Harm Reduction Engagement and Ongoing Opioid Use Among Adults Receiving Methadone or Buprenorphine in Philadelphia

Harm Reduction Engagement and Ongoing Opioid Use Among Adults Receiving Methadone or Buprenorphine in Philadelphia | 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 Research Article Harm Reduction Engagement and Ongoing Opioid Use Among Adults Receiving Methadone or Buprenorphine in Philadelphia William Brincheiro, Nolan Chiles, Lara Carson Weinstein, William Jangro, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7558770/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 03 Jan, 2026 Read the published version in Harm Reduction Journal → Version 1 posted 13 You are reading this latest preprint version Abstract Background Opioid Use Disorder (OUD), a chronic condition with significant health and social consequences, has been intensified by synthetic opioids such as fentanyl. While medications for OUD (MOUD), such as buprenorphine and methadone, reduce mortality and improve treatment retention, MOUD recipients may continue to engage in high-risk substance use. Harm reduction services (HRSs), including syringe exchange sites, supervised injection facilities, or sites that distribute fentanyl test strips or naloxone, may help mitigate the risks of continued use. This study explores engagement with harm reduction services and opioid use practices among adults receiving MOUD in Philadelphia, including differences in these outcomes between methadone and buprenorphine recipients. Methods We conducted a cross-sectional survey of 116 adults receiving buprenorphine or methadone for moderate-to-severe OUD at three Philadelphia treatment sites between November 2023 and October 2024. The participants completed a RedCAP-based questionnaire assessing recent opioid use, access to and attitudes towards HRS, and substance use practices. Statistical analyses were performed via chi-square and Kruskal‒Wallis tests. Results Overall, 37% of participants reported recent illicit opioid use, primarily via injection with various sterile injection practices. Sixty-one percent of all participants had accessed harm reduction services at least once, yet regular use was uncommon, with only 29% reporting access in the past week. Access to harm reduction services was significantly associated with fentanyl test strip use (p = 0.002) but not with consistent sterile injection practices (p = 0.20). Compared with methadone recipients, buprenorphine recipients were more likely to access harm reduction services, feel welcomed at these sites, recommend them to others, and perceive a positive community impact (all p < 0.05). No differences in recent opioid use were observed between treatment groups or across racial groups. Conclusions Despite active MOUD treatment, many patients reported high-risk opioid use. Positive attitudes toward and engagement with harm reduction services were more common among buprenorphine recipients, suggesting that differences in MOUD setting and structure may influence engagement with harm reduction. These findings support the integration of harm reduction strategies into MOUD programs, particularly among methadone recipients, to reduce risk and improve outcomes among individuals with OUD. Harm Reduction Opioid Use Disorder Injection drug use Methadone Buprenorphine Treatment engagement Figures Figure 1 Background Opioid Use Disorder (OUD) is a chronic, relapsing condition linked to high rates of morbidity and mortality, including overdose, infectious disease, and co-occurring mental health issues. 1,2 An estimated 2.7 million Americans are affected, with 81,806 opioid-involved overdose deaths reported in 2022—a fourfold increase in risk compared to a decade ago. 3-6 The rise of fentanyl and other synthetic opioids has intensified these outcomes. Despite the availability of effective treatments, many individuals face barriers such as limited access, stigma, and overly reductive approaches to care. 1,7,8 Addressing OUD remains an urgent public health priority. Medication for OUD (MOUD) is a well-established and effective treatment. Both buprenorphine and methadone improve treatment retention, reduce relapses, and lower opioid-related mortality while also decreasing the risk of infections such as HIV and hepatitis C. 7-11 Their use is often guided by individual patient needs. Methadone, a full agonist, offers strong retention benefits but requires daily visits to certified treatment programs and carries a higher overdose risk when combined with other opioids. 12-14 Buprenorphine, a partial agonist, presents a lower risk of respiratory depression, allows for outpatient prescription, and is classified as a Schedule III substance in many states. 8,10,12,15,16 Each option has distinct advantages and limitations, necessitating personalized decision-making by patients and providers (Table 1). Table 1: Comparison of Methadone and Buprenorphine in the treatment of Opioid Use Disorder Methadone Buprenorphine Treatment Retention Higher retention than buprenorphine Lower retention than methadone Overdose Risk Higher overdose risk Lower overdose risk Adverse Effects More sedation and cardiac side effects Fewer adverse effects overall Practical Considerations Daily in-clinic dosing required Can be prescribed in office-based settings Despite the effectiveness of MOUD, ongoing opioid use during treatment remains common, particularly with the emergence of potent synthetic opioids such as fentanyl, which may require higher MOUD doses. Studies have shown that patients receiving MOUD often continue using opioids, especially when co-using stimulants such as cocaine or methamphetamine, which significantly increases the risk of relapse. 18 One retrospective study reported rising rates of fentanyl, methamphetamine, and cocaine use among patients on methadone between 2017 and 2021. 19 Another study reported that 58% of MOUD trial participants returned to illicit opioid use, with stimulant use as a major contributor. 20 Individuals who continue using opioids while on MOUD are often younger and more likely to report depression, share injection equipment, engage in transactional sex, and use stimulants—highlighting a critical gap in addressing the complex needs of this population. 21 It remains unclear whether ongoing opioid use during MOUD reflects fentanyl-adulterated stimulant use or a return to illicit opioid use. Regardless, these patterns reveal a gap in the current OUD treatment. If patients on MOUD continue to use opioids—intentionally or not—strategies to reduce harm become essential. Harm reduction should therefore be a key consideration when initiating MOUD and a meaningful outcome to assess throughout treatment. Harm reduction—an approach that seeks to minimize the negative consequences of drug use without requiring abstinence—may help address this treatment gap. 22,23 Interventions such as naloxone distribution, supervised injection sites, syringe exchange programs, and safer use education have been shown to reduce overdose deaths, infectious disease transmission, and other health risks. 7 For example, integrating syringe exchange programs with MOUD lowers hepatitis C rates, 24 whereas naloxone access significantly decreases overdose fatalities. 7,8,25-27 Compared with abstinence-only models, harm reduction offers a more practical, sustainable, and less stigmatizing framework for improving outcomes in individuals with OUD. 28 Research on the intersection of MOUD and harm reduction remains limited. Little is known about how often or in what ways individuals use opioids while on MOUD, and even less is understood about their engagement with harm reduction services (HRSs). If patients continue opioid use during treatment, understanding their behaviors and likelihood of accessing or recommending HRSs can inform provider education, clinical decision-making, and treatment outcomes. Additionally, examining differences between methadone and buprenorphine patients may help tailor harm reduction counseling. This study aims to assess harm reduction outcomes among individuals receiving MOUD and compare them by treatment type, with a secondary objective of estimating the prevalence of ongoing illicit opioid use. These insights may support more effective, patient-centered care for people with OUD. Methods Study Aim and Design: This cross-sectional study evaluated harm reduction outcomes and recent opioid use in MOUD patients. The outcomes included HRS access, harm reduction attitudes, and safer use practices. HRSs encompassed syringe programs, naloxone sites, and supervised injection facilities. Safer use included “sterile” injection, non-injection methods (e.g. snorting), and safer venous injection sites. Setting and Participants: Adults (18+) with moderate-to-severe OUD receiving methadone or buprenorphine at three Philadelphia sites were recruited: Pathways to Housing Integrated Care Clinic PA (integrated primary and behavioral healthcare), Thomas Jefferson University Narcotic Addiction Rehabilitation Program (TJU-NARP) (opioid treatment program), and the Stephen Klein Wellness Center (SKWC) (integrated primary and behavioral healthcare). MOUD was provided via primary care or other settings. The participants had to be medically and psychiatrically stable, as confirmed by an onsite physician. Approval was granted by the Thomas Jefferson University Institutional Review Board (#2023-2182). Data collection: A REDCap-based survey, adapted from a 2020 British Columbia CDC Harm Reduction Client Survey, 28 captured demographics, OUD history, current substance use, and attitudes toward HRSs (via a Likert scale). Surveys were completed privately on an iPad after informed consent was obtained. Every eligible individual onsite when a trained medical student was present was invited to participate. The participants received a $5 gift card. Data analysis SPSS software was used for analysis. Chi-square tests were used to assess categorical relationships. T tests compared age across sites and HRS attitudes by MOUD group. Kruskal-Wallis tests were used to assess attitude differences by OUD duration, MOUD duration, HRS use, and test strip use. This test was preferred because more than two groups were being compared and because the data were not expected to be normally distributed. Results Descriptive Statistics Demographics : A total of 116 participants were surveyed between November 2023 and October 2024: 71 on methadone (TJU-NARP) and 44 on buprenorphine (Pathways or SKWC). Most were White (61.5%) or Black (28.8%). The duration of opioid use was most commonly 5–10 years (23%) or more than 10 years (65%). The MOUD duration followed a similar pattern. Detailed information is presented in Table 2 . Table 2 Self-reported demographic information (n = 116) among all MOUD recipients Demographics NARP n = 72 Pathways n = 26 Stephen Klein n = 18 Total n = 116 Sex (assigned at birth) Male 42 (58%) 17 (65%) 11 (61%) 70 (60%) Female 30 (42%) 9 (35%) 7 (39%) 46 (40%) Race White 50 (69%) 18 (69%) 6 (33%) 74 (64%) Black 15 (21%) 4 (15%) 12 (67%) 31 (27%) Other 7 (10%) 4 (15%) 0 (0%) 11 (10%) Ethnicity Non-Hispanic 66 (92%) 21 (81%) 18 (100%) 105 (91%) Hispanic 5 (7%) 5 (19%) 0 (0%) 10 (9%) Length of OUD* < 1 month 0 (0%) 0 (0%) 0 (0%) 0 (0%) 1 month – 1 year 0 (0%) 0 (0%) 0 (0%) 0 (0%) 1 year – 3 years 1 (1%) 2 (8%) 1 (6%) 4 (3%) 3 years – 5 years 4 (6%) 2 (8%) 3 (17%) 9 (8%) 5 years – 10 years 13 (18%) 8 (31%) 5 (28%) 26 (22%) > 10 years 52 (72%) 14 (54%) 9 (50%) 75 (65%) Length Receiving MOUD* < 1 month 1 (1%) 3 (12%) 0 (0%) 4 (3%) 1 month – 1 year 3 (4%) 5 (19%) 2 (11%) 10 (9%) 1 year – 3 years 8 (11%) 8 (31%) 5 (28%) 21 (18%) 3 years – 5 years 8 (11%) 3 (12%) 4 (22%) 15 (12%) 5 years – 10 years 26 (36%) 6 (23%) 3 (17%) 35 (31%) > 10 years 25 (35%) 1 (4%) 4 (22%) 30 (26%) Legend OUD = Opioid Use Disorder; MOUD = Medication for Opioid Use Disorder; NARP = Narcotic Addiction Rehabilitation Program. * Length of OUD is the participant’s self-reported time using opioids, whereas length receiving MOUD is the cumulative time a participant reported being in treatment Access to HRS Participants were asked whether they had ever visited sites offering syringes, fentanyl test strips, naloxone, or supervised drug consumption. Among the total sample, 61% reported prior access to HRSs. Among these, 52.2% had last used a service more than three months ago, and only 29% had accessed one within the past week. Most reported using HRSs once a month or less (56%), whereas 22% used them weekly or daily. The most frequently accessed services were syringe exchange programs (54%) and naloxone distribution sites (46%). Among those who had not accessed HRSs, the most common reason was a lack of perceived need (49%); 12% specifically cited sobriety, and the remainder did not elaborate. Additional data are presented in Fig. 1 . Substance use practices : Participants were asked about illicit opioid use in the past six months, route of administration, and use of fentanyl test strips. Overall, 37% reported recent opioid use—35.2% among methadone recipients and 39.5% among those receiving buprenorphine. Injection was the most common route (48%), followed by snorting (31%) and swallowing (10%). Among those using via injection, 65% used their arms and 20% used legs or thighs. Sterile injection practices varied: 40% reported cleaning injection sites “always” or “most of the time,” whereas another 40% did so “rarely” or “never.” Participants who preferred snorting often cited concerns about infection (29%). Only 26% reported using fentanyl test strips in the past six months. Attitude towards HRSs Using a Likert scale, participants rated their agreement with statements about harm reduction services. Overall, attitudes were positive—most participants reported feeling welcomed at HRS sites and expressed a willingness to recommend them. Only 16% reported feeling judged when accessing these services. Additional details are provided in Table 3 . Table 3 Participant Attitudes Toward harm reduction services (HRS) (n = 115) “Agree” or “Strongly Agree” n (%) Attitude Statement N = 115 I am likely to use HRSs 52 (45%) I am likely to recommend HRSs to a friend 75 (66%) I feel welcome at HRSs 67 (58%) I feel judged at HRSs 18 (16%) I wish there were more HRSs 61 (54%) HRSs have a positive effect on me and my community 60 (52%) I can easily get to HRSs 62 (54%) Legend : HRS = harm reduction services (sites supplying syringes, fentanyl test strips, or naloxone (Narcan)) Comparisons Race and attitude toward HRSs Kruskal‒Wallis tests revealed no significant differences in attitudes toward HRS between self-identified Black and White participants ( p = 0.10 to 0.93). Similarly, no significant differences were observed in HRS use ( X² (1, N = 115) = 1.8, p = 0.18), recent opioid use ( X² (1, N = 115) = 0, p = 1.0), or fentanyl test strip use ( X² (1, N = 115) = 0.05, p = 0.82) by race. OUD duration and HRSs Kruskal‒Wallis tests revealed no significant differences in attitudes toward HRSs based on duration of OUD diagnosis (p = 0.22–0.70), nor in HRS use (X² (5, N = 115) = 3.93, p = 0.27) or fentanyl test strip use (X² (5, N = 115) = 4.57, p = 0.21). While perceived judgment at HRS sites varied significantly by length of MOUD treatment (X² (5, N = 115) = 11.35, p = 0.04), this result lacked a clear clinical or theoretical pattern and was not emphasized in interpretation. Other harm reduction measures were not significantly associated with MOUD duration (p = 0.23–0.89). MOUD Type and HRS Recent opioid use did not differ significantly between buprenorphine and methadone participants (X² (1, N = 114) = 0.07, p = 0.79). However, buprenorphine recipients were significantly more likely to have accessed HRSs in the past six months (X² (1, N = 115) = 11.7, p = 0.001) and to report using, recommending, feeling welcomed at, and perceiving positive community impact from HRSs (p = 0.002, 0.022, 0.004, 0.039, respectively). No significant group differences were observed for perceived judgment, desire for more sites, or ease of access (p = 0.085, 0.117, 0.361, respectively; Table 4 ). Table 4 Comparison of Attitude Responses Between MOUD Treatment Groups Treatment Group Agree/ Strongly Agree n (%) Disagree/ Strongly Disagree n (%) Chi-square (X²) p-value Attitude statement I am likely to use HRS Buprenorphine 27 (61%) 10 (23%) Methadone 25 (35%) 31 (44%) 6.15 0.01 I am likely to recommend HRS to a friend Buprenorphine 32 (73%) 4 (10%) Methadone 43 (61%) 16 (23%) 2.55 0.11 I feel welcome at HRS sites Buprenorphine 32 (73%) 4 (10%) Methadone 35 (49%) 19 (27%) 5.38 0.02 I feel judged at HRS sites Buprenorphine 6 (14%) 33 (75%) Methadone 12 (17%) 45 (63%) 0.19 0.67 I wish there were more HRS sites Buprenorphine 26 (59%) 5 (11%) Methadone 35 (49%) 21 (30%) 3.39 0.07 HRS sites have a positive effect on me and my community Buprenorphine 28 (64%) 4 (10%) Methadone 32 (45%) 18 (25%) 4.36 0.04 I can easily get to HRS sites Buprenorphine 27 (61%) 10 (23%) Methadone 35 (49%) 15 (21%) 0.004 0.95 Legend : HRS = harm reduction services (sites supplying syringes, fentanyl test strips, or naloxone (Narcan)) B = Buprenorphine; M = Methadone Statistically significant findings (α = 0.05) are shown in bold. HRS Access and Use Practices HRS access was significantly associated with fentanyl test strip use (X² (1, N = 115) = 9.92, p = 0.002) but not with sterile injection practices ( X ² (1, N = 20) = 1.64, p = 0.20). Discussion Most participants receiving MOUD had utilized harm reduction services (HRSs), particularly syringe exchange programs and naloxone distribution sites, although usage was generally infrequent. Only 29% reported access in the past week, and 56% used HRS once a month or less. Patients in abstinence often declined HRS use, citing a lack of need, whereas active users—especially those using stimulants—may avoid HRS due to concerns about relapse triggers. A key finding was that 37% of the participants continued to use opioids while on MOUD, most commonly through injection. Among those who injected, fewer than half reported consistent use of sterile techniques. While HRS access did not significantly improve sterile practices, it was associated with increased fentanyl test strip use—a behavior that may reduce overdose risk. In settings such as Philadelphia, where fentanyl is widespread, the utility of test strips is debated. 34 – 36 However, they may still serve a role for individuals using counterfeit pills or methamphetamine, particularly in regions with more variability in drug contamination. Future research should explore their evolving relevance. The participants generally viewed HRSs positively, with most reporting feeling welcomed and likely to recommend these services. Few reported feeling judged. This finding supports the idea that HRSs function as nonstigmatizing spaces. Unlike previous studies showing racial disparities in harm reduction engagement, 37 we found no significant differences by race—possibly reflecting the specific characteristics of our sample or local context but warranting further investigation. Despite individual support for HRSs, enthusiasm for expanding them into communities was lower. The participants often acknowledged the personal benefits of HRS but expressed discomfort with their presence in local neighborhoods. Qualitative research is needed to explore this disconnect. We found that while recent opioid use did not differ significantly between groups, buprenorphine participants were more likely to use HRSs, recommend them, feel welcomed at these sites, and perceive a positive community impact. These findings suggest that methadone patients may benefit from greater psychosocial support and stigma reduction strategies. These differences may also reflect distinct treatment environments and patient populations. At TJU-NARP, where methadone is administered, patients often have prior negative experiences with buprenorphine (e.g., precipitated withdrawal or initiation challenges with fentanyl use) or need daily supervised dosing. While this structure offers consistency, it may also foster stigma or reduce autonomy. In contrast, buprenorphine is typically provided in less restrictive settings with integrated primary care, offering patients more flexibility and potentially fostering more positive perceptions of harm reduction. Methadone patients may also have more severe OUD histories, repeated relapses, or failed attempts in less structured programs, contributing to internalized stigma and negative perceptions. While Pathways to Housing and TJU-NARP both serve individuals experiencing housing instability and ongoing opioid use, SKWC—a Federally Qualified Health Center—sees patients with comparatively more housing stability and less severe relapse histories, which may foster more favorable views of treatment and HRS. Additionally, TJU-NARP is farther from Prevention Point (6.2 miles) than SKWC (4.1 miles) or Pathways (4.2 miles), possibly contributing to lower HRS access among methadone patients. These contextual differences highlight the need for follow-up interviews to better understand how site-specific factors and stigma shape harm reduction engagement across treatment types. This study has several limitations. As a retrospective study using a convenience sample limited to individuals currently receiving MOUD, we were unable to assess harm reduction outcomes among those not on MOUD or establish causality between MOUD type and harm reduction engagement. We also did not collect data on substance use prior to MOUD initiation, limiting insight into behavioral change. Self-reported, in-person data collection introduced potential for recall and social desirability bias. Finally, the study was conducted solely in Philadelphia, which may limit generalizability. As the first study to explore harm reduction engagement among individuals receiving MOUD, our findings suggest several directions for future research. Longitudinal studies tracking substance use before and after MOUD initiation could clarify whether MOUD promotes safer practices. Comparisons with non-MOUD populations may help establish causality. Qualitative research is also warranted to explore HRS perceptions—especially among methadone patients and at the community level. OUD is a chronic, complex condition requiring multifaceted treatment. Given that many individuals on MOUD continue to use opioids, understanding how harm reduction intersects with treatment is essential. While high-risk use persists, HRSs are generally valued—particularly among buprenorphine recipients. These findings support the potential for harm reduction to serve as a meaningful treatment outcome in the care of individuals with OUD. Conclusions This study underscores the complex interplay between medication for opioid use disorder (MOUD), harm reduction services (HRS), and ongoing opioid use. While most participants had utilized HRSs at some point, regular use was less common. Notably, 37% reported recent opioid use—often via injection—with inconsistent adherence to safer practices, challenging the assumption that MOUD equates to abstinence. Access to HRS was significantly associated with fentanyl test strip use, a promising harm reduction behavior, particularly for individuals using stimulants. However, in settings such as Philadelphia where fentanyl is ubiquitous, the utility of test trips may be limited, highlighting the need for broader harm reduction strategies adapted to the realities of the evolving drug supply. We also found that harm reduction engagement varied by MOUD type. Compared with methadone recipients, buprenorphine recipients were more likely to access HRSs and held more favorable attitudes toward these services, suggesting that the treatment structure may influence patients’ perceptions and behaviors. Interestingly, we observed no significant racial differences in HRS engagement, which contrasts with prior research and points to broader social or structural factors that warrant further investigation. The participants generally held positive views of HRSs, with most feeling welcomed and willing to recommend these services. However, perceived judgment varied by MOUD duration, suggesting that treatment length may shape harm reduction experiences. Combined with the discrepancy between individual support and lower community-level endorsement of HRS expansion, these findings point to the need for further research into the social and psychological factors influencing engagement. In conclusion, this study highlights the importance of integrating harm reduction strategies into MOUD programs. Expanding access to HRSs and providing patient-centered education on safer use practices may improve outcomes for those who continue using opioids during treatment. Addressing these gaps can help advance a more holistic and compassionate approach to OUD care—one that supports both individual recovery and broader public health. Abbreviations • OUD Opioid Use Disorder • MOUD Medication for Opioid Use Disorder • HRS Harm reduction services • TJU NARP–Thomas Jefferson University Narcotic Addiction Rehabilitation Program • SKWC Stephen Klein Wellness Center Declarations Sources of Support/Funding This research was supported by Sidney Kimmel Medical College Conflicts of Interest None Ethics approval and consent to participate: This study was approved by the Thomas Jefferson University Institutional Review Board (IRB protocol iRISID #2023-2182). All participants completed an IRB-approved written informed consent and received a copy of their informed consent. Consent for publication Not applicable Availability of data and materials The datasets generated and analyzed during the current study are not publicly available due to confidentiality protections but are available from the corresponding author upon reasonable request. Competing interests The authors declare that they have no competing interests. Funding This study did not receive any external funding Authors’ contributions WB conceived and designed the study, received IRB approval, collected data, interpreted the data, and was a major contributor to the writing of the manuscript. NC collected data, analyzed the data, interpreted the data, and was a major contributor to the writing of the manuscript. LCW made substantial contributions to the conceptions of the study and substantively revised the manuscript. WJ substantively revised the manuscript. RH made substantial contributions to the acquisition of data. Acknowledgements The authors thank the staff and patients at the participating treatment sites for their time and collaboration. We also thank Brooke Mauriello and the Family Medicine Department for their support of this work. References Saloner B, McGinty EE, Beletsky L, et al. A Public Health Strategy for the Opioid Crisis. Public Health Rep. 2018;133(1):24-34. doi: 10.1177/0033354918793627. PMID: 30426871; PMCID: PMC6243441. National Institute on Drug Abuse (US). Common Comorbidities with Substance Use Disorders Research Report. (2020, April). Available from: https://www.ncbi.nlm.nih.gov/books/NBK571451/ Centers for Disease Control and Prevention. Substance Use & Substance Use Disorders. (2024). Available from: https://wwwnc.cdc.gov/travel/yellowbook/2024/additional-considerations/substance-use Accessed February 4, 2025. Centers for Disease Control and Prevention. Treatment for Opioid Use Disorder: Population Estimates - United States, 2022. MMWR. 2024;73(25):567-574. doi:10.15585/mmwr.mm7325a1. Dydyk AM, Jain NK, Gupta M. Opioid Use Disorder. StatPearls Publishing; 2025. PMID: 31985959. Gugala E, Briggs O, Moczygemba LR, Brown CM, Hill LG. Opioid harm reduction: A scoping review of physician and system-level gaps in knowledge, education, and practice. Subst Abus. 2022;43(1):972-987. doi: 10.1080/08897077.2022.2060423. PMID: 35426772. Taylor JL, Johnson S, Cruz R, Gray JR, Schiff D, Bagley SM. Integrating Harm Reduction into Outpatient Opioid Use Disorder Treatment Settings: Harm Reduction in Outpatient Addiction Treatment. J Gen Intern Med. 2021;36(12):3810-3819. doi: 10.1007/s11606-021-06904-4. Epub 2021 Jun 22. PMID: 34159545; PMCID: PMC8218967. Israel BS, Belcher AM, Ford JD. A Harm Reduction Framework for Integrated Treatment of Co-Occurring Opioid Use Disorder and Trauma-Related Disorders. J Dual Diagn. 2024;20(1):52-85. Patnode CD, Perdue LA, Rushkin M, et al. Screening for Unhealthy Drug Use: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2020;323(22):2310-2328. doi: 10.1001/jama.2019.21381. PMID: 32515820. Schuckit MA. Treatment of Opioid-Use Disorders. N Engl J Med. 2016;375(4):357-368. doi:10.1056/NEJMra1604339. MacArthur GJ, Minozzi S, Martin N, et al. Opiate substitution treatment and HIV transmission in people who inject drugs: systematic review and meta-analysis. BMJ. 2012;345:e5945. doi: 10.1136/bmj.e5945. PMID: 23038795; PMCID: PMC3489107. Degenhardt L, Clark B, Macpherson G, et al. Buprenorphine versus methadone for the treatment of opioid dependence: a systematic review and meta-analysis of randomised and observational studies. Lancet Psychiatry. 2023;10(6):386-402. doi: 10.1016/S2215-0366(23)00095-0. Epub 2023 May 8. Erratum in: Lancet Psychiatry. 2024;11(4):e8. doi: 10.1016/S2215-0366(24)00004-X. PMID: 37167985. Mattick RP, Breen C, Kimber J, Davoli M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev. 2014;2014(2):CD002207. doi: 10.1002/14651858.CD002207.pub4. PMID: 24500948; PMCID: PMC10617756. Bahji A, Cheng B, Gray S, Stuart H. Reduction in mortality risk with opioid agonist therapy: a systematic review and meta-analysis. Acta Psychiatr Scand. 2019;140(4):313-339. doi: 10.1111/acps.13088. PMID: 31419306. Lofwall MR, Walsh SL, Nunes EV, et al. Weekly and Monthly Subcutaneous Buprenorphine Depot Formulations vs Daily Sublingual Buprenorphine with Naloxone for Treatment of Opioid Use Disorder: A Randomized Clinical Trial. JAMA Intern Med. 2018;178(6):764–773. doi:10.1001/jamainternmed.2018.1052. Zoorob R, Kowalchuk A, Mejia de Grubb M. Buprenorphine Therapy for Opioid Use Disorder. Am Fam Physician. 2018;97(5):313-320. PMID: 29671504. Gomes T, McCormack D, Bozinoff N, et al. Duration of use and outcomes among people with opioid use disorder initiating methadone and buprenorphine in Ontario: a population-based propensity-score matched cohort study. Addiction. 2022;117(7):1972-1981. doi: 10.1111/add.15862. Epub 2022 Mar 21. PMID: 35257434; PMCID: PMC9313829. Pearce LA, Min JE, Piske M, et al. Opioid agonist treatment and risk of mortality during opioid overdose public health emergency: population based retrospective cohort study. BMJ. 2020;368:m772. doi: 10.1136/bmj.m772. PMID: 32234712; PMCID: PMC7190018. Nielsen S, Tse WC, Larance B. Opioid agonist treatment for people who are dependent on pharmaceutical opioids. Cochrane Database Syst Rev. 2022;9(9):CD011117. doi: 10.1002/14651858.CD011117.pub3. PMID: 36063082; PMCID: PMC9443668. Gottlieb DJ, Shiner B, Hoyt JE, et al. A comparison of mortality rates for buprenorphine versus methadone treatments for opioid use disorder. Acta Psychiatr Scand. 2023;147(1):6-15. doi: 10.1111/acps.13477. Epub 2022 Jul 23. PMID: 35837885. Shulman M, Wai JM, Nunes EV. Buprenorphine Treatment for Opioid Use Disorder: An Overview. CNS Drugs. 2019;33(6):567-580. doi: 10.1007/s40263-019-00637-z. PMID: 31062259; PMCID: PMC6585403. Castillo F, Hu MC, Liu Y, et al. Risks of returning to opioid use at treatment entry and early in opioid use disorder treatment: Role of non-opioid substances. Drug Alcohol Depend. 2023;251:110926. doi: 10.1016/j.drugalcdep.2023.110926. Epub 2023 Aug 9. PMID: 37604012; PMCID: PMC10712265. Saloner B, Whitley P, Dawson E, et al. Polydrug use among patients on methadone medication treatment: Evidence from urine drug testing to inform patient safety. Addiction. 2023;118(8):1549-1556. doi: 10.1111/add.16180. Epub 2023 May 9. PMID: 37158468; PMCID: PMC10330099. Foot C, Korthuis PT, Tsui JI, et al. Associations between stimulant use and return to illicit opioid use following initiation onto medication for opioid use disorder. Addiction. 2024;119(1):149-157. doi: 10.1111/add.16334. Epub 2023 Sep 15. PMID: 37712113; PMCID: PMC11139042. Chandra DK, Altice FL, Copenhaver MM, et al. Purposeful Fentanyl Use and Associated Factors among Opioid-Dependent People Who Inject Drugs. Subst Use Misuse. 2021;56(7):979-987. doi: 10.1080/10826084.2021.1901931. Epub 2021 Mar 26. PMID: 33769199. Chan CA, Canver B, McNeil R, Sue KL. Harm Reduction in Health Care Settings. Med Clin North Am. 2022;106(1):201-217. Kalk NJ. Harm reduction in opioid treatment: an established idea under threat. Wiley Addiction. 2018;114(1):20-21. Platt L, Minozzi S, Reed J, et al. Needle syringe programmes and opioid substitution therapy for preventing hepatitis C transmission in people who inject drugs. Cochrane Database Syst Rev. 2017;9:CD012021. doi: 10.1002/14651858.CD012021.pub2. Levengood TW, Yoon GH, Davoust MJ, et al. Supervised injection facilities as harm reduction: A systematic review. Am J Prev Med. 2021;61(5):738–749. Hawk KF, Vaca FE, D'Onofrio G. Reducing Fatal Opioid Overdose: Prevention, Treatment and Harm Reduction Strategies. Yale J Biol Med. 2015;88(3):235-245. PMID: 26339206; PMCID: PMC4553643. Walley AY, Xuan Z, Hackman HH, et al. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis. BMJ. 2013;346:f174. doi: 10.1136/bmj.f174. Huhn AS, Gipson CD. Promoting harm reduction as a treatment outcome in substance use disorders. Exp Clin Psychopharmacol. 2021;29(3):217-218. doi: 10.1037/pha0000494. British Columbia Centre for Disease Control. Harm Reduction Client Survey. 2021. Available from: http://www.bccdc.ca/health-professionals/data-reports/harm-reduction-client-survey Accessed April 12, 2023. Contella L, Snyder ML, Kang P, Tolan NV, Melanson SEF. Clinical performance of a new lateral flow immunoassay for xylazine detection. Clin Chem Lab Med. 2024. doi: 10.1515/cclm-2024-0947. Epub ahead of print. PMID: 39392655. PA Groundhogs. 2023–2024 Progress Report. Available from: https://pagroundhogs.org/data. Wallace B, Shkolnikov I, Kielty C, et al. Is fentanyl in everything? Examining the unexpected occurrence of illicit opioids in British Columbia’s drug supply. Harm Reduct J. 2025;22:28. doi: 10.1186/s12954-025-01189-w. Mistler CB, Chandra DK, Copenhaver MM, et al. Engagement in Harm Reduction Strategies After Suspected Fentanyl Contamination Among Opioid-Dependent Individuals. J Community Health. 2021;46:349-357. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 03 Jan, 2026 Read the published version in Harm Reduction Journal → Version 1 posted Editorial decision: Revision requested 28 Oct, 2025 Reviews received at journal 23 Oct, 2025 Reviews received at journal 20 Oct, 2025 Reviews received at journal 14 Oct, 2025 Reviews received at journal 03 Oct, 2025 Reviewers agreed at journal 02 Oct, 2025 Reviewers agreed at journal 02 Oct, 2025 Reviewers agreed at journal 01 Oct, 2025 Reviewers agreed at journal 01 Oct, 2025 Reviewers invited by journal 30 Sep, 2025 Editor assigned by journal 08 Sep, 2025 Submission checks completed at journal 08 Sep, 2025 First submitted to journal 07 Sep, 2025 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. 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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-7558770","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":525418561,"identity":"f518ac48-7c08-4383-b359-6c609d7cc238","order_by":0,"name":"William 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02:42:12","extension":"html","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":120110,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7558770/v1/1756bb54e801f83c59d06963.html"},{"id":93543300,"identity":"c97856e5-05ff-4a0f-a79d-83e7d3c5e5c5","added_by":"auto","created_at":"2025-10-15 02:42:12","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":67679,"visible":true,"origin":"","legend":"\u003cp\u003eParticipant Use of HRS and Reasons for Not Using HRS\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7558770/v1/8d0f3cfdbae5f3584e47ad8a.png"},{"id":99545288,"identity":"c0f35c41-9066-4ec0-b94a-4d1abd7e9be7","added_by":"auto","created_at":"2026-01-05 16:05:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1240500,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7558770/v1/7a6b953d-d912-41a3-8c79-3a5a30109ba6.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Harm Reduction Engagement and Ongoing Opioid Use Among Adults Receiving Methadone or Buprenorphine in Philadelphia","fulltext":[{"header":"Background","content":"\u003cp\u003eOpioid Use Disorder (OUD) is a chronic, relapsing condition linked to high rates of morbidity and mortality, including overdose, infectious disease, and co-occurring mental health issues.\u003csup\u003e1,2\u003c/sup\u003e\u0026nbsp; An estimated 2.7 million Americans are affected, with 81,806 opioid-involved overdose deaths reported in 2022\u0026mdash;a fourfold increase in risk compared to a decade ago.\u003csup\u003e3-6\u003c/sup\u003e\u0026nbsp; The rise of fentanyl and other synthetic opioids has intensified these outcomes. Despite the availability of effective treatments, many individuals face barriers such as limited access, stigma, and overly reductive approaches to care.\u003csup\u003e1,7,8\u003c/sup\u003e Addressing OUD remains an urgent public health priority.\u003c/p\u003e\n\u003cp\u003eMedication for OUD (MOUD) is a well-established and effective treatment. Both buprenorphine and methadone improve treatment retention, reduce relapses, and lower opioid-related mortality while also decreasing the risk of infections such as HIV and hepatitis C.\u003csup\u003e7-11\u003c/sup\u003e Their use is often guided by individual patient needs. Methadone, a full agonist, offers strong retention benefits but requires daily visits to certified treatment programs and carries a higher overdose risk when combined with other opioids.\u003csup\u003e12-14\u003c/sup\u003e Buprenorphine, a partial agonist, presents a lower risk of respiratory depression, allows for outpatient prescription, and is classified as a Schedule III substance in many states.\u003csup\u003e8,10,12,15,16\u003c/sup\u003e Each option has distinct advantages and limitations, necessitating personalized decision-making by patients and providers (Table 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1:\u003c/strong\u003e Comparison of Methadone and Buprenorphine in the treatment of Opioid Use Disorder\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"636\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 230px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMethadone\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBuprenorphine\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003eTreatment Retention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 230px;\"\u003e\n \u003cp\u003eHigher retention than buprenorphine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003eLower retention than methadone\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003eOverdose Risk\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 230px;\"\u003e\n \u003cp\u003eHigher overdose risk\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003eLower overdose risk\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003eAdverse Effects\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 230px;\"\u003e\n \u003cp\u003eMore sedation and cardiac side effects\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003eFewer adverse effects overall\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003ePractical Considerations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 230px;\"\u003e\n \u003cp\u003eDaily in-clinic dosing required\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003eCan be prescribed in office-based settings\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eDespite the effectiveness of MOUD, ongoing opioid use during treatment remains common, particularly with the emergence of potent synthetic opioids such as fentanyl, which may require higher MOUD doses. Studies have shown that patients receiving MOUD often continue using opioids, especially when co-using stimulants such as cocaine or methamphetamine, which significantly increases the risk of relapse.\u003csup\u003e18\u003c/sup\u003e One retrospective study reported rising rates of fentanyl, methamphetamine, and cocaine use among patients on methadone between 2017 and 2021.\u003csup\u003e19\u003c/sup\u003e Another study reported that 58% of MOUD trial participants returned to illicit opioid use, with stimulant use as a major contributor.\u003csup\u003e20\u003c/sup\u003e Individuals who continue using opioids while on MOUD are often younger and more likely to report depression, share injection equipment, engage in transactional sex, and use stimulants\u0026mdash;highlighting a critical gap in addressing the complex needs of this population.\u003csup\u003e21\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eIt remains unclear whether ongoing opioid use during MOUD reflects fentanyl-adulterated stimulant use or a return to illicit opioid use. Regardless, these patterns reveal a gap in the current OUD treatment. If patients on MOUD continue to use opioids\u0026mdash;intentionally or not\u0026mdash;strategies to reduce harm become essential. Harm reduction should therefore be a key consideration when initiating MOUD and a meaningful outcome to assess throughout treatment.\u003c/p\u003e\n\u003cp\u003eHarm reduction\u0026mdash;an approach that seeks to minimize the negative consequences of drug use without requiring abstinence\u0026mdash;may help address this treatment gap.\u003csup\u003e22,23\u003c/sup\u003e Interventions such as naloxone distribution, supervised injection sites, syringe exchange programs, and safer use education have been shown to reduce overdose deaths, infectious disease transmission, and other health risks.\u003csup\u003e7\u003c/sup\u003e For example, integrating syringe exchange programs with MOUD lowers hepatitis C rates,\u003csup\u003e24\u003c/sup\u003e whereas naloxone access significantly decreases overdose fatalities.\u003csup\u003e7,8,25-27\u003c/sup\u003e\u0026nbsp; Compared with abstinence-only models, harm reduction offers a more practical, sustainable, and less stigmatizing framework for improving outcomes in individuals with OUD.\u003csup\u003e28\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eResearch on the intersection of MOUD and harm reduction remains limited. Little is known about how often or in what ways individuals use opioids while on MOUD, and even less is understood about their engagement with harm reduction services (HRSs). If patients continue opioid use during treatment, understanding their behaviors and likelihood of accessing or recommending HRSs can inform provider education, clinical decision-making, and treatment outcomes. Additionally, examining differences between methadone and buprenorphine patients may help tailor harm reduction counseling. This study aims to assess harm reduction outcomes among individuals receiving MOUD and compare them by treatment type, with a secondary objective of estimating the prevalence of ongoing illicit opioid use. These insights may support more effective, patient-centered care for people with OUD.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy Aim and Design:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis cross-sectional study evaluated harm reduction outcomes and recent opioid use in MOUD patients. The outcomes included HRS access, harm reduction attitudes, and safer use practices. HRSs encompassed syringe programs, naloxone sites, and supervised injection facilities. Safer use included “sterile” injection, non-injection methods (e.g. snorting), and safer venous injection sites.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSetting and Participants:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAdults (18+) with moderate-to-severe OUD receiving methadone or buprenorphine at three Philadelphia sites were recruited: Pathways to Housing Integrated Care Clinic PA (integrated primary and behavioral healthcare), Thomas Jefferson University Narcotic Addiction Rehabilitation Program (TJU-NARP) (opioid treatment program), and the Stephen Klein Wellness Center (SKWC) (integrated primary and behavioral healthcare). MOUD was provided via primary care or other settings. The participants had to be medically and psychiatrically stable, as confirmed by an onsite physician. Approval was granted by the Thomas Jefferson University Institutional Review Board (#2023-2182).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA REDCap-based survey, adapted from a 2020 British Columbia CDC Harm Reduction Client Survey,\u003csup\u003e28\u003c/sup\u003e captured demographics, OUD history, current substance use, and attitudes toward HRSs (via a Likert scale). Surveys were completed privately on an iPad after informed consent was obtained. Every eligible individual onsite when a trained medical student was present was invited to participate. The participants received a $5 gift card.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSPSS software was used for analysis. Chi-square tests were used to assess categorical relationships. T tests compared age across sites and HRS attitudes by MOUD group. Kruskal-Wallis tests were used to assess attitude differences by OUD duration, MOUD duration, HRS use, and test strip use. This test was preferred because more than two groups were being compared and because the data were not expected to be normally distributed.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eDescriptive Statistics\u003c/h2\u003e\u003cp\u003e\u003cem\u003eDemographics\u003c/em\u003e: A total of 116 participants were surveyed between November 2023 and October 2024: 71 on methadone (TJU-NARP) and 44 on buprenorphine (Pathways or SKWC). Most were White (61.5%) or Black (28.8%). The duration of opioid use was most commonly 5\u0026ndash;10 years (23%) or more than 10 years (65%). The MOUD duration followed a similar pattern. Detailed information is presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\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\u003eSelf-reported demographic information (n\u0026thinsp;=\u0026thinsp;116) among all MOUD recipients\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e\u003cp\u003eDemographics\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNARP\u003c/p\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;72\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePathways\u003c/p\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;26\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eStephen Klein n\u0026thinsp;=\u0026thinsp;18\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;116\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eSex (assigned at birth)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e42 (58%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e17 (65%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e11 (61%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e70 (60%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30 (42%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9 (35%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7 (39%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e46 (40%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eRace\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWhite\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e50 (69%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18 (69%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6 (33%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e74 (64%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBlack\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15 (21%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4 (15%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12 (67%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e31 (27%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOther\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (10%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4 (15%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e11 (10%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eEthnicity\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNon-Hispanic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e66 (92%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e21 (81%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e18 (100%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e105 (91%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHispanic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5 (19%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e10 (9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003e\u003cb\u003eLength of OUD*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;1 month\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 month \u0026ndash; 1 year\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 year \u0026ndash; 3 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2 (8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1 (6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e4 (3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 years \u0026ndash; 5 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2 (8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3 (17%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e9 (8%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 years \u0026ndash; 10 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13 (18%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8 (31%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5 (28%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e26 (22%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;10 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e52 (72%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14 (54%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e9 (50%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e75 (65%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003e\u003cb\u003eLength Receiving MOUD*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;1 month\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3 (12%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e4 (3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 month \u0026ndash; 1 year\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5 (19%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2 (11%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e10 (9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 year \u0026ndash; 3 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (11%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8 (31%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5 (28%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e21 (18%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 years \u0026ndash; 5 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (11%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3 (12%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4 (22%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e15 (12%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 years \u0026ndash; 10 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26 (36%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6 (23%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3 (17%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e35 (31%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;10 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25 (35%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 (4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4 (22%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e30 (26%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eLegend\u003c/strong\u003e\u003cp\u003e\u003cem\u003eOUD\u0026thinsp;=\u0026thinsp;Opioid Use Disorder; MOUD\u0026thinsp;=\u0026thinsp;Medication for Opioid Use Disorder; NARP\u0026thinsp;=\u0026thinsp;Narcotic Addiction Rehabilitation Program.\u003c/em\u003e\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e * Length of OUD is the participant\u0026rsquo;s self-reported time using opioids, whereas length receiving MOUD is the cumulative time a participant reported being in treatment\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eAccess to HRS\u003c/strong\u003e\u003cp\u003eParticipants were asked whether they had ever visited sites offering syringes, fentanyl test strips, naloxone, or supervised drug consumption. Among the total sample, 61% reported prior access to HRSs. Among these, 52.2% had last used a service more than three months ago, and only 29% had accessed one within the past week. Most reported using HRSs once a month or less (56%), whereas 22% used them weekly or daily. The most frequently accessed services were syringe exchange programs (54%) and naloxone distribution sites (46%). Among those who had not accessed HRSs, the most common reason was a lack of perceived need (49%); 12% specifically cited sobriety, and the remainder did not elaborate. Additional data are presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eSubstance use practices\u003c/em\u003e: Participants were asked about illicit opioid use in the past six months, route of administration, and use of fentanyl test strips. Overall, 37% reported recent opioid use\u0026mdash;35.2% among methadone recipients and 39.5% among those receiving buprenorphine. Injection was the most common route (48%), followed by snorting (31%) and swallowing (10%). Among those using via injection, 65% used their arms and 20% used legs or thighs. Sterile injection practices varied: 40% reported cleaning injection sites \u0026ldquo;always\u0026rdquo; or \u0026ldquo;most of the time,\u0026rdquo; whereas another 40% did so \u0026ldquo;rarely\u0026rdquo; or \u0026ldquo;never.\u0026rdquo; Participants who preferred snorting often cited concerns about infection (29%). Only 26% reported using fentanyl test strips in the past six months.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eAttitude towards HRSs\u003c/strong\u003e\u003cp\u003eUsing a Likert scale, participants rated their agreement with statements about harm reduction services. Overall, attitudes were positive\u0026mdash;most participants reported feeling welcomed at HRS sites and expressed a willingness to recommend them. Only 16% reported feeling judged when accessing these services. Additional details are provided in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eParticipant Attitudes Toward harm reduction services (HRS) (n\u0026thinsp;=\u0026thinsp;115)\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\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ldquo;Agree\u0026rdquo; or \u0026ldquo;Strongly Agree\u0026rdquo; n (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAttitude Statement\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;115\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eI am likely to use HRSs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e52 (45%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eI am likely to recommend HRSs to a friend\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e75 (66%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eI feel welcome at HRSs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e67 (58%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eI feel judged at HRSs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18 (16%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eI wish there were more HRSs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e61 (54%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHRSs have a positive effect on me and my community\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e60 (52%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eI can easily get to HRSs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e62 (54%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLegend\u003c/b\u003e: \u003cem\u003eHRS\u0026thinsp;=\u0026thinsp;harm reduction services (sites supplying syringes, fentanyl test strips, or naloxone (Narcan))\u003c/em\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\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eComparisons\u003c/h2\u003e\u003cp\u003e\u003cstrong\u003eRace and attitude toward HRSs\u003c/strong\u003e\u003cp\u003eKruskal‒Wallis tests revealed no significant differences in attitudes toward HRS between self-identified Black and White participants (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.10 to 0.93). Similarly, no significant differences were observed in HRS use (\u003cem\u003eX\u0026sup2;\u003c/em\u003e (1, \u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;115)\u0026thinsp;=\u0026thinsp;1.8, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.18), recent opioid use (\u003cem\u003eX\u0026sup2;\u003c/em\u003e (1, \u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;115)\u0026thinsp;=\u0026thinsp;0, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.0), or fentanyl test strip use (\u003cem\u003eX\u0026sup2;\u003c/em\u003e (1, \u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;115)\u0026thinsp;=\u0026thinsp;0.05, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.82) by race.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eOUD duration and HRSs\u003c/strong\u003e\u003cp\u003eKruskal‒Wallis tests revealed no significant differences in attitudes toward HRSs based on duration of OUD diagnosis (p\u0026thinsp;=\u0026thinsp;0.22\u0026ndash;0.70), nor in HRS use (X\u0026sup2; (5, N\u0026thinsp;=\u0026thinsp;115)\u0026thinsp;=\u0026thinsp;3.93, p\u0026thinsp;=\u0026thinsp;0.27) or fentanyl test strip use (X\u0026sup2; (5, N\u0026thinsp;=\u0026thinsp;115)\u0026thinsp;=\u0026thinsp;4.57, p\u0026thinsp;=\u0026thinsp;0.21). While perceived judgment at HRS sites varied significantly by length of MOUD treatment (X\u0026sup2; (5, N\u0026thinsp;=\u0026thinsp;115)\u0026thinsp;=\u0026thinsp;11.35, p\u0026thinsp;=\u0026thinsp;0.04), this result lacked a clear clinical or theoretical pattern and was not emphasized in interpretation. Other harm reduction measures were not significantly associated with MOUD duration (p\u0026thinsp;=\u0026thinsp;0.23\u0026ndash;0.89).\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMOUD Type and HRS\u003c/strong\u003e\u003cp\u003eRecent opioid use did not differ significantly between buprenorphine and methadone participants (X\u0026sup2; (1, N\u0026thinsp;=\u0026thinsp;114)\u0026thinsp;=\u0026thinsp;0.07, p\u0026thinsp;=\u0026thinsp;0.79). However, buprenorphine recipients were significantly more likely to have accessed HRSs in the past six months (X\u0026sup2; (1, N\u0026thinsp;=\u0026thinsp;115)\u0026thinsp;=\u0026thinsp;11.7, p\u0026thinsp;=\u0026thinsp;0.001) and to report using, recommending, feeling welcomed at, and perceiving positive community impact from HRSs (p\u0026thinsp;=\u0026thinsp;0.002, 0.022, 0.004, 0.039, respectively). No significant group differences were observed for perceived judgment, desire for more sites, or ease of access (p\u0026thinsp;=\u0026thinsp;0.085, 0.117, 0.361, respectively; Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of Attitude Responses Between MOUD Treatment Groups\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eTreatment Group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eAgree/ Strongly Agree\u003c/p\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eDisagree/ Strongly Disagree\u003c/p\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eChi-square (X\u0026sup2;)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAttitude statement\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eI am likely to use HRS\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBuprenorphine\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e27 (61%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10 (23%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMethadone\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25 (35%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e31 (44%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6.15\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e0.01\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eI am likely to recommend HRS to a friend\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBuprenorphine\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e32 (73%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4 (10%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMethadone\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e43 (61%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e16 (23%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.55\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.11\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eI feel welcome at HRS sites\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBuprenorphine\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e32 (73%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4 (10%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMethadone\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35 (49%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e19 (27%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5.38\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e0.02\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eI feel judged at HRS sites\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBuprenorphine\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (14%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e33 (75%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMethadone\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12 (17%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e45 (63%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.19\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.67\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eI wish there were more HRS sites\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBuprenorphine\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26 (59%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5 (11%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMethadone\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35 (49%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e21 (30%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3.39\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.07\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eHRS sites have a positive effect on me and my community\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBuprenorphine\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28 (64%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4 (10%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMethadone\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e32 (45%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18 (25%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4.36\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e0.04\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eI can easily get to HRS sites\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBuprenorphine\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e27 (61%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10 (23%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMethadone\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35 (49%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e15 (21%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.004\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.95\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLegend\u003c/b\u003e: \u003cem\u003eHRS\u0026thinsp;=\u0026thinsp;harm reduction services (sites supplying syringes, fentanyl test strips, or naloxone (Narcan))\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eB\u0026thinsp;=\u0026thinsp;Buprenorphine; M\u0026thinsp;=\u0026thinsp;Methadone\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eStatistically significant findings (α\u0026thinsp;=\u0026thinsp;0.05) are shown in\u003c/em\u003e \u003cb\u003ebold.\u003c/b\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\u003cp\u003e\u003cstrong\u003eHRS Access and Use Practices\u003c/strong\u003e\u003cp\u003eHRS access was significantly associated with fentanyl test strip use (X\u0026sup2; (1, \u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;115)\u0026thinsp;=\u0026thinsp;9.92, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002) but not with sterile injection practices (\u003cem\u003eX\u003c/em\u003e\u0026sup2; (1, \u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;20)\u0026thinsp;=\u0026thinsp;1.64, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.20).\u003c/p\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003e Most participants receiving MOUD had utilized harm reduction services (HRSs), particularly syringe exchange programs and naloxone distribution sites, although usage was generally infrequent. Only 29% reported access in the past week, and 56% used HRS once a month or less. Patients in abstinence often declined HRS use, citing a lack of need, whereas active users\u0026mdash;especially those using stimulants\u0026mdash;may avoid HRS due to concerns about relapse triggers.\u003c/p\u003e\u003cp\u003eA key finding was that 37% of the participants continued to use opioids while on MOUD, most commonly through injection. Among those who injected, fewer than half reported consistent use of sterile techniques. While HRS access did not significantly improve sterile practices, it was associated with increased fentanyl test strip use\u0026mdash;a behavior that may reduce overdose risk.\u003c/p\u003e\u003cp\u003eIn settings such as Philadelphia, where fentanyl is widespread, the utility of test strips is debated.\u003csup\u003e\u003cspan additionalcitationids=\"CR35\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e However, they may still serve a role for individuals using counterfeit pills or methamphetamine, particularly in regions with more variability in drug contamination. Future research should explore their evolving relevance.\u003c/p\u003e\u003cp\u003eThe participants generally viewed HRSs positively, with most reporting feeling welcomed and likely to recommend these services. Few reported feeling judged. This finding supports the idea that HRSs function as nonstigmatizing spaces. Unlike previous studies showing racial disparities in harm reduction engagement,\u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e we found no significant differences by race\u0026mdash;possibly reflecting the specific characteristics of our sample or local context but warranting further investigation.\u003c/p\u003e\u003cp\u003eDespite individual support for HRSs, enthusiasm for expanding them into communities was lower. The participants often acknowledged the personal benefits of HRS but expressed discomfort with their presence in local neighborhoods. Qualitative research is needed to explore this disconnect.\u003c/p\u003e\u003cp\u003eWe found that while recent opioid use did not differ significantly between groups, buprenorphine participants were more likely to use HRSs, recommend them, feel welcomed at these sites, and perceive a positive community impact. These findings suggest that methadone patients may benefit from greater psychosocial support and stigma reduction strategies. These differences may also reflect distinct treatment environments and patient populations. At TJU-NARP, where methadone is administered, patients often have prior negative experiences with buprenorphine (e.g., precipitated withdrawal or initiation challenges with fentanyl use) or need daily supervised dosing. While this structure offers consistency, it may also foster stigma or reduce autonomy. In contrast, buprenorphine is typically provided in less restrictive settings with integrated primary care, offering patients more flexibility and potentially fostering more positive perceptions of harm reduction.\u003c/p\u003e\u003cp\u003eMethadone patients may also have more severe OUD histories, repeated relapses, or failed attempts in less structured programs, contributing to internalized stigma and negative perceptions. While Pathways to Housing and TJU-NARP both serve individuals experiencing housing instability and ongoing opioid use, SKWC\u0026mdash;a Federally Qualified Health Center\u0026mdash;sees patients with comparatively more housing stability and less severe relapse histories, which may foster more favorable views of treatment and HRS. Additionally, TJU-NARP is farther from Prevention Point (6.2 miles) than SKWC (4.1 miles) or Pathways (4.2 miles), possibly contributing to lower HRS access among methadone patients.\u003c/p\u003e\u003cp\u003eThese contextual differences highlight the need for follow-up interviews to better understand how site-specific factors and stigma shape harm reduction engagement across treatment types.\u003c/p\u003e\u003cp\u003eThis study has several limitations. As a retrospective study using a convenience sample limited to individuals currently receiving MOUD, we were unable to assess harm reduction outcomes among those not on MOUD or establish causality between MOUD type and harm reduction engagement. We also did not collect data on substance use prior to MOUD initiation, limiting insight into behavioral change. Self-reported, in-person data collection introduced potential for recall and social desirability bias. Finally, the study was conducted solely in Philadelphia, which may limit generalizability.\u003c/p\u003e\u003cp\u003eAs the first study to explore harm reduction engagement among individuals receiving MOUD, our findings suggest several directions for future research. Longitudinal studies tracking substance use before and after MOUD initiation could clarify whether MOUD promotes safer practices. Comparisons with non-MOUD populations may help establish causality. Qualitative research is also warranted to explore HRS perceptions\u0026mdash;especially among methadone patients and at the community level.\u003c/p\u003e\u003cp\u003eOUD is a chronic, complex condition requiring multifaceted treatment. Given that many individuals on MOUD continue to use opioids, understanding how harm reduction intersects with treatment is essential. While high-risk use persists, HRSs are generally valued\u0026mdash;particularly among buprenorphine recipients. These findings support the potential for harm reduction to serve as a meaningful treatment outcome in the care of individuals with OUD.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study underscores the complex interplay between medication for opioid use disorder (MOUD), harm reduction services (HRS), and ongoing opioid use. While most participants had utilized HRSs at some point, regular use was less common. Notably, 37% reported recent opioid use\u0026mdash;often via injection\u0026mdash;with inconsistent adherence to safer practices, challenging the assumption that MOUD equates to abstinence. Access to HRS was significantly associated with fentanyl test strip use, a promising harm reduction behavior, particularly for individuals using stimulants. However, in settings such as Philadelphia where fentanyl is ubiquitous, the utility of test trips may be limited, highlighting the need for broader harm reduction strategies adapted to the realities of the evolving drug supply.\u003c/p\u003e\u003cp\u003eWe also found that harm reduction engagement varied by MOUD type. Compared with methadone recipients, buprenorphine recipients were more likely to access HRSs and held more favorable attitudes toward these services, suggesting that the treatment structure may influence patients\u0026rsquo; perceptions and behaviors. Interestingly, we observed no significant racial differences in HRS engagement, which contrasts with prior research and points to broader social or structural factors that warrant further investigation.\u003c/p\u003e\u003cp\u003eThe participants generally held positive views of HRSs, with most feeling welcomed and willing to recommend these services. However, perceived judgment varied by MOUD duration, suggesting that treatment length may shape harm reduction experiences. Combined with the discrepancy between individual support and lower community-level endorsement of HRS expansion, these findings point to the need for further research into the social and psychological factors influencing engagement.\u003c/p\u003e\u003cp\u003eIn conclusion, this study highlights the importance of integrating harm reduction strategies into MOUD programs. Expanding access to HRSs and providing patient-centered education on safer use practices may improve outcomes for those who continue using opioids during treatment. Addressing these gaps can help advance a more holistic and compassionate approach to OUD care\u0026mdash;one that supports both individual recovery and broader public health.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u0026bull; OUD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eOpioid Use Disorder\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u0026bull; MOUD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMedication for Opioid Use Disorder\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u0026bull; HRS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHarm reduction services\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u0026bull; TJU\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNARP\u0026ndash;Thomas Jefferson University Narcotic Addiction Rehabilitation Program\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u0026bull; SKWC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eStephen Klein Wellness Center\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cu\u003e\u003cstrong\u003eSources of Support/Funding\u003c/strong\u003e\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThis research was supported by Sidney Kimmel Medical College\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e\u003cstrong\u003eConflicts of Interest\u003c/strong\u003e\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the\u0026nbsp;Thomas Jefferson University Institutional Review Board (IRB protocol iRISID #2023-2182). All participants completed an IRB-approved written informed consent and received a copy of their informed consent. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analyzed during the current study are not publicly available due to confidentiality protections but are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study did not receive any external funding\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWB conceived and designed the study, received IRB approval, collected data, interpreted the data, and was a major contributor to the writing of the manuscript. NC collected data, analyzed the data, interpreted the data, and was a major contributor to the writing of the manuscript. LCW made substantial contributions to the conceptions of the study and substantively revised the manuscript. WJ substantively revised the manuscript. RH made substantial contributions to the acquisition of data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank the staff and patients at the participating treatment sites for their time and collaboration. We also thank Brooke Mauriello and the Family Medicine Department for their support of this work.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSaloner B, McGinty EE, Beletsky L, et al. A Public Health Strategy for the Opioid Crisis. Public Health Rep. 2018;133(1):24-34. doi: 10.1177/0033354918793627. PMID: 30426871; PMCID: PMC6243441.\u003c/li\u003e\n\u003cli\u003eNational Institute on Drug Abuse (US). Common Comorbidities with Substance Use Disorders Research Report. (2020, April). Available from: https://www.ncbi.nlm.nih.gov/books/NBK571451/\u003c/li\u003e\n\u003cli\u003eCenters for Disease Control and Prevention. Substance Use \u0026amp; Substance Use Disorders. (2024). Available from: https://wwwnc.cdc.gov/travel/yellowbook/2024/additional-considerations/substance-use Accessed February 4, 2025.\u003c/li\u003e\n\u003cli\u003eCenters for Disease Control and Prevention. Treatment for Opioid Use Disorder: Population Estimates - United States, 2022. MMWR. 2024;73(25):567-574. doi:10.15585/mmwr.mm7325a1.\u003c/li\u003e\n\u003cli\u003eDydyk AM, Jain NK, Gupta M. Opioid Use Disorder. StatPearls Publishing; 2025. PMID: 31985959.\u003c/li\u003e\n\u003cli\u003eGugala E, Briggs O, Moczygemba LR, Brown CM, Hill LG. Opioid harm reduction: A scoping review of physician and system-level gaps in knowledge, education, and practice. Subst Abus. 2022;43(1):972-987. doi: 10.1080/08897077.2022.2060423. PMID: 35426772.\u003c/li\u003e\n\u003cli\u003eTaylor JL, Johnson S, Cruz R, Gray JR, Schiff D, Bagley SM. Integrating Harm Reduction into Outpatient Opioid Use Disorder Treatment Settings: Harm Reduction in Outpatient Addiction Treatment. J Gen Intern Med. 2021;36(12):3810-3819. doi: 10.1007/s11606-021-06904-4. Epub 2021 Jun 22. PMID: 34159545; PMCID: PMC8218967.\u003c/li\u003e\n\u003cli\u003eIsrael BS, Belcher AM, Ford JD. A Harm Reduction Framework for Integrated Treatment of Co-Occurring Opioid Use Disorder and Trauma-Related Disorders. J Dual Diagn. 2024;20(1):52-85.\u003c/li\u003e\n\u003cli\u003ePatnode CD, Perdue LA, Rushkin M, et al. Screening for Unhealthy Drug Use: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2020;323(22):2310-2328. doi: 10.1001/jama.2019.21381. PMID: 32515820.\u003c/li\u003e\n\u003cli\u003eSchuckit MA. Treatment of Opioid-Use Disorders. N Engl J Med. 2016;375(4):357-368. doi:10.1056/NEJMra1604339.\u003c/li\u003e\n\u003cli\u003eMacArthur GJ, Minozzi S, Martin N, et al. Opiate substitution treatment and HIV transmission in people who inject drugs: systematic review and meta-analysis. BMJ. 2012;345:e5945. doi: 10.1136/bmj.e5945. PMID: 23038795; PMCID: PMC3489107.\u003c/li\u003e\n\u003cli\u003eDegenhardt L, Clark B, Macpherson G, et al. Buprenorphine versus methadone for the treatment of opioid dependence: a systematic review and meta-analysis of randomised and observational studies. Lancet Psychiatry. 2023;10(6):386-402. doi: 10.1016/S2215-0366(23)00095-0. Epub 2023 May 8. Erratum in: Lancet Psychiatry. 2024;11(4):e8. doi: 10.1016/S2215-0366(24)00004-X. PMID: 37167985.\u003c/li\u003e\n\u003cli\u003eMattick RP, Breen C, Kimber J, Davoli M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev. 2014;2014(2):CD002207. doi: 10.1002/14651858.CD002207.pub4. PMID: 24500948; PMCID: PMC10617756.\u003c/li\u003e\n\u003cli\u003eBahji A, Cheng B, Gray S, Stuart H. Reduction in mortality risk with opioid agonist therapy: a systematic review and meta-analysis. Acta Psychiatr Scand. 2019;140(4):313-339. doi: 10.1111/acps.13088. PMID: 31419306.\u003c/li\u003e\n\u003cli\u003eLofwall MR, Walsh SL, Nunes EV, et al. Weekly and Monthly Subcutaneous Buprenorphine Depot Formulations vs Daily Sublingual Buprenorphine with Naloxone for Treatment of Opioid Use Disorder: A Randomized Clinical Trial. JAMA Intern Med. 2018;178(6):764\u0026ndash;773. doi:10.1001/jamainternmed.2018.1052.\u003c/li\u003e\n\u003cli\u003eZoorob R, Kowalchuk A, Mejia de Grubb M. Buprenorphine Therapy for Opioid Use Disorder. Am Fam Physician. 2018;97(5):313-320. PMID: 29671504.\u003c/li\u003e\n\u003cli\u003eGomes T, McCormack D, Bozinoff N, et al. Duration of use and outcomes among people with opioid use disorder initiating methadone and buprenorphine in Ontario: a population-based propensity-score matched cohort study. Addiction. 2022;117(7):1972-1981. doi: 10.1111/add.15862. Epub 2022 Mar 21. PMID: 35257434; PMCID: PMC9313829.\u003c/li\u003e\n\u003cli\u003ePearce LA, Min JE, Piske M, et al. Opioid agonist treatment and risk of mortality during opioid overdose public health emergency: population based retrospective cohort study. BMJ. 2020;368:m772. doi: 10.1136/bmj.m772. PMID: 32234712; PMCID: PMC7190018.\u003c/li\u003e\n\u003cli\u003eNielsen S, Tse WC, Larance B. Opioid agonist treatment for people who are dependent on pharmaceutical opioids. Cochrane Database Syst Rev. 2022;9(9):CD011117. doi: 10.1002/14651858.CD011117.pub3. PMID: 36063082; PMCID: PMC9443668.\u003c/li\u003e\n\u003cli\u003eGottlieb DJ, Shiner B, Hoyt JE, et al. A comparison of mortality rates for buprenorphine versus methadone treatments for opioid use disorder. Acta Psychiatr Scand. 2023;147(1):6-15. doi: 10.1111/acps.13477. Epub 2022 Jul 23. PMID: 35837885.\u003c/li\u003e\n\u003cli\u003eShulman M, Wai JM, Nunes EV. Buprenorphine Treatment for Opioid Use Disorder: An Overview. CNS Drugs. 2019;33(6):567-580. doi: 10.1007/s40263-019-00637-z. PMID: 31062259; PMCID: PMC6585403.\u003c/li\u003e\n\u003cli\u003eCastillo F, Hu MC, Liu Y, et al. Risks of returning to opioid use at treatment entry and early in opioid use disorder treatment: Role of non-opioid substances. Drug Alcohol Depend. 2023;251:110926. doi: 10.1016/j.drugalcdep.2023.110926. Epub 2023 Aug 9. PMID: 37604012; PMCID: PMC10712265.\u003c/li\u003e\n\u003cli\u003eSaloner B, Whitley P, Dawson E, et al. Polydrug use among patients on methadone medication treatment: Evidence from urine drug testing to inform patient safety. Addiction. 2023;118(8):1549-1556. doi: 10.1111/add.16180. Epub 2023 May 9. PMID: 37158468; PMCID: PMC10330099.\u003c/li\u003e\n\u003cli\u003eFoot C, Korthuis PT, Tsui JI, et al. Associations between stimulant use and return to illicit opioid use following initiation onto medication for opioid use disorder. Addiction. 2024;119(1):149-157. doi: 10.1111/add.16334. Epub 2023 Sep 15. PMID: 37712113; PMCID: PMC11139042.\u003c/li\u003e\n\u003cli\u003eChandra DK, Altice FL, Copenhaver MM, et al. Purposeful Fentanyl Use and Associated Factors among Opioid-Dependent People Who Inject Drugs. Subst Use Misuse. 2021;56(7):979-987. doi: 10.1080/10826084.2021.1901931. Epub 2021 Mar 26. PMID: 33769199.\u003c/li\u003e\n\u003cli\u003eChan CA, Canver B, McNeil R, Sue KL. Harm Reduction in Health Care Settings. Med Clin North Am. 2022;106(1):201-217.\u003c/li\u003e\n\u003cli\u003eKalk NJ. Harm reduction in opioid treatment: an established idea under threat. Wiley Addiction. 2018;114(1):20-21.\u003c/li\u003e\n\u003cli\u003ePlatt L, Minozzi S, Reed J, et al. Needle syringe programmes and opioid substitution therapy for preventing hepatitis C transmission in people who inject drugs. Cochrane Database Syst Rev. 2017;9:CD012021. doi: 10.1002/14651858.CD012021.pub2.\u003c/li\u003e\n\u003cli\u003eLevengood TW, Yoon GH, Davoust MJ, et al. Supervised injection facilities as harm reduction: A systematic review. Am J Prev Med. 2021;61(5):738\u0026ndash;749.\u003c/li\u003e\n\u003cli\u003eHawk KF, Vaca FE, D\u0026apos;Onofrio G. Reducing Fatal Opioid Overdose: Prevention, Treatment and Harm Reduction Strategies. Yale J Biol Med. 2015;88(3):235-245. PMID: 26339206; PMCID: PMC4553643.\u003c/li\u003e\n\u003cli\u003eWalley AY, Xuan Z, Hackman HH, et al. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis. BMJ. 2013;346:f174. doi: 10.1136/bmj.f174.\u003c/li\u003e\n\u003cli\u003eHuhn AS, Gipson CD. Promoting harm reduction as a treatment outcome in substance use disorders. Exp Clin Psychopharmacol. 2021;29(3):217-218. doi: 10.1037/pha0000494.\u003c/li\u003e\n\u003cli\u003eBritish Columbia Centre for Disease Control. Harm Reduction Client Survey. 2021. Available from: http://www.bccdc.ca/health-professionals/data-reports/harm-reduction-client-survey Accessed April 12, 2023.\u003c/li\u003e\n\u003cli\u003eContella L, Snyder ML, Kang P, Tolan NV, Melanson SEF. Clinical performance of a new lateral flow immunoassay for xylazine detection. Clin Chem Lab Med. 2024. doi: 10.1515/cclm-2024-0947. Epub ahead of print. PMID: 39392655.\u003c/li\u003e\n\u003cli\u003ePA Groundhogs. 2023\u0026ndash;2024 Progress Report. Available from: https://pagroundhogs.org/data.\u003c/li\u003e\n\u003cli\u003eWallace B, Shkolnikov I, Kielty C, et al. Is fentanyl in everything? Examining the unexpected occurrence of illicit opioids in British Columbia\u0026rsquo;s drug supply. Harm Reduct J. 2025;22:28. doi: 10.1186/s12954-025-01189-w.\u003c/li\u003e\n\u003cli\u003eMistler CB, Chandra DK, Copenhaver MM, et al. Engagement in Harm Reduction Strategies After Suspected Fentanyl Contamination Among Opioid-Dependent Individuals. J Community Health. 2021;46:349-357.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"harm-reduction-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"harj","sideBox":"Learn more about [Harm Reduction Journal](http://harmreductionjournal.biomedcentral.com/)","snPcode":"12954","submissionUrl":"https://submission.nature.com/new-submission/12954/3","title":"Harm Reduction Journal","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Harm Reduction, Opioid Use Disorder, Injection drug use, Methadone, Buprenorphine, Treatment engagement","lastPublishedDoi":"10.21203/rs.3.rs-7558770/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7558770/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e\u003cp\u003eOpioid Use Disorder (OUD), a chronic condition with significant health and social consequences, has been intensified by synthetic opioids such as fentanyl. While medications for OUD (MOUD), such as buprenorphine and methadone, reduce mortality and improve treatment retention, MOUD recipients may continue to engage in high-risk substance use. Harm reduction services (HRSs), including syringe exchange sites, supervised injection facilities, or sites that distribute fentanyl test strips or naloxone, may help mitigate the risks of continued use. This study explores engagement with harm reduction services and opioid use practices among adults receiving MOUD in Philadelphia, including differences in these outcomes between methadone and buprenorphine recipients.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWe conducted a cross-sectional survey of 116 adults receiving buprenorphine or methadone for moderate-to-severe OUD at three Philadelphia treatment sites between November 2023 and October 2024. The participants completed a RedCAP-based questionnaire assessing recent opioid use, access to and attitudes towards HRS, and substance use practices. Statistical analyses were performed via chi-square and Kruskal‒Wallis tests.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e\u003cp\u003eOverall, 37% of participants reported recent illicit opioid use, primarily via injection with various sterile injection practices. Sixty-one percent of all participants had accessed harm reduction services at least once, yet regular use was uncommon, with only 29% reporting access in the past week. Access to harm reduction services was significantly associated with fentanyl test strip use (p\u0026thinsp;=\u0026thinsp;0.002) but not with consistent sterile injection practices (p\u0026thinsp;=\u0026thinsp;0.20). Compared with methadone recipients, buprenorphine recipients were more likely to access harm reduction services, feel welcomed at these sites, recommend them to others, and perceive a positive community impact (all p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). No differences in recent opioid use were observed between treatment groups or across racial groups.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions\u003c/b\u003e\u003c/p\u003e\u003cp\u003eDespite active MOUD treatment, many patients reported high-risk opioid use. Positive attitudes toward and engagement with harm reduction services were more common among buprenorphine recipients, suggesting that differences in MOUD setting and structure may influence engagement with harm reduction. These findings support the integration of harm reduction strategies into MOUD programs, particularly among methadone recipients, to reduce risk and improve outcomes among individuals with OUD.\u003c/p\u003e","manuscriptTitle":"Harm Reduction Engagement and Ongoing Opioid Use Among Adults Receiving Methadone or Buprenorphine in Philadelphia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-15 02:42:07","doi":"10.21203/rs.3.rs-7558770/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-29T02:08:29+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-23T20:42:29+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-20T19:29:32+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-14T18:23:51+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-04T03:36:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"6533700193789538135621249780126978861","date":"2025-10-03T02:52:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"22684475395643803513233374514232948510","date":"2025-10-02T16:47:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"140991919628590988298358690051371494583","date":"2025-10-01T13:39:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"20935824099470577568730462867991278681","date":"2025-10-01T10:53:06+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-01T02:45:47+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-08T08:29:27+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-08T08:28:23+00:00","index":"","fulltext":""},{"type":"submitted","content":"Harm Reduction Journal","date":"2025-09-07T23:37:19+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"harm-reduction-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"harj","sideBox":"Learn more about [Harm Reduction Journal](http://harmreductionjournal.biomedcentral.com/)","snPcode":"12954","submissionUrl":"https://submission.nature.com/new-submission/12954/3","title":"Harm Reduction Journal","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b6e722c3-8d8c-49b1-a794-4e4fdae78b21","owner":[],"postedDate":"October 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-05T16:00:22+00:00","versionOfRecord":{"articleIdentity":"rs-7558770","link":"https://doi.org/10.1186/s12954-025-01366-x","journal":{"identity":"harm-reduction-journal","isVorOnly":false,"title":"Harm Reduction Journal"},"publishedOn":"2026-01-03 15:57:08","publishedOnDateReadable":"January 3rd, 2026"},"versionCreatedAt":"2025-10-15 02:42:07","video":"","vorDoi":"10.1186/s12954-025-01366-x","vorDoiUrl":"https://doi.org/10.1186/s12954-025-01366-x","workflowStages":[]},"version":"v1","identity":"rs-7558770","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7558770","identity":"rs-7558770","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}