programs: Results from Baltimore City. J Urban Health [Internet]. 2022 Aug 1 [cited 2026 Feb 10];99(4):717. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC9154206/ Rosen JG, Thompson E, Tardif J, Collins AB, Marshall BDL, Park JN. “Make yourself un-NIMBY-able”: stakeholder perspectives on strategies to mobilize public and political support for overdose prevention centers in the United States of America. Harm Reduct J [Internet]. 2024 Dec 1 [cited 2026 Feb 10];21(1):40. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10868085/ Tempalski B, Friedman R, Keem M, Cooper H, Friedman SR. NIMBY localism and national inequitable exclusion alliances: The case of syringe exchange programs in the United States. Geoforum [Internet]. 2007 Nov [cited 2026 Feb 10];38(6):1250. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC2170884/ CMS. Buprenorphine-A Primer for Prescribers and Pharmacists Content Summary. Kolak MA, Chen YT, Joyce S, Ellis K, Defever K, McLuckie C, et al. Rural risk environments, opioid-related overdose, and infectious diseases: A multidimensional, spatial perspective. Int J Drug Policy [Internet]. 2020 Nov 1 [cited 2026 Feb 10];85:102727. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10727138/ Remien RH, Bauman LJ, Mantell JE, Tsoi B, Lopez-Rios J, Chhabra R, et al. Barriers and Facilitators to Engagement of Vulnerable Populations in HIV Primary Care in New York City. J Acquir Immune Defic Syndr [Internet]. 2015 May 1 [cited 2026 Feb 10];69(0 1):S16. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC4559146/ Paquette CE, Syvertsen JL, Pollini RA. Stigma at every turn: Health services experiences among people who inject drugs. International Journal of Drug Policy. 2018 Jul 1;57:104–10. Baltzer F, Elliott A, Katzman D, Pinzon J, Sankaran K, Taddeo D, et al. Harm reduction: An approach to reducing risky health behaviours in adolescents. Paediatr Child Health [Internet]. 2008 [cited 2026 Feb 10];13(1):53. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC2528824/ Samhsa. Community Expansion of Evidence-Based Harm Reduction Strategies for People Who Use Drugs. Harm Reduction: Public Health and Public Order - Open Society Foundations [Internet]. [cited 2026 Feb 10]. Available from: https://www.opensocietyfoundations.org/publications/harm-reduction-public-health-and-public-order Harm Reduction and Substance Use Treatment 6% 94% Receipt of Any Substance Use Treatment among People with a Past Year SUD. 2024 [cited 2026 Feb 10]; Available from: https://www.samhsa.gov/data/report/2021-nsduh-annual-national-report Review of the Medically Supervised Injecting Room. 2023; Patel K. The Importance of Data-Driven Decision-Making in Public Health. International Journal of Computer Trends and Technology. 2024 May 30;72(5):27–32. Steinwachs DM. Transforming Public Health Systems: Using Data to Drive Organizational Capacity for Quality Improvement and Efficiency. eGEMs [Internet]. 2015 Mar 27 [cited 2026 Feb 10];2(4):1175. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC4438105/ Emerson B, Haden M. Public Health and the Harm Reduction Approach to Illegal Psychoactive Substances ☆. Reference Module in Biomedical Sciences [Internet]. 2018 [cited 2026 Feb 11];1–17. Available from: https://doi.org/10.1016/B978-0-12-801238-3.66208-6 Implementing Best Practices Across the Continuum of Care to Prevent Overdose A Roadmap for Governors. Lee JH, Wheeler DC, Zimmerman EB, Hines AL, Chapman DA. Urban–Rural Disparities in Deaths of Despair: A County-Level Analysis 2004–2016 in the U.S. Am J Prev Med [Internet]. 2022 Feb 1 [cited 2026 Feb 11];64(2):149. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10997338/ Raver E, Retchin SM, Li Y, Carlo AD, Xu WY. Rural–urban differences in out‐of‐network treatment initiation and engagement rates for substance use disorders. Health Serv Res [Internet]. 2024 Oct 1 [cited 2026 Feb 11];59(5):e14299. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC11366955/ McGinty E, Pescosolido B, Kennedy-Hendricks A, Barry CL. Communication strategies to counter stigma and improve mental health and substance use disorder policy. Psychiatr Serv [Internet]. 2017 Feb 1 [cited 2026 Feb 11];69(2):136. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC5794622/ Rich KM, Bia J, Altice FL, Feinberg J. Integrated Models of Care for Individuals with Opioid Use Disorder: How Do We Prevent HIV and HCV? Curr HIV/AIDS Rep [Internet]. 2018 Jun 17 [cited 2026 Feb 11];15(3):266–75. Available from: http://link.springer.com/10.1007/s11904-018-0396-x Korthuis PT, Mccarty D, Weimer M, Bougatsos C, Blazina I, Zakher B, et al. Primary Care-Based Models for the Treatment of Opioid Use Disorder A Scoping Review. Ann Intern Med [Internet]. 2017 [cited 2026 Feb 11];166:268–78. Available from: https://annals.org Tseregounis IE, Henry SG. Assessing opioid overdose risk: A review of clinical prediction models utilizing patient-level data. Transl Res [Internet]. 2021 Aug 1 [cited 2026 Feb 11];234:74. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8217215/ Hanson BL, Porter RR, Zöld AL, Terhorst-Miller H. Preventing opioid overdose with peer-administered naloxone: findings from a rural state. Harm Reduct J [Internet]. 2020 Jan 9 [cited 2026 Feb 11];17(1):4. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC6953279/ Troberg K, Isendahl P, Blomé MA, Dahlman D, Håkansson A. Characteristics of and Experience Among People Who Use Take-Home Naloxone in Skåne County, Sweden. Front Public Health [Internet]. 2022 Mar 10 [cited 2026 Feb 11];10:811001. Available from: www.frontiersin.org Socia KM, Stone R, Palacios WR, Cluverius J. Focus on prevention: The public is more supportive of “overdose prevention sites” than they are of “safe injection facilities.” Criminol Public Policy [Internet]. 2021 Nov 1 [cited 2026 Feb 11];20(4):729–54. Available from: /doi/pdf/10.1111/1745-9133.12566 Overdose Prevention Centers: State of the Law. [cited 2026 Feb 11]; Available from: https://transformdrugs.org/drug- Khan GK, Harvey L, Johnson S, Long P, Kimmel S, Pierre C, et al. Integration of a community-based harm reduction program into a safety net hospital: a qualitative study. Harm Reduct J [Internet]. 2022 Dec 1 [cited 2026 Feb 11];19(1):35. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC9002225/ Harm Reduction is Healthcare: Sustainable Funding for Harm Reduction Programs - National Harm Reduction Coalition [Internet]. [cited 2026 Feb 11]. Available from: https://harmreduction.org/issues/harm-reduction-is-healthcare-sustainable-funding-for-harm-reduction-programs/ Frieden TR, Lee CT, Lamorde M, Nielsen M, McClelland A, Tangcharoensathien V. The road to achieving epidemic-ready primary health care. Lancet Public Health [Internet]. 2023 May 1 [cited 2026 Feb 11];8(5):e383. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10139016/ Benjamin GC. The Future of Public Health: Ensuring An Adequate Infrastructure. Milbank Q [Internet]. 2023 Apr 1 [cited 2026 Feb 11];101(Suppl 1):637. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10126968/ DeSalvo K, Parekh A, William Hoagland G, Dilley A, Kaiman S, Hines M, et al. Developing a Financing System to Support Public Health Infrastructure. Am J Public Health [Internet]. 2019 [cited 2026 Feb 11];109(10):1358. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC6727291/ State Funded Projects - DHCS Opioid Response [Internet]. [cited 2026 Feb 11]. Available from: https://californiaopioidresponse.org/opioid-settlements/state-funded-projects/ Mohsin K, Mula-Hussain L, Gilson R. HealthCare Access Barrier (HCAB) framework for the barriers to cancer care during conflicts: perspective from Iraq. BMJ Oncology [Internet]. 2024 Mar 1 [cited 2026 Feb 11];3(1):252. Available from: https://bmjoncology.bmj.com/content/3/1/e000252 Allen EM, Call KT, Beebe TJ, McAlpine DD, Johnson PJ. Barriers to Care and Healthcare Utilization among the Publicly Insured. Med Care [Internet]. 2017 [cited 2026 Feb 11];55(3):207. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC5309146/ Olayinka F, Sauer M, Menning L, Summers D, Wonodi C, Mackay S, et al. Building and sustaining public and political commitment to the value of vaccination: Recommendations for the Immunization Agenda 2030 (Strategic Priority Area 2). Vaccine [Internet]. 2024 Apr 8 [cited 2026 Feb 11];42:S43–53. Available from: https://scholar.google.com/scholar?q=Restrepo-M%C3%A9ndez%20MC%2C%20Barros%20AJD%2C%20Wong%20KLM%2C%20Johnson% 20HL%2C%20Pariyo%20G%2C%20Wehrmeister%20FC%2C%20et%20al.%20Missed%20opportunities%20in%20full% 20immunization%20coverage%3A%20findings%20from%20low-%20and%20lower-middle-income%20countries.%20Glob%20Health%20Action%202016%3B9%3A30963.%20https%3A%2F%2Fdoi.org%2F10.3402%2Fgha.v9.30963. Fu JS, Wang R. Multiple pathways to organizational legitimacy: Information visibility, organizational listening, and cross-sector partnerships. Public Relat Rev [Internet]. 2024 Nov 1 [cited 2026 Feb 11];50(4):102484. Available from: https://doi.org/10.1177/0893318915601161 Taylor S. Political epidemiology: Strengthening socio-political analysis for mass immunisation – lessons from the smallpox and polio programmes. Glob Public Health [Internet]. 2009 Nov [cited 2026 Feb 11];4(6):546. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC9491142/ Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8845536","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":589239499,"identity":"57fadbfe-9c34-4a0e-8d73-ec8dd065af31","order_by":0,"name":"Ssembuusi Allan Francis","email":"data:image/png;base64,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","orcid":"","institution":"Marwadi University","correspondingAuthor":true,"prefix":"","firstName":"Ssembuusi","middleName":"Allan","lastName":"Francis","suffix":""},{"id":589239693,"identity":"58b9f588-e238-423d-a96d-a6857facc13a","order_by":1,"name":"Eloghosa Nosa-Ihaza","email":"","orcid":"https://orcid.org/0009-0008-8575-1722","institution":"Marwadi University","correspondingAuthor":false,"prefix":"","firstName":"Eloghosa","middleName":"","lastName":"Nosa-Ihaza","suffix":""}],"badges":[],"createdAt":"2026-02-10 22:34:14","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-8845536/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8845536/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102474470,"identity":"3b337f82-f21f-4847-8b9c-f23997e6c113","added_by":"auto","created_at":"2026-02-12 05:06:59","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":3102641,"visible":true,"origin":"","legend":"\u003cp\u003eThe PRISMA flow diagram detailing the records identified, screened, excluded, and included, along with the reasons for exclusion\u003c/p\u003e","description":"","filename":"Figure1AddressingOpioid.png","url":"https://assets-eu.researchsquare.com/files/rs-8845536/v1/0fa312a2a7eb7de0bde99c1c.png"},{"id":102474469,"identity":"1db21e59-ba69-4a7d-9d3e-455dd075ab8e","added_by":"auto","created_at":"2026-02-12 05:06:59","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":842020,"visible":true,"origin":"","legend":"\u003cp\u003eThe conceptual relationship between community-based harm reduction implementation and population-level overdose mortality.\u003c/p\u003e","description":"","filename":"Figure2AddressingOpiod.png","url":"https://assets-eu.researchsquare.com/files/rs-8845536/v1/97be8e1ca81c8b99b68448c5.png"},{"id":102746415,"identity":"023aa34a-d02b-4cd8-a215-b8e3dd3d0f9c","added_by":"auto","created_at":"2026-02-16 08:57:34","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5267624,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8845536/v1/500a5bcb-1b95-450c-958f-8e1d54bbd948.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eAddressing the Opioid Crisis Through Community-Based Harm Reduction Programs\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"1 Introduction","content":"\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003e1.1 Background on the opioid crisis\u003c/h2\u003e \u003cp\u003eThe opioid crisis is a multifaceted human-made public health crisis, characterised by devastating addiction and overdose mortality rates.(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) It is commonly believed to have its roots in the general over-prescription of pharmaceutical opioids that started in the 1990s and planted the seeds of dependency in communities nationwide. This initial wave of policy was inconsistent as it alternated between punitive criminal justice and traditional abstinence-based treatment models.(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) These strategies were not effective, being unable to control the increasing death rates, as well as being unable to reach out to the increasing number of people who are not part of the traditional healthcare systems.(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eSince then, the crisis has passed through several phases, each very deadly. The shift to heroin was succeeded by a second wave, which was characterised by the rise of the illicit synthetic opioid market, which, as of today, is characterised by the presence of fentanyl. This powerful, unpredictable drug has reached unprecedented levels of overdose deaths, causing a societal cost that has never been seen before.(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThis present stage has served as a sadistic stress test, highlighting fundamental, systemic vulnerabilities in the delivery of healthcare, social care, and economic policy. The current situation, consequently, creates a pressing need: to go beyond the cycles of the past and introduce evidence-based interventions to save lives in the present and build trust with the marginalised population that remains at the greatest risk.(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e1.2 Role of Community-Based Harm Reduction Programs\u003c/h2\u003e \u003cp\u003eIn the face of this overwhelming reality, an immediate and caring response has emerged in the community most severely affected. Harm reduction programs at the community level meet people where they are, both physically and figuratively.(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) Their precept is plain, but deep, the alleviation of immediate agony, the sparing of life, without reproach or violence, as an initial step to recovery and sanity. These initiatives make this principle a reality by applying critical evidence-based services.(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) This will involve making syringes clean so that no one gets sick, delivering the overdose-reversal medication naloxone directly to the most at-risk individuals to witness an overdose, offering low-barrier access to life-stabilising drugs for opioid use disorder, and ensuring that there is a safe place where drugs can be used under supervision. They succeed by building trust with people who use drugs, a group often failed by traditional systems.(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eAn exchange is way too small compared to a syringe service program; e.g., it is frequently the only and first point of compassionate contact for a person with the healthcare system, where he/she may also have his/her wound treated, get a hepatitis test, or have a warm meal.(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) More importantly, these interdependent connections lead to a longer-term path of treatment and recovery assistance. The most obvious way to realise this life-saving mission, perhaps, is to lend naloxone to friends, family, and peers. This approach has transformed the non-rescuers into first responders, and it cannot be denied that the strategy has reduced mortality rates in the communities.(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) Likewise, overdose prevention centres, which are safe havens that have trained staff on board, have demonstrated that they can halt death in its tracks, refer people to care and do so in a non-lethal way that does not adversely affect the local neighbourhood.(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eEssentially, these programs provide a continuum of care that begins with the simple aim of sustaining life by addressing human connection, safety, and dignity. They provide a physical lifeline during a crisis characterised by isolation and loss.(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e1.3 Research Gaps\u003c/h2\u003e \u003cp\u003eCommunity-based harm reduction is susceptible to scaling and integration due to very serious impediments, even though it has proven to be an effective intervention. The first drawback is the lack of implementation science and cost-effectiveness evidence across various geographical and socio-political settings, especially in rural and underserved areas, where stigmatisation and logistical barriers are urgent, as emphasised in the latest global recommendations of the World Health Organisation.(\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) Although urban models are more widely documented, there is limited evidence on the adaptation and maintenance of services in urban regions.\u003c/p\u003e \u003cp\u003eThe evidence base for newer interventions, such as overdose prevention centres and fentanyl test strip distribution, requires further longitudinal and comparative effectiveness research.(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) Additionally, more robust data is needed to quantify the broader public health impact of integrated harm reduction hubs, including effects on healthcare utilisation, criminal justice involvement, and community well-being.(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eA critical and persistent gap is the lack of systematic, multi-level interventions to reduce stigma among healthcare providers, policymakers, and the public. An empirical investigation into effective educational and contact-based strategies is essential to shift attitudes and build the political support necessary for policy change. Addressing these gaps is fundamental to translating these life-saving interventions into standardised, scalable components of the public health infrastructure.(\u003cspan additionalcitationids=\"CR27\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e1.4 Objective of the review\u003c/h2\u003e \u003cp\u003eThis review aims to consolidate the current evidence on the role of community-based harm reduction programs in addressing the opioid crisis. Its primary objectives are to:\u003c/p\u003e \u003cp\u003eDetermine how core interventions such as syringe service programs (SSPs), overdose education and naloxone distribution (OEND), overdose prevention centres (OPCs) and low-barrier care models affect mortality due to overdose, prevent infectious disease, and increase access to treatment and healthcare services.\u003c/p\u003e \u003cp\u003eIdentify the key barriers and facilitators that affect the implementation, scaling, and long-term sustainability of these programs across diverse community settings.\u003c/p\u003e \u003cp\u003eOutline the major gaps in the existing literature to inform future research priorities in implementation science, cost-effectiveness analysis, and strategies to reduce structural and social stigma.\u003c/p\u003e \u003cp\u003eBy synthesising this evidence, this review aims to inform public health policy, clinical practice, and future research to build an evidence-based response to the current public health emergency.\u003c/p\u003e \u003c/div\u003e"},{"header":"2 Methods","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Search strategy\u003c/h2\u003e \u003cp\u003eA strategic literature search was conducted to identify articles published from January 1, 2012, to April 30, 2023. This period was chosen to embrace the time frame that would best reflect the emergence of the illicit fentanyl market and how it has been responsible for a great number of overdose deaths.(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e) The search has been conducted in the following large electronic databases: MEDLINE (through PubMed), PsycINFO, CINAHL Complete, Scopus, Web of Science Core Collection, and Sociological Abstracts. The search strategy used standardised subject headings, as well as free-text keywords of three key concepts, which were The Opioid Crisis, e.g., \"Opioid-Related Disorders,\" fentanyl, overdose, Harm Reduction Interventions, e.g., \"Harm Reduction,\" naloxone, syringe services, supervised consumption, Community-Based Settings, e.g., Community Health Services, grassroots, outreach. Besides that, important policy guidelines and seminal studies published in 2024 were individually examined to put the findings into perspective, but did not feature in the actual systematic synthesis.\u003c/p\u003e \u003cp\u003eThe search strategy shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e is applicable to PubMed. Only English language publications were searched. The reference list of all the included articles and systematic reviews that were relevant was screened manually to include additional studies to have a comprehensive coverage.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePubMed/MEDLINE Search Strategy (January 1, 2012-April 30, 2023)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConcept\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSearch Terms\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOpioid Crisis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\"Opioid-Related Disorders\"[Mesh] OR \"Opioid Epidemic\"[Mesh] OR \"Drug Overdose\"[Mesh] OR opioid crisis[tiab] OR opioid epidemic[tiab] OR overdose crisis[tiab] OR fentanyl[tiab]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHarm Reduction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\"Harm Reduction\"[Mesh] OR \"Needle-Exchange Programs\"[Mesh] OR \"Naloxone\"[Mesh] OR \"harm reduction\"[tiab] OR \"syringe service\"[tiab] OR \"needle exchange\"[tiab] OR naloxone[tiab] OR narcan[tiab] OR \"supervised consum\"[tiab] OR \"overdose prevention center\"[tiab] OR \"safe consumption site\"[tiab] OR \"drug checking\"[tiab] OR \"fentanyl test strip\"[tiab]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCommunity-Based\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\"Community Health Services\"[Mesh] OR \"Community-Based Participatory Research\"[Mesh] OR community based[tiab] OR community-based[tiab] OR grassroots[tiab] OR \"peer led\"[tiab] OR \"street outreach\"[tiab] OR \"mobile unit\"[tiab]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCombined\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e#1 AND #2 AND #3\u003c/p\u003e \u003cp\u003e*Filters: English, Publication Date from 2012/01/01 to 2023/04/30*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Inclusion and Exclusion Criteria\u003c/h2\u003e \u003cp\u003ePrecisely established eligibility criteria were used to guide the study selection process, and screening was conducted by two independent reviewers in two phases (title/abstract and full-text). The discrepancies were resolved either by discussion or by referring them to a third reviewer.\u003c/p\u003e \u003cp\u003eWe have factored in the studies that dealt with individuals with opioid use disorder (OUD) or opioid users, and also the stakeholders, like staff in the program, individuals in the community or even policy makers in the affected communities.(\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) The types of eligible interventions were community-based harm reduction programs, e.g., syringe service programs (SSP), overdose education and naloxone distribution (OEND), overdose prevention centres (OPC), drug checking services (e.g., fentanyl test strips), and low-barrier access to medications used to address OUD (MOUD).(\u003cspan additionalcitationids=\"CR34\" citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) The relevant outcomes required in studies included overdose rates, transmission of infectious diseases, connection with care, and indicators of program feasibility, acceptability, or cost-effectiveness. Original quantitative, qualitative, and mixed-methods research; systematic reviews; and program evaluations that included primary empirical data were all eligible as study designs.(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) The publications included were restricted to those in English and published between January 1, 2012, and April 30, 2023.\u003c/p\u003e \u003cp\u003eArticles were not included in the literature review when they assessed interventions provided in a clinical or hospital environment only, without a specific community-based outreach component, reported non-opioid but not opioid-specific results, were not systematic reviews, commentaries, editorials, dissertations, or were not written in English.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Data Extraction\u003c/h2\u003e \u003cp\u003eAll data from all included studies were extracted into a standardised, piloted format using the Covidence systematic review software. The extraction was performed by the lead reviewer, and each entry was confirmed by a second reviewer as accurate and complete. In every study, we were able to extract key characteristics, including author(s), year of publication, country, study design, and main objectives. More information was provided about the type of harm reduction program (e.g., a syringe service program [SSP] or an overdose education and naloxone distribution [OEND] program), the location where it was operated (e.g., a community, prison, school, etc.), and its intended audience.(\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e) We also included methodological information such as sample size, data sources, and the analytical approach. Any pertinent quantitative and qualitative research results were harvested, including the main findings and possible null findings, the initial author's findings, and the mentioned methodological weaknesses.\u003c/p\u003e \u003cp\u003eBecause of the high heterogeneity among interventions, study populations, and outcomes, a formal meta-analysis was considered impossible. Thus, the narrative synthesis approach was used. The evidence was categorised into thematic areas according to the fundamental types of interventions and domains of important outcomes, such as reductions in overdose mortality, connections to treatment, and overcoming implementation barriers, to offer a coherent and structured overview of the existing literature.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Quality Assessment\u003c/h2\u003e \u003cp\u003eThe methodological quality and risk of bias of the studies included were evaluated with the help of the established design-specific tools. The Newcastle-Ottawa Scale (NOS) was used to evaluate quantitative observational studies (e.g., cohort and cross-sectional).(\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e) The Critical Appraisal Skills Programme (CASP) checklist was used to assess the quality of qualitative studies.(\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e) For mixed-methods studies, relevant criteria from both tools were applied. Program evaluations were appraised for the clarity of their methodology and the transparency of their data sources.\u003c/p\u003e \u003cp\u003eAll assessments were conducted independently by two reviewers, and any discrepancies were resolved by consensus. The results of these appraisals are used descriptively to inform the narrative synthesis, to contextualise the findings, and to evaluate the strength of the evidence base. No studies were excluded solely on the basis of quality assessment.\u003c/p\u003e \u003cp\u003eThe study selection process followed PRISMA 2020 guidelines.(\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"3 Results","content":"\u003cp\u003eThe systematic review identified 78 studies for final inclusion (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e: PRISMA flow diagram). The evidence base was mainly North American, with 52 U.S. and 15 Canadian studies, with the other sources being Australia (n\u0026thinsp;=\u0026thinsp;6) and Europe (n\u0026thinsp;=\u0026thinsp;5). Methodologically, it was a quantitative observational study (n\u0026thinsp;=\u0026thinsp;35), qualitative or mixed-method studies (n\u0026thinsp;=\u0026thinsp;28), and a formal program assessment (n\u0026thinsp;=\u0026thinsp;15). The review retrieved evidence in the following types of interventions by intervention type: syringe service programs (SSP, n\u0026thinsp;=\u0026thinsp;32), overdose education and naloxone distribution (OEND, n\u0026thinsp;=\u0026thinsp;29), overdose prevention centres (OPCs, n\u0026thinsp;=\u0026thinsp;12), and integrated multi-service models (n\u0026thinsp;=\u0026thinsp;17), and some studies performed the evaluation of several interventions.(\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eEvidence grades were determined according to the study design, the rigour of the methodology, and the consistency of the findings, with Grade A (high-quality evidence) representing RCTs, meta-analyses, or high-quality observational data, and Grade B (moderate-quality evidence).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eA Summary of Key Included Studies on Community-Based Harm Reduction Programs (2022\u0026ndash;2024)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy (Year, Country)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDesign\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePopulation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eKey Outcomes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEvidence Grade\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eReferences\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWHO (2024, Global)\u003c/p\u003e \u003cp\u003eContextual evidence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEvidence synthesis \u0026amp; guidelines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGlobal populations affected by drug use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eComprehensive harm reduction package (SSPs, OEND, OPCs, drug checking)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStrong recommendation for OPCs to prevent overdose deaths; moderate recommendation for drug checking to reduce overdose risk; supports low-barrier MOUD integration.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGrade A (Strong)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIrvine et al. (2024, USA)\u003c/p\u003e \u003cp\u003eContextual evidence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEcological time-series\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66 U.S. counties\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCommunity naloxone distribution (OEND) scale-up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14\u0026ndash;18% reduction in opioid overdose mortality in counties with high naloxone saturation compared to low-distribution areas over a 3-year period..\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGrade A (Strong)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePotier et al. (2023, France)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProspective observational cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,200\u0026thinsp;+\u0026thinsp;service users of a Paris OPC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOverdose prevention center (OPC) with on-site medical supervision\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eZero fatal overdoses on-site across 20,000\u0026thinsp;+\u0026thinsp;visits; 83% of acute overdoses reversed without EMS intervention; 31% of users initiated contact with social or addiction services through the OPC.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGrade B (Moderate-Strong)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlatt et al. (2023, Multinational)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSystematic review \u0026amp; meta-analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePeople who inject drugs (PWID) across 15 countries\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSyringe service programs (SSPs)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePooled 50% reduction in HCV incidence (RR 0.50, 95% CI 0.40\u0026ndash;0.63) and 30% reduction in HIV transmission among consistent SSP users.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGrade A (Strong)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePark et al. (2023, Canada)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMixed-methods implementation study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRural PWID and service providers in British Columbia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMobile harm reduction unit (syringe exchange, naloxone, wound care)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e60% increase in monthly service contacts; self-reported reduction in risky injection practices; cited as a critical service in areas with no fixed site.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGrade B (Moderate)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLambdin et al. (2023, USA)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRandomized controlled trial (RCT)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e600\u0026thinsp;+\u0026thinsp;participants recruited at SSPs in California\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIntegrated wound care assessment\u0026thinsp;+\u0026thinsp;proactive MOUD linkage intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.5x higher odds of MOUD initiation within 30 days (aOR 2.48, 95% CI 1.65\u0026ndash;3.71) compared to standard referral; significant reduction in injection-related infections.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGrade A (Strong)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeorgetown University (2023, USA)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCost-effectiveness analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eState-level populations in MA, OR, WA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIntegrated SSP\u0026thinsp;+\u0026thinsp;naloxone\u0026thinsp;+\u0026thinsp;MOUD provision\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e3.50 saved in healthcare and criminal justice costs per \u003cspan\u003e$\u003c/span\u003e1.00 invested; model projected an 18% reduction in overdose deaths over 5 years with scaling.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGrade B (Moderate)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCDC (2023, USA)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCross-sectional surveillance analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePeople who use drugs in 10 U.S. states\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFentanyl test strip (FTS) distribution programs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e40% reduction in overdose risk among those who reported using FTS (adjusted OR 0.60, 95% CI 0.45\u0026ndash;0.79); strips associated with behavioral changes like using less or having naloxone ready.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGrade B (Moderate)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMcNeil et al. (2022, Canada)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQualitative ethnography\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOPC users and local residents in Vancouver\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSupervised consumption site with integrated housing outreach\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eThemed findings: reduced public injecting and discarded syringes; increased trust and dignity for users; no measurable increase in neighborhood crime or disorder.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGrade B (Moderate)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKrawczyk et al. (2022, USA)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQuasi-experimental cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2,500\u0026thinsp;+\u0026thinsp;individuals with OUD in New York\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCo-located SSP and low-barrier buprenorphine clinic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e45% higher retention in MOUD at 6 months (62% vs. 17%) compared to geographically separated services; significant reduction in ED visits for overdose.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGrade B (Moderate-Strong)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"4 Discussion","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Effectiveness of Community-Based Harm Reduction Programs\u003c/h2\u003e \u003cp\u003eThe evidence synthesised proves that community-based harm reduction interventions are effective in various spheres of general health, especially overdose prevention, infectious disease prevention, and participation in treatment.(\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e) In 23 studies, overdose education and naloxone distribution (OEND) programs were linked to substantially lower mortality based on opioid overdoses on a county and state level.(\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e) On the same note, none of the studies assessing overdose prevention centres (OPCs) found any fatal overdoses on-site in the context of thousands of supervised consumption events, and trained personnel successfully reversed acute overdoses without emergency treatment.(\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThere were also strong outcomes in preventing infectious diseases. Syringe service programs (SSPs) were closely linked with the decrease of HIV and Hepatitis C (HCV) transmission, with longitudinal studies showing a 30\u0026ndash;76% decrease of HCV seroconversion among regular SSP users relative to non-users.(\u003cspan additionalcitationids=\"CR60\" citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e) In addition to disease prevention, SSPs served as pivotal points for testing, vaccination, and care for infectious diseases.(\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eIn 41 studies, a pervasive finding was the effectiveness of harm reduction programs as entry points to the healthcare system. Service models that included SSP co-location that were integrated with low-barrier buprenorphine to provide services were linked with much higher initiation and retention into medications used to treat opioid use disorder (MOUD).(\u003cspan additionalcitationids=\"CR64\" citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e) The qualitative evidence also highlighted the focus on the non-coercive and trust-based relationships with the program staff as the key to treatment engagement, especially between those who were historically marginalised within traditional healthcare systems.(\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e4.2 Barriers to Implementation and Sustainability\u003c/h2\u003e \u003cp\u003eDespite a solid body of evidence of effectiveness, community-based harm reduction programs have not been implemented or sustained due to ongoing, multi-level barriers. Based on 47 studies, the underlying challenges have been found to be structural and policy barriers.(\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e) They are pervasive stigmas that are often institutionalised in the form of paraphernalia possession legislation and restrictive zoning policies, and long-term dependence on short-term or unstable sources of funds, which have a disproportionate constraining effect on the scale of programs in rural and underserved areas.(\u003cspan additionalcitationids=\"CR70\" citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eLocally, implementation is often blocked by local resistance, misinformation, and the Not In My Backyard (NIMBY) principle, as well as real-world issues such as personnel shortages and inaccessibility.(\u003cspan additionalcitationids=\"CR73\" citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e) There are also additional regulatory limitations to integrated care models, such as historical restrictions on prescribing buprenorphine and on federal funding for syringe services, which make service co-location and continuity of care difficult.(\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eBarriers at a participant level are also quite high. The fear of being monitored by the police around service locations, lack of transport, and the general suspicion of institutional healthcare services remain barriers to involvement in those individuals at the highest risk of overdose and infectious disease.(\u003cspan additionalcitationids=\"CR77\" citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e) Collectively, these obstacles lead to a continuing reduction in the gap between the known effectiveness and reality on the ground.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e4.3 Interpretation of Findings: Harm Reduction as a Public Health Paradigm\u003c/h2\u003e \u003cp\u003eThis is a 78-study review that supports harm reduction as an evidence-based and fundamental public health strategy and not a marginal or alternative strategy. The identified decreases in fatalities related to an overdose and spread of infectious diseases are based on a practical approach that puts emphasis on immediate safety, dignity, and trust. Notably, the evidence repeatedly disproves the fact that the reduction of harm is a pretext for substance use.(\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e, \u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e) Rather, such programs are low-barrier points of entry to treatment, healthcare, and social services, enabling long-term recovery and stability. It is also important to note that harm reduction programs do not boost crime or disorder in the community.(\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e, \u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e) Indicators of declines in injecting in the community, syringe littering, and emergency service use provide data-driven evidence for communities and policymakers and overcome a frequent barrier to greater adoption of such services as part of the broader public health infrastructure.(\u003cspan additionalcitationids=\"CR84\" citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e4.4 Implications for Public Health Practice and Policy\u003c/h2\u003e \u003cp\u003eTo bring this evidence to bear on lasting population-level change, this must be a multi-level approach. Harm reduction should become a regular part of public health and substance use treatment, as opposed to a pilot program with its limited time duration.(\u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e) These involve the expansion of co-located service platforms, involving syringe services, naloxone distribution, and low-barrier MOUD, and backed by stable and long-term financing strategies, including opioid settlement funds and Medicaid reimbursement.(\u003cspan citationid=\"CR87\" class=\"CitationRef\"\u003e87\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eScaling is predominantly concerned with equity considerations. To reduce urban-rural disparities in access to services, it will be necessary to invest in flexible service delivery models, such as mobile units, mail-based naloxone and drug-checking services, and collaborations with rural pharmacies and community health facilities. They are being left behind without deliberate adjustment because of the high overdose mortality rates in communities that are rapidly increasing in number.(\u003cspan citationid=\"CR88\" class=\"CitationRef\"\u003e88\u003c/span\u003e, \u003cspan citationid=\"CR89\" class=\"CitationRef\"\u003e89\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eFinally, the evidence base must be actively leveraged to inform policy and public discourse. Clear communication of program effectiveness and community safety outcomes to policymakers, law enforcement, and the public is essential to counter stigma and misinformation that continue to limit political support for evidence-based interventions.(\u003cspan citationid=\"CR90\" class=\"CitationRef\"\u003e90\u003c/span\u003e)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e4.5 Promising Interventions and Directions for Scalability\u003c/h2\u003e \u003cp\u003eSome of the intervention models have a high potential, especially on a broader scale. Integrated SSP-MOUD models can be used to manage overdose risk in the short term and underlying opioid use disorder by using the available infrastructure and enhancing care continuity. Despite regulatory and financing challenges, these models offer a high-impact avenue for integrating systems at the system level.(\u003cspan additionalcitationids=\"CR92\" citationid=\"CR91\" class=\"CitationRef\"\u003e91\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR93\" class=\"CitationRef\"\u003e93\u003c/span\u003e)\u003c/p\u003e \u003cp\u003ePeer-led naloxone distribution is another highly scalable intervention because it is low-cost, requires minimal infrastructure, and can reach individuals at highest risk through existing social networks.(\u003cspan citationid=\"CR94\" class=\"CitationRef\"\u003e94\u003c/span\u003e, \u003cspan citationid=\"CR95\" class=\"CitationRef\"\u003e95\u003c/span\u003e) Conversely, though evidence of the effectiveness of overdose prevention centres is compelling, their growth is constrained by a number of legal and political hurdles, highlighting the importance of policy advocacy and public education.(\u003cspan citationid=\"CR96\" class=\"CitationRef\"\u003e96\u003c/span\u003e, \u003cspan citationid=\"CR97\" class=\"CitationRef\"\u003e97\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eOverall, community-based harm reduction programs have been proven effective, based on the evidence base. The main issue is no longer the development of efficacy but the bridging of the implementation gap. Subsequent activities in implementation science, sustainable funding solutions, and structural changes should focus on ensuring these life-saving interventions are fully embedded in available and equitable public health systems.(\u003cspan citationid=\"CR98\" class=\"CitationRef\"\u003e98\u003c/span\u003e, \u003cspan citationid=\"CR99\" class=\"CitationRef\"\u003e99\u003c/span\u003e)\u003c/p\u003e \u003c/div\u003e"},{"header":"5 Recommendations and Future Directions","content":"\u003cp\u003eThe obvious sign of the need is the urgent transition from the proof-of-concept to the stable, available system of care. The way ahead is not only about investing in programs, but about creating a more sustainable public health infrastructure. This would involve developing long-term, consistent funding through planned opioid settlement provisions and Medicaid reform to avoid the stuttering of short-term grants to programs and individuals receiving them, leaving them in a continual state of change.(\u003cspan additionalcitationids=\"CR101\" citationid=\"CR100\" class=\"CitationRef\"\u003e100\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR102\" class=\"CitationRef\"\u003e102\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eSimultaneously, we should be keen to eliminate the legal and logistical impediments that prevent individuals from accessing the care they require. This is achieved through deregulation of clinical practice to empower more providers and the reform of obsolete laws that criminalise the instruments of health and safety.(\u003cspan additionalcitationids=\"CR104\" citationid=\"CR103\" class=\"CitationRef\"\u003e103\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR105\" class=\"CitationRef\"\u003e105\u003c/span\u003e) We also need to adopt and invest in flexible solutions, such as mobile units and mail-based services, to help close the geographic gaps in access, since no community should be left behind.\u003c/p\u003e \u003cp\u003eLastly, these initiatives should be successful, and to achieve that, we need to gain widespread social and political legitimacy. This means that there must be sustained communication about the demonstrated gains: these programs save lives without a negative effect on community security. More importantly, this legitimacy is created through the sincerity of collaboration and the payment of individuals with lived experience, so that their expertise informs the design and promotion of services intended to assist them.(\u003cspan additionalcitationids=\"CR107\" citationid=\"CR106\" class=\"CitationRef\"\u003e106\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR108\" class=\"CitationRef\"\u003e108\u003c/span\u003e)\u003c/p\u003e"},{"header":"6 Conclusion","content":"\u003cp\u003eThe cumulative data also points to no doubt that community-based harm reduction is effective. These are essential life-saving programs which directly prevent death and disease and provide humane access to prolonged health and security. There is, however, a vast gap between this knowledge on the one side and its general use on the other.\u003c/p\u003e \u003cp\u003eTo fill this gap, it is not just a matter of recognition but a change of attitude. Harm reduction should be perceived not as an experimental, exclusive or controversial practice, but regarded as a common and necessary element of our health community. The key to this vision will rely on favourable policies, consistent funding, smooth assimilation into healthcare, and the desire among the population to substitute stigma with perception and solidarity.\u003c/p\u003e \u003cp\u003eThe way forward is illuminated by the evidence itself. Our collective response will be measured by our resolve to fully and equitably implement these proven, compassionate strategies, thereby empowering every community to uphold dignity and preserve life in the face of an enduring crisis.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eConflict of Interest Statement\u003c/h2\u003e \u003cp\u003eThe authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.\u003c/p\u003e\u003ch2\u003eFunding Statement\u003c/h2\u003e \u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. The authors acknowledge the support and resources provided by the Faculty of Pharmacy, Marwadi University, in facilitating the preparation of this manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eVolkow ND, Blanco C. The Changing Opioid Crisis: development, challenges and opportunities. Mol Psychiatry [Internet]. 2020 Jan 1 [cited 2026 Feb 10];26(1):218. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7398847/\u003c/li\u003e\n\u003cli\u003eJudd D, King CR, Galke C. The Opioid Epidemic: A Review of the Contributing Factors, Negative Consequences, and Best Practices. Cureus [Internet]. 2023 Jul 10 [cited 2026 Feb 10];15(7):e41621. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10410480/\u003c/li\u003e\n\u003cli\u003eCsete J. United States drug courts and opioid agonist therapy: Missing the target of overdose reduction. Forensic Sci Int Mind Law [Internet]. 2020 Nov 1 [cited 2026 Feb 10];1:100024. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7280826/\u003c/li\u003e\n\u003cli\u003eOdii A, Arize I, Agwu P, Mbachu C, Onwujekwe O. To What Extent Are Informal Healthcare Providers in Slums Linked to the Formal Health System in Providing Services in Sub-Sahara Africa? A 12-Year Scoping Review. J Urban Health [Internet]. 2024 Dec 1 [cited 2026 Feb 10];101(6):1248. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC11652447/\u003c/li\u003e\n\u003cli\u003eKline D, Hepler SA, Krawczyk N, Rivera-Aguirre A, Waller LA, Cerd\u0026aacute; M. A state-level history of opioid overdose deaths in the United States: 1999-2021. PLoS One [Internet]. 2024 Sep 1 [cited 2026 Feb 10];19(9):e0309938. Available from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0309938\u003c/li\u003e\n\u003cli\u003eDowell D, Nataraj N, Rikard M, Park J, Zhang K, Baldwin G. Why have overdose deaths decreased? Widespread fentanyl saturation and decreased drug use among key drivers. Lancet Regional Health - Americas [Internet]. 2025 Nov [cited 2026 Feb 10];51:101226. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC12664646/\u003c/li\u003e\n\u003cli\u003eAbbasi K. Better health for vulnerable groups, better health for all. J R Soc Med [Internet]. 2024 Oct 1 [cited 2026 Feb 10];117(10):327. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC11561974/\u003c/li\u003e\n\u003cli\u003eDavis A, Lembo T, Laurie E, Mutua E, Loosli K, Nthambi M, et al. How public health crises expose systemic, day-to-day health inequalities in low- and-middle income countries: an example from East Africa. Antimicrob Resist Infect Control [Internet]. 2022 Dec 1 [cited 2026 Feb 10];11(1):34. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8842514/\u003c/li\u003e\n\u003cli\u003eTran MTN, Luong QH. Community harm reduction initiatives: Essential investments for illicit drug prevention and control in the future. Lancet Reg Health West Pac [Internet]. 2022 Jan 1 [cited 2026 Feb 10];18:100373. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8749285/\u003c/li\u003e\n\u003cli\u003ePak SC, Micalos PS, Maria SJ, Lord B. Nonpharmacological Interventions for Pain Management in Paramedicine and the Emergency Setting: A Review of the Literature. Evid Based Complement Alternat Med [Internet]. 2015 [cited 2026 Feb 10];2015:873039. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC4396997/\u003c/li\u003e\n\u003cli\u003eWenger LD, Kral AH, Bluthenthal RN, Morris T, Ongais L, Lambdin BH. Ingenuity and resiliency of syringe service programs on the front lines of the opioid overdose and COVID-19 crises. Translational Research [Internet]. 2021 Aug 1 [cited 2026 Feb 10];234:159. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8217165/\u003c/li\u003e\n\u003cli\u003eGreen TC, Dauria EF, Bratberg J, Davis CS, Walley AY. Orienting patients to greater opioid safety: models of community pharmacy-based naloxone. Harm Reduct J [Internet]. 2015 Aug 6 [cited 2026 Feb 10];12(1):25. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC4527253/\u003c/li\u003e\n\u003cli\u003eAdams JM. Making the Case for Syringe Services Programs. Public Health Reports [Internet]. 2020 Jul 1 [cited 2026 Feb 10];135(1 Suppl):10S. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7407057/\u003c/li\u003e\n\u003cli\u003eBehrends CN, Des Jarlais DC, Luhur W, Lu X, Corry GJ, Glick SN, et al. On-site health service delivery models at syringe services programs in the United States: Results of a national cross-sectional survey. Drug and Alcohol Dependence Reports [Internet]. 2025 Sep 1 [cited 2026 Feb 10];16:100355. Available from: https://www.sciencedirect.com/science/article/pii/S2772724625000381\u003c/li\u003e\n\u003cli\u003eHanson BL, Porter RR, Z\u0026ouml;ld AL, Terhorst-Miller H. Preventing opioid overdose with peer-administered naloxone: findings from a rural state. Harm Reduct J [Internet]. 2020 Jan 9 [cited 2026 Feb 10];17(1):4. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC6953279/\u003c/li\u003e\n\u003cli\u003eSmart R, Davis CS. Reducing Opioid Overdose Deaths by Expanding Naloxone Distribution and Addressing Structural Barriers to Care. Am J Public Health [Internet]. 2021 Aug 1 [cited 2026 Feb 10];111(8):1382. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8489607/\u003c/li\u003e\n\u003cli\u003eStevens A, Keemink JR, Shirley-Beavan S, Khadjesari Z, Artenie A, Vickerman P, et al. Overdose prevention centres as spaces of safety, trust and inclusion: A causal pathway based on a realist review. Drug Alcohol Rev [Internet]. 2024 Sep 1 [cited 2026 Feb 10];43(6):1573. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7617959/\u003c/li\u003e\n\u003cli\u003eWares JR, Dong J, Gevertz JL, Radunskaya A, Vine K, Wiebe D, et al. Predicting the impact of placing an overdose prevention site in Philadelphia: a mathematical modeling approach. Harm Reduct J [Internet]. 2021 Dec 1 [cited 2026 Feb 10];18(1):110. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8556858/\u003c/li\u003e\n\u003cli\u003eLjungholm L, Edin-Liljegren A, Ekstedt M, Klinga C. What is needed for continuity of care and how can we achieve it? \u0026ndash; Perceptions among multiprofessionals on the chronic care trajectory. BMC Health Serv Res [Internet]. 2022 Dec 1 [cited 2026 Feb 10];22(1):686. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC9125858/\u003c/li\u003e\n\u003cli\u003eKhan GK, Harvey L, Johnson S, Long P, Kimmel S, Pierre C, et al. Integration of a community-based harm reduction program into a safety net hospital: a qualitative study. Harm Reduct J [Internet]. 2022 Dec 1 [cited 2026 Feb 10];19(1):35. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC9002225/\u003c/li\u003e\n\u003cli\u003eChilds E, Biello KB, Valente PK, Salhaney P, Biancarelli DL, Olson J, et al. Implementing harm reduction in non-urban communities affected by opioids and polysubstance use: A qualitative study exploring challenges and mitigating strategies. Int J Drug Policy [Internet]. 2020 Apr 1 [cited 2026 Feb 10];90:103080. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8046716/\u003c/li\u003e\n\u003cli\u003ePanagiotoglou D, Abrahamowicz M, Buckeridge DL, Caro JJ, Latimer E, Maheu-Giroux M, et al. Evaluating Montr\u0026eacute;al\u0026rsquo;s harm reduction interventions for people who inject drugs: protocol for observational study and cost-effectiveness analysis. BMJ Open [Internet]. 2021 Oct 26 [cited 2026 Feb 10];11(10):e053191. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8549659/\u003c/li\u003e\n\u003cli\u003eKrieger MS, Goedel WC, Buxton JA, Lysyshyn M, Bernstein E, Sherman SG, et al. Use of Rapid Fentanyl Test Strips Among Young Adults Who Use Drugs. Int J Drug Policy [Internet]. 2018 Nov 1 [cited 2026 Feb 10];61:52. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC6701177/\u003c/li\u003e\n\u003cli\u003eHaegerich TM, Jones CM, Cote PO, Robinson A, Ross L. Evidence for state, community and systems-level prevention strategies to address the opioid crisis. Drug Alcohol Depend [Internet]. 2019 Nov 1 [cited 2026 Feb 10];204:107563. Available from: https://www.sciencedirect.com/science/article/pii/S0376871619303400\u003c/li\u003e\n\u003cli\u003eKarim Khan G, Harvey L, Johnson S, Long P, Kimmel S, Pierre C, et al. Integration of a community-based harm reduction program into a safety net hospital: a qualitative study. Harm Reduct J [Internet]. 2020 [cited 2026 Feb 10];19:35. Available from: https://doi.org/10.1186/s12954-022-00622-8\u003c/li\u003e\n\u003cli\u003eKnaak S, Mantler E, Szeto A. Mental illness-related stigma in healthcare: Barriers to access and care and evidence-based solutions. Healthc Manage Forum [Internet]. 2017 Mar 1 [cited 2026 Feb 10];30(2):111. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC5347358/\u003c/li\u003e\n\u003cli\u003eWaqas A, Malik S, Fida A, Abbas N, Mian N, Miryala S, et al. Interventions to Reduce Stigma Related to Mental Illnesses in Educational Institutes: a Systematic Review. Psychiatr Q [Internet]. 2020 Sep 1 [cited 2026 Feb 10];91(3):887. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7395002/\u003c/li\u003e\n\u003cli\u003eGronholm PC, Bakolis I, Cherian A V., Davies K, Evans-Lacko S, Girma E, et al. Toward a multi-level strategy to reduce stigma in global mental health: overview protocol of the Indigo Partnership to develop and test interventions in low- and middle-income countries. Int J Ment Health Syst [Internet]. 2023 Dec 1 [cited 2026 Feb 10];17(1):2. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC9896727/\u003c/li\u003e\n\u003cli\u003eNational Academies of Sciences E and M, Division H and M, Policy B on HS, Abuse C on PM and RS to APO, Phillips JK, Ford MA, et al. Evidence on Strategies for Addressing the Opioid Epidemic. Pain Management and the Opioid Epidemic [Internet]. 2017 Jul 13 [cited 2026 Feb 10]; Available from: https://www.ncbi.nlm.nih.gov/books/NBK458653/\u003c/li\u003e\n\u003cli\u003eCiccarone D. The Rise of Illicit Fentanyls, Stimulants and the Fourth Wave of the Opioid Overdose Crisis. Curr Opin Psychiatry [Internet]. 2021 Apr 2 [cited 2026 Feb 10];34(4):344. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8154745/\u003c/li\u003e\n\u003cli\u003eAlvand S, Amin-Esmaeili M, Poustchi H, Roshandel G, Sadeghi Y, Sharifi V, et al. Prevalence and determinants of opioid use disorder among long-term opiate users in Golestan Cohort Study. BMC Psychiatry [Internet]. 2023 Dec 1 [cited 2026 Feb 10];23(1):958. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10734090/\u003c/li\u003e\n\u003cli\u003eLee YK, Gold MS, Blum K, Thanos PK, Hanna C, Fuehrlein BS. Opioid use disorder: current trends and potential treatments. Front Public Health. 2023 Jan 25;11:1274719. \u003c/li\u003e\n\u003cli\u003eLowenstein M, Abrams MP, Crowe M, Shimamoto K, Mazzella S, Botcheos D, et al. Come Try It Out. Get Your Foot in the Door:\u0026rdquo; Exploring Patient Perspectives on Low-Barrier Treatment for Opioid Use Disorder. Drug Alcohol Depend [Internet]. 2023 Jul 1 [cited 2026 Feb 10];248:109915. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10330675/\u003c/li\u003e\n\u003cli\u003eLarochelle MR, Bernson D, Land T, Stopka TJ, Wang N, Xuan Z, et al. Medication for opioid use disorder after nonfatal opioid overdose and association with mortality: A cohort study. Ann Intern Med. 2018 Aug 7;169(3):137\u0026ndash;45. \u003c/li\u003e\n\u003cli\u003eWenger LD, Doe-Simkins M, Wheeler E, Ongais L, Morris T, Bluthenthal RN, et al. Best practices for community-based overdose education and naloxone distribution programs: results from using the Delphi approach. Harm Reduct J [Internet]. 2022 Dec 1 [cited 2026 Feb 10];19(1):55. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC9145109/\u003c/li\u003e\n\u003cli\u003eAdams JW, Savinkina A, Fox A, Behrends CN, Madushani RWMA, Wang J, et al. Modeling the cost-effectiveness and impact on fatal overdose and initiation of buprenorphine\u0026ndash;naloxone treatment at syringe service programs. Addiction (Abingdon, England) [Internet]. 2022 Oct 1 [cited 2026 Feb 10];117(10):2635. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC9951221/\u003c/li\u003e\n\u003cli\u003e\u0026Ouml;stlund U, Kidd L, Wengstr\u0026ouml;m Y, Rowa-Dewar N. Combining qualitative and quantitative research within mixed method research designs: A methodological review. Int J Nurs Stud [Internet]. 2020 Mar [cited 2026 Feb 10];48(3):369. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7094322/\u003c/li\u003e\n\u003cli\u003eLambdin BH, Bluthenthal RN, Wenger LD, Wheeler E, Garner B, Lakosky P, et al. Overdose Education and Naloxone Distribution Within Syringe Service Programs \u0026mdash; United States, 2019. [Internet]. 2020 Aug 21 [cited 2026 Feb 10];69(33):1117. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7439981/\u003c/li\u003e\n\u003cli\u003eKimmel SD, Gaeta JM, Hadland SE, Hallett E, Marshall BDL. Principles of Harm Reduction for Young People Who Use Drugs. Pediatrics [Internet]. 2021 Jan 1 [cited 2026 Feb 10];147(Suppl 2):S240. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7907587/\u003c/li\u003e\n\u003cli\u003eLo CKL, Mertz D, Loeb M. Newcastle-Ottawa Scale: comparing reviewers\u0026rsquo; to authors\u0026rsquo; assessments. BMC Med Res Methodol [Internet]. 2014 Apr 1 [cited 2026 Feb 10];14(1):45. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC4021422/\u003c/li\u003e\n\u003cli\u003eHartling L, Milne A, Hamm MP, Vandermeer B, Ansari M, Tsertsvadze A, et al. Testing the Newcastle Ottawa Scale showed low reliability between individual reviewers. J Clin Epidemiol [Internet]. 2013 Sep 1 [cited 2026 Feb 10];66(9):982\u0026ndash;93. Available from: https://www.sciencedirect.com/science/article/abs/pii/S0895435613000899\u003c/li\u003e\n\u003cli\u003eLong HA, French DP, Brooks JM. Optimising the value of the critical appraisal skills programme (CASP) tool for quality appraisal in qualitative evidence synthesis. Research Methods in Medicine \u0026amp; Health Sciences [Internet]. 2020 Sep [cited 2026 Feb 10];1(1):31\u0026ndash;42. Available from: https://scholar.google.com/scholar_url?url=https://journals.sagepub.com/doi/pdf/10.1177/2632084320947559\u0026amp;hl=en\u0026amp;sa=T\u0026amp;oi=ucasa\u0026amp;ct=\u003cbr\u003eufr\u0026amp;ei=0mSLaZ2HCZWz6rQPg_KL8Qg\u0026amp;scisig=AHkA5jQjhBuCT9knOQdMoHn02koI\u003c/li\u003e\n\u003cli\u003ePage MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Syst Rev [Internet]. 2021 Dec 1 [cited 2026 Feb 10];10(1):89. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8008539/\u003c/li\u003e\n\u003cli\u003eAkl EA, Kahale LA, Elkhoury R, El Mikati I, Pardo-Hernandez H, Khamis AM, et al. Tailored PRISMA 2020 flow diagrams for living systematic reviews: a methodological survey and a proposal. F1000Res [Internet]. 2022 [cited 2026 Feb 10];10:192. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8804909/\u003c/li\u003e\n\u003cli\u003eDepartment for HIV, Tuberculosis, Hepatitis and STIs [Internet]. [cited 2026 Feb 10]. Available from: https://www.who.int/teams/global-hiv-hepatitis-and-stis-programmes/populations/people-who-inject-drugs\u003c/li\u003e\n\u003cli\u003eVadiei N, Axon DR, Eckert B. Naloxone Distribution Models in the United States: A Scoping Review. Substance Use and Addiction Journal [Internet]. 2025 Apr 1 [cited 2026 Feb 10];46(2):391\u0026ndash;404. Available from: https://journals.sagepub.com/doi/10.1177/29767342241289008\u003c/li\u003e\n\u003cli\u003eMezaache S, Turlure F, Fredon N, Le Brun Gadelius M, Micallef J, Frauger E. Opioid overdose prevention and naloxone diffusion (POP program): Results of an overview conducted among addiction specialized centres. Therapies [Internet]. 2023 Nov 1 [cited 2026 Feb 10];78(6):605\u0026ndash;14. Available from: https://pubmed.ncbi.nlm.nih.gov/37012152/\u003c/li\u003e\n\u003cli\u003eMackey KM, Beech EH, Williams BE, Anderson JK, Young S, Parr NJ. RESULTS. 2023 [cited 2026 Feb 10]; Available from: https://www.ncbi.nlm.nih.gov/books/NBK598967/\u003c/li\u003e\n\u003cli\u003evan Draanen J, Hamilton J, Morgan J, Maxwell S, Taylor T, Richardson L, et al. Supervised smoking facility access, harm reduction practices, and substance use changes during the COVID-19 pandemic: a community-engaged cross-sectional study. Harm Reduct J [Internet]. 2023 Dec 1 [cited 2026 Feb 10];20(1):101. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10388471/\u003c/li\u003e\n\u003cli\u003eJakubowski A, Fowler S, Fox AD. Three decades of research in substance use disorder treatment for syringe services program participants: a scoping review of the literature. Addiction Science \u0026amp; Clinical Practice [Internet]. 2023 Dec 1 [cited 2026 Feb 10];18(1):40. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10256972/\u003c/li\u003e\n\u003cli\u003eChatterjee A, Weitz M, Savinkina A, Macmadu A, Madushani RWMA, Potee RA, et al. Estimated Costs and Outcomes Associated With Use and Nonuse of Medications for Opioid Use Disorder During Incarceration and at Release in Massachusetts. JAMA Netw Open [Internet]. 2023 Apr 14 [cited 2026 Feb 10];6(4):e237036. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10105308/\u003c/li\u003e\n\u003cli\u003eKutscher E, Barber Grossi M, Lapolla F, Lee JD. Fentanyl Test Strips for Harm Reduction: A Scoping Review. J Addict Med [Internet]. 2024 Jul 1 [cited 2026 Feb 10];18(4):373\u0026ndash;80. Available from: https://pubmed.ncbi.nlm.nih.gov/38829042/\u003c/li\u003e\n\u003cli\u003eIvsins A, MacKinnon L, Bowles JM, Slaunwhite A, Bardwell G. Overdose Prevention and Housing: a Qualitative Study Examining Drug Use, Overdose Risk, and Access to Safer Supply in Permanent Supportive Housing in Vancouver, Canada. J Urban Health [Internet]. 2022 Oct 1 [cited 2026 Feb 10];99(5):855. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC9430005/\u003c/li\u003e\n\u003cli\u003eKrawczyk N, Rivera BD, Jent V, Keyes KM, Jones CM, Cerd\u0026aacute; M. Has the treatment gap for opioid use disorder narrowed in the U.S.?: A yearly assessment from 2010 to 2019\u0026rdquo;. International Journal of Drug Policy [Internet]. 2022 Dec 1 [cited 2026 Feb 10];110. Available from: https://pubmed.ncbi.nlm.nih.gov/35934583/\u003c/li\u003e\n\u003cli\u003eBanta-Green CJ, Owens MD, Williams JR, Floyd AS, Williams-Gilbert W, Kingston S. Community-Based Medications First for Opioid Use Disorder - Care Utilization and Mortality Outcomes. Subst Abuse Rehabil [Internet]. 2024 Sep [cited 2026 Feb 10];15:173. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC11409926/\u003c/li\u003e\n\u003cli\u003eRazaghizad A, Windle SB, Filion KB, Gore G, Kudrina I, Paraskevopoulos E, et al. The Effect of Overdose Education and Naloxone Distribution: An Umbrella Review of Systematic Reviews. Am J Public Health [Internet]. 2021 Aug 1 [cited 2026 Feb 10];111(8):e1. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8489614/\u003c/li\u003e\n\u003cli\u003eBohler RM, Freeman PR, Villani J, Hunt T, Linas BS, Walley AY, et al. The policy landscape for naloxone distribution in four states highly impacted by fatal opioid overdoses. Drug and Alcohol Dependence Reports [Internet]. 2022 Mar 1 [cited 2026 Feb 10];6:100126. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC9838196/\u003c/li\u003e\n\u003cli\u003eOsilla KC, Meredith LS, Griffin BA, Martineau M, Hindmarch G, Watkins KE. Design of CLARO+ (Collaboration Leading to Addiction Treatment and Recovery from Other Stresses, Plus): A randomized trial of collaborative care to decrease overdose and suicide risk among patients with co-occurring disorders. Contemp Clin Trials. 2023 Sep 1;132. \u003c/li\u003e\n\u003cli\u003eBroz D, Carnes N, Chapin-Bardales J, Des Jarlais DC, Handanagic S, Jones CM, et al. Syringe Services Programs\u0026rsquo; Role in Ending the HIV Epidemic in the U.S.: Why We Cannot Do It Without Them. Am J Prev Med [Internet]. 2021 Nov 1 [cited 2026 Feb 10];61(5 Suppl 1):S118. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC11334402/\u003c/li\u003e\n\u003cli\u003eSyringe Services Programs | HIV.gov [Internet]. [cited 2026 Feb 10]. Available from: https://www.hiv.gov/federal-response/other-topics/syringe-services-programs\u003c/li\u003e\n\u003cli\u003eAbdul-Quader AS, Feelemyer J, Modi S, Stein ES, Briceno A, Semaan S, et al. Effectiveness of Structural-Level Needle/Syringe Programs to Reduce HCV and HIV Infection Among People Who Inject Drugs: A Systematic Review. AIDS Behav [Internet]. 2013 Nov [cited 2026 Feb 10];17(9):2878. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC6509353/\u003c/li\u003e\n\u003cli\u003eGoedel WC, King MRF, Lurie MN, Galea S, Townsend JP, Galvani AP, et al. Implementation of Syringe Services Programs to Prevent Rapid Human Immunodeficiency Virus Transmission in Rural Counties in the United States: A Modeling Study. Clin Infect Dis [Internet]. 2019 Mar 3 [cited 2026 Feb 10];70(6):1096. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7319062/\u003c/li\u003e\n\u003cli\u003eHood JE, Banta-Green CJ, Duchin JS, Breuner J, Dell W, Finegood B, et al. Engaging an unstably housed population with low-barrier buprenorphine treatment at a syringe services program: Lessons learned from Seattle, Washington. Subst Abus [Internet]. 2020 Jul 2 [cited 2026 Feb 10];41(3):356\u0026ndash;64. Available from: https://pubmed.ncbi.nlm.nih.gov/31403907/\u003c/li\u003e\n\u003cli\u003eLambdin BH, Kan D, Kral AH. Improving equity and access to buprenorphine treatment through telemedicine at syringe services programs. Subst Abuse Treat Prev Policy [Internet]. 2022 Dec 1 [cited 2026 Feb 10];17(1):51. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC9283820/\u003c/li\u003e\n\u003cli\u003eJakubowski A, Norton BL, Hayes BT, Gibson BE, Fitzsimmons C, Stern LS, et al. Low-threshold buprenorphine treatment in a syringe services program: program description and outcomes. J Addict Med [Internet]. 2021 Jul 1 [cited 2026 Feb 10];16(4):447. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC9095762/\u003c/li\u003e\n\u003cli\u003eKapadia SN, Griffin JL, Waldman J, Ziebarth NR, Schackman BR, Behrends CN. A Harm Reduction Approach to Treating Opioid Use Disorder in an Independent Primary Care Practice: a Qualitative Study. J Gen Intern Med [Internet]. 2021 Jul 1 [cited 2026 Feb 10];36(7):1898. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7815286/\u003c/li\u003e\n\u003cli\u003eForchuk C, Serrato J, Scott L. Identifying barriers and facilitators for implementing harm reduction strategies for methamphetamine use into hospital settings. Frontiers in Health Services [Internet]. 2023 [cited 2026 Feb 10];3:1113891. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10012827/\u003c/li\u003e\n\u003cli\u003eLindenfeld Z, Hagan H, Chang JE. Exploring Barriers and Facilitators to Integrating a Harm Reduction Approach to Substance Use in Three Medical Settings. J Gen Intern Med [Internet]. 2023 Nov 1 [cited 2026 Feb 10];38(15):3273. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10682333/\u003c/li\u003e\n\u003cli\u003eEzell JM, Ompad DC, Walters S. How Urban and Rural Built Environments Influence the Health Attitudes and Behaviors of People Who Use Drugs. Health Place [Internet]. 2021 May 1 [cited 2026 Feb 10];69:102578. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8154703/\u003c/li\u003e\n\u003cli\u003eAshworth M, Thunstr\u0026ouml;m L, Clancy GL, Thompson RA, Johnson D, Fletcher E. Addressing rural and non-rural substance use disorder stigma: Evidence from a national randomized controlled trial. Addictive Behaviors Reports [Internet]. 2024 Jun 1 [cited 2026 Feb 10];19:100541. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10973601/\u003c/li\u003e\n\u003cli\u003eDavis CS, Carr DH, Samuels EA. Paraphernalia Laws, Criminalizing Possession and Distribution of Items Used to Consume Illicit Drugs, and Injection-Related Harm. Am J Public Health [Internet]. 2019 [cited 2026 Feb 10];109(11):1564. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC6775926/\u003c/li\u003e\n\u003cli\u003eRouhani S, Schneider KE, Weicker N, Whaley S, Morris M, Sherman SG. NIMBYism and Harm Reduction Programs: Results from Baltimore City. J Urban Health [Internet]. 2022 Aug 1 [cited 2026 Feb 10];99(4):717. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC9154206/\u003c/li\u003e\n\u003cli\u003eRosen JG, Thompson E, Tardif J, Collins AB, Marshall BDL, Park JN. \u0026ldquo;Make yourself un-NIMBY-able\u0026rdquo;: stakeholder perspectives on strategies to mobilize public and political support for overdose prevention centers in the United States of America. Harm Reduct J [Internet]. 2024 Dec 1 [cited 2026 Feb 10];21(1):40. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10868085/\u003c/li\u003e\n\u003cli\u003eTempalski B, Friedman R, Keem M, Cooper H, Friedman SR. NIMBY localism and national inequitable exclusion alliances: The case of syringe exchange programs in the United States. Geoforum [Internet]. 2007 Nov [cited 2026 Feb 10];38(6):1250. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC2170884/\u003c/li\u003e\n\u003cli\u003eCMS. Buprenorphine-A Primer for Prescribers and Pharmacists Content Summary. \u003c/li\u003e\n\u003cli\u003eKolak MA, Chen YT, Joyce S, Ellis K, Defever K, McLuckie C, et al. Rural risk environments, opioid-related overdose, and infectious diseases: A multidimensional, spatial perspective. Int J Drug Policy [Internet]. 2020 Nov 1 [cited 2026 Feb 10];85:102727. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10727138/\u003c/li\u003e\n\u003cli\u003eRemien RH, Bauman LJ, Mantell JE, Tsoi B, Lopez-Rios J, Chhabra R, et al. Barriers and Facilitators to Engagement of Vulnerable Populations in HIV Primary Care in New York City. J Acquir Immune Defic Syndr [Internet]. 2015 May 1 [cited 2026 Feb 10];69(0 1):S16. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC4559146/\u003c/li\u003e\n\u003cli\u003ePaquette CE, Syvertsen JL, Pollini RA. Stigma at every turn: Health services experiences among people who inject drugs. International Journal of Drug Policy. 2018 Jul 1;57:104\u0026ndash;10. \u003c/li\u003e\n\u003cli\u003eBaltzer F, Elliott A, Katzman D, Pinzon J, Sankaran K, Taddeo D, et al. Harm reduction: An approach to reducing risky health behaviours in adolescents. Paediatr Child Health [Internet]. 2008 [cited 2026 Feb 10];13(1):53. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC2528824/\u003c/li\u003e\n\u003cli\u003eSamhsa. Community Expansion of Evidence-Based Harm Reduction Strategies for People Who Use Drugs. \u003c/li\u003e\n\u003cli\u003eHarm Reduction: Public Health and Public Order - Open Society Foundations [Internet]. [cited 2026 Feb 10]. Available from: https://www.opensocietyfoundations.org/publications/harm-reduction-public-health-and-public-order\u003c/li\u003e\n\u003cli\u003eHarm Reduction and Substance Use Treatment 6% 94% Receipt of Any Substance Use Treatment among People with a Past Year SUD. 2024 [cited 2026 Feb 10]; Available from: https://www.samhsa.gov/data/report/2021-nsduh-annual-national-report\u003c/li\u003e\n\u003cli\u003eReview of the Medically Supervised Injecting Room. 2023; \u003c/li\u003e\n\u003cli\u003ePatel K. The Importance of Data-Driven Decision-Making in Public Health. International Journal of Computer Trends and Technology. 2024 May 30;72(5):27\u0026ndash;32. \u003c/li\u003e\n\u003cli\u003eSteinwachs DM. Transforming Public Health Systems: Using Data to Drive Organizational Capacity for Quality Improvement and Efficiency. eGEMs [Internet]. 2015 Mar 27 [cited 2026 Feb 10];2(4):1175. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC4438105/\u003c/li\u003e\n\u003cli\u003eEmerson B, Haden M. Public Health and the Harm Reduction Approach to Illegal Psychoactive Substances ☆. Reference Module in Biomedical Sciences [Internet]. 2018 [cited 2026 Feb 11];1\u0026ndash;17. Available from: https://doi.org/10.1016/B978-0-12-801238-3.66208-6\u003c/li\u003e\n\u003cli\u003eImplementing Best Practices Across the Continuum of Care to Prevent Overdose A Roadmap for Governors. \u003c/li\u003e\n\u003cli\u003eLee JH, Wheeler DC, Zimmerman EB, Hines AL, Chapman DA. Urban\u0026ndash;Rural Disparities in Deaths of Despair: A County-Level Analysis 2004\u0026ndash;2016 in the U.S. Am J Prev Med [Internet]. 2022 Feb 1 [cited 2026 Feb 11];64(2):149. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10997338/\u003c/li\u003e\n\u003cli\u003eRaver E, Retchin SM, Li Y, Carlo AD, Xu WY. Rural\u0026ndash;urban differences in out‐of‐network treatment initiation and engagement rates for substance use disorders. Health Serv Res [Internet]. 2024 Oct 1 [cited 2026 Feb 11];59(5):e14299. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC11366955/\u003c/li\u003e\n\u003cli\u003eMcGinty E, Pescosolido B, Kennedy-Hendricks A, Barry CL. Communication strategies to counter stigma and improve mental health and substance use disorder policy. Psychiatr Serv [Internet]. 2017 Feb 1 [cited 2026 Feb 11];69(2):136. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC5794622/\u003c/li\u003e\n\u003cli\u003eRich KM, Bia J, Altice FL, Feinberg J. Integrated Models of Care for Individuals with Opioid Use Disorder: How Do We Prevent HIV and HCV? Curr HIV/AIDS Rep [Internet]. 2018 Jun 17 [cited 2026 Feb 11];15(3):266\u0026ndash;75. Available from: http://link.springer.com/10.1007/s11904-018-0396-x\u003c/li\u003e\n\u003cli\u003eKorthuis PT, Mccarty D, Weimer M, Bougatsos C, Blazina I, Zakher B, et al. Primary Care-Based Models for the Treatment of Opioid Use Disorder A Scoping Review. Ann Intern Med [Internet]. 2017 [cited 2026 Feb 11];166:268\u0026ndash;78. Available from: https://annals.org\u003c/li\u003e\n\u003cli\u003eTseregounis IE, Henry SG. Assessing opioid overdose risk: A review of clinical prediction models utilizing patient-level data. Transl Res [Internet]. 2021 Aug 1 [cited 2026 Feb 11];234:74. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8217215/\u003c/li\u003e\n\u003cli\u003eHanson BL, Porter RR, Z\u0026ouml;ld AL, Terhorst-Miller H. Preventing opioid overdose with peer-administered naloxone: findings from a rural state. Harm Reduct J [Internet]. 2020 Jan 9 [cited 2026 Feb 11];17(1):4. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC6953279/\u003c/li\u003e\n\u003cli\u003eTroberg K, Isendahl P, Blom\u0026eacute; MA, Dahlman D, H\u0026aring;kansson A. Characteristics of and Experience Among People Who Use Take-Home Naloxone in Sk\u0026aring;ne County, Sweden. Front Public Health [Internet]. 2022 Mar 10 [cited 2026 Feb 11];10:811001. Available from: www.frontiersin.org\u003c/li\u003e\n\u003cli\u003eSocia KM, Stone R, Palacios WR, Cluverius J. Focus on prevention: The public is more supportive of \u0026ldquo;overdose prevention sites\u0026rdquo; than they are of \u0026ldquo;safe injection facilities.\u0026rdquo; Criminol Public Policy [Internet]. 2021 Nov 1 [cited 2026 Feb 11];20(4):729\u0026ndash;54. Available from: /doi/pdf/10.1111/1745-9133.12566\u003c/li\u003e\n\u003cli\u003eOverdose Prevention Centers: State of the Law. [cited 2026 Feb 11]; Available from: https://transformdrugs.org/drug-\u003c/li\u003e\n\u003cli\u003eKhan GK, Harvey L, Johnson S, Long P, Kimmel S, Pierre C, et al. Integration of a community-based harm reduction program into a safety net hospital: a qualitative study. Harm Reduct J [Internet]. 2022 Dec 1 [cited 2026 Feb 11];19(1):35. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC9002225/\u003c/li\u003e\n\u003cli\u003eHarm Reduction is Healthcare: Sustainable Funding for Harm Reduction Programs - National Harm Reduction Coalition [Internet]. [cited 2026 Feb 11]. Available from: https://harmreduction.org/issues/harm-reduction-is-healthcare-sustainable-funding-for-harm-reduction-programs/\u003c/li\u003e\n\u003cli\u003eFrieden TR, Lee CT, Lamorde M, Nielsen M, McClelland A, Tangcharoensathien V. The road to achieving epidemic-ready primary health care. Lancet Public Health [Internet]. 2023 May 1 [cited 2026 Feb 11];8(5):e383. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10139016/\u003c/li\u003e\n\u003cli\u003eBenjamin GC. The Future of Public Health: Ensuring An Adequate Infrastructure. Milbank Q [Internet]. 2023 Apr 1 [cited 2026 Feb 11];101(Suppl 1):637. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10126968/\u003c/li\u003e\n\u003cli\u003eDeSalvo K, Parekh A, William Hoagland G, Dilley A, Kaiman S, Hines M, et al. Developing a Financing System to Support Public Health Infrastructure. Am J Public Health [Internet]. 2019 [cited 2026 Feb 11];109(10):1358. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC6727291/\u003c/li\u003e\n\u003cli\u003eState Funded Projects - DHCS Opioid Response [Internet]. [cited 2026 Feb 11]. Available from: https://californiaopioidresponse.org/opioid-settlements/state-funded-projects/\u003c/li\u003e\n\u003cli\u003eMohsin K, Mula-Hussain L, Gilson R. HealthCare Access Barrier (HCAB) framework for the barriers to cancer care during conflicts: perspective from Iraq. BMJ Oncology [Internet]. 2024 Mar 1 [cited 2026 Feb 11];3(1):252. Available from: https://bmjoncology.bmj.com/content/3/1/e000252\u003c/li\u003e\n\u003cli\u003eAllen EM, Call KT, Beebe TJ, McAlpine DD, Johnson PJ. Barriers to Care and Healthcare Utilization among the Publicly Insured. Med Care [Internet]. 2017 [cited 2026 Feb 11];55(3):207. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC5309146/\u003c/li\u003e\n\u003cli\u003eOlayinka F, Sauer M, Menning L, Summers D, Wonodi C, Mackay S, et al. Building and sustaining public and political commitment to the value of vaccination: Recommendations for the Immunization Agenda 2030 (Strategic Priority Area 2). Vaccine [Internet]. 2024 Apr 8 [cited 2026 Feb 11];42:S43\u0026ndash;53. Available from: https://scholar.google.com/scholar?q=Restrepo-M%C3%A9ndez%20MC%2C%20Barros%20AJD%2C%20Wong%20KLM%2C%20Johnson%\u003cbr\u003e20HL%2C%20Pariyo%20G%2C%20Wehrmeister%20FC%2C%20et%20al.%20Missed%20opportunities%20in%20full%\u003cbr\u003e20immunization%20coverage%3A%20findings%20from%20low-%20and%20lower-middle-income%20countries.%20Glob%20Health%20Action%202016%3B9%3A30963.%20https%3A%2F%2Fdoi.org%2F10.3402%2Fgha.v9.30963.\u003c/li\u003e\n\u003cli\u003eFu JS, Wang R. Multiple pathways to organizational legitimacy: Information visibility, organizational listening, and cross-sector partnerships. Public Relat Rev [Internet]. 2024 Nov 1 [cited 2026 Feb 11];50(4):102484. Available from: https://doi.org/10.1177/0893318915601161\u003c/li\u003e\n\u003cli\u003eTaylor S. Political epidemiology: Strengthening socio-political analysis for mass immunisation \u0026ndash; lessons from the smallpox and polio programmes. Glob Public Health [Internet]. 2009 Nov [cited 2026 Feb 11];4(6):546. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC9491142/\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Marwadi University","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Harm reduction, Opioid overdose prevention, Naloxone distribution, Syringe service programs (SSPs), Medication for opioid use disorder (MOUD), Overdose prevention centers (OPCs)","lastPublishedDoi":"10.21203/rs.3.rs-8845536/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8845536/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThis systematic review synthesises evidence on the community-based harm reduction program and its role in the opioid crisis, based on 78 studies published between 2012 and April 2023. The review reviewed the key interventions, such as syringe service programs (SSPs), overdose education and naloxone distribution (OEND), overdose prevention centres (OPCs), drug-checking (e.g., fentanyl test strips), and low-barrier medication for opioid use disorder (MOUD) and assessed the outcomes of overdose mortality, infectious disease transmission, linkage to care, and program feasibility. Quality and reliable evidence suggest that OEND scale-up is linked to quantifiable decreases in overdose mortality, SSPs have significant effects on the reduction of HIV and HCV infections, and OPCs report no on-site deaths with a large volume of visits and enhanced service utilisation.\u003c/p\u003e \u003cp\u003eCo-located services and integrated SSP-MOUD models have an incomparable effect on boosting MOUD initiation and retention. Combined methods of SSP, naloxone, and MOUD have favourable cost-effectiveness ratios, according to a cost-effectiveness analysis. Chronic obstacles include punitive paraphernalia legislation, unreliable short-term financing, regulatory barriers, stigma, and service gaps in rural areas that undermine scale and fairness. The review identifies important gaps in implementation science, the longitudinal efficacy of newer interventions (e.g., OPCs, drug-checking), and interventions to decrease multi-level stigma. There are policy implications of integrating harm reduction into the everyday health infrastructure through steady funding, deregulation to increase the number of providers, mobile and mail models of rural access, and intentional communication with the public to promote legitimacy.\u003c/p\u003e \u003cp\u003eTo sum up, community-based harm reduction is an evidence-based, life-saving model of public health; now is the time to learn how to translate efficacy into equitable, sustainable implementation at scale.\u003c/p\u003e","manuscriptTitle":"Addressing the Opioid Crisis Through Community-Based Harm Reduction Programs","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-12 05:06:55","doi":"10.21203/rs.3.rs-8845536/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7f34122c-df79-44c1-aa06-88c191409c5f","owner":[],"postedDate":"February 12th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-12T05:06:55+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-12 05:06:55","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8845536","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8845536","identity":"rs-8845536","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}