We interviewed twenty-one hospitalized patients with OUD. The mean age of participants was 45 years (Table 2). Nearly one-third of participants were female (29%). Two-thirds of participants identified as white (67%). Nearly one in five participants were Latinx (19%), with about a quarter of participants identifying as Black (24%). Forty-three percent of participants were hospitalized for infections such as bacteremia, osteomyelitis, sepsis, and/or cellulitis. About a quarter (24%) had a primary diagnosis not directly related to drug use. Most participants (95%) currently used opioids, with about a third also reporting current use of stimulants and/or sedatives and 14% reporting current alcohol use. All participants were using at least one substance.

Table 2 Participant characteristics

The study team identified three major themes by grouping codes: (1): applicability and Acceptability of Harm Reduction Practices for Oneself; (2) Applicability and Acceptability of Harm Reduction Practices for Others; (3) Perceptions of Harm Reduction Conversations. Below we detail each theme and provide illustrative quotations, with the parenthetical number following each quote representing the anonymized patient identifier we assigned to each participant.

Theme 1: Applicability and Acceptability of Harm Reduction Practices for Oneself

When asked about their understanding of and prior knowledge about harm reduction, most participants were familiar with harm reduction strategies, mainly discussing specific safer use practices or tools such as sterile syringes, naloxone, and medications for OUD rather than viewing harm reduction as a philosophical approach. For participants not familiar with the term “harm reduction,” we provided a brief definition after which participants often realized that they actually were familiar with the concept. For example, when asked about the concept of harm reduction one participant responded, “What’s that?” [18] but after clarification said that they had heard of and used principles from harm reduction. While not asked explicitly about the applicability and acceptability of harm reduction practices for themselves versus for others, participants naturally drew this distinction. This theme explores participants attitudes towards the use of harm reduction practices for their own health and safety. Many participants routinely incorporated safer use techniques in their own lives while others were less sure about the utility of harm reduction strategies for themselves.

Some participants embraced a harm reduction approach to drug use, finding such an approach applicable and acceptable for themselves. One participant shared, “I always practice using new needles. Usually, I’m with somebody and we have naloxone onsite.” [2]. Recognizing that abstinence is not a feasible or desirable outcome for everyone, some participants noted the utility of harm reduction for themselves in case their aspirations for recovery did not go as planned. One participant planning to abstain from drugs after hospitalization, though aware of the possibility of returning to drug use, endorsed being prepared with harm reduction supplies: “Am I gonna say that I’m never gonna use again? I would never say that because anything can happen. But do I want to not use? Absolutely. But I’d willing to take [harm reduction supplies] that people [offer].” [4].

Another group of participants was unsure if harm reduction practices were applicable to them if they did not inject drugs. For example, one participant shared that “I don't do needles. I'm a pill popper myself.” [7]. When asked about harm reduction strategies, another participant responded, “Let me clear–I don’t have no IV problem.” [2]. In these cases, participants perceived lower risks associated with their substance use because they did not inject and drew a distinction between general support of harm reduction strategies and the applicability of these practices to them as individuals.

The acceptability of some harm reduction interventions provided by members of the care team in the hospital setting was mixed, especially among those in or planning for abstinence following discharge. In particular, this was true for sterile syringes and other harm reduction strategies aimed at reducing infectious disease transmission that were perceived as running counter to their goals for abstinence. One participant stated that they were opposed to accepting syringes because they were in recovery: “I wouldn't even take [syringes] at this point, I would tell them I don't need it, so why would I even take it? I wouldn't.” [9]. A few participants were unclear if syringes were congruent with their goals and concerned that they may serve as a trigger for substance use, with one stating “That’s gonna make me think more along the lines of picking up again rather than not having those things in my house.” [14]. Another participant shared that being offered syringes “…would put me in a relapse mode.” [20].

Overall, participants varied in their perceptions of the relevance of harm reduction practices for their own lives. Some were candid in their desire to incorporate harm reduction strategies for their own health and safety; others did not consider them relevant in their lives, often because they did not inject drugs or because they were in recovery. Some participants acknowledged the risk of return to substance use as a risk for themselves despite their intentions to remain abstinent following discharge and were open to the relevance of harm reduction practices in that context.

Theme 2: Applicability and Acceptability of Harm Reduction Practices for Others

Given that many participants drew distinctions between harm reduction practices for themselves versus for others, this theme includes discussion of participants’ attitudes about harm reduction practices for others. Participants defined harm reduction for others broadly, describing a range of interventions from distribution of basic supplies like clothing to interventions to reduce overdose and prevent infectious disease transmission. Supplies to meet basic needs (e.g., clothes, bus fare) were acceptable to participants for others. As one participant noted, “Make sure that they have viable shoes and socks and underwear and T-shirts and bus fare… give them a card that they can get on the [subway] with or the trolley or the bus. Or they can get something to eat.” [2].

Participants found supplies to prevent overdose applicable and acceptable for use on others. Naloxone distribution was perceived as an acceptable and expected component of treatment regardless of intention to remain abstinent in the future, often citing the fact that it could be used to assist others. When asked how they would feel if they were given naloxone upon discharge, one participant explained that “I don’t abuse [drugs], so I wouldn’t need Narcan for myself, but I can have it for somebody else.” [17]. This participant had a similar view of fentanyl test strips, finding them not applicable for themself but acceptable for others, stating “I wouldn’t need [fentanyl test strips], but the test strips is definitely needed [for others] to stay safe.” [17]. Another participant not currently using drugs shared something similar, “Narcan is always good to have in case you see somebody that’s in trouble” [20]. Another participant who found naloxone acceptable for others stated, “There's always Narcan. Yeah, it's always got a Narcan in your pocket because you never know [when you can help someone else].” [3] Overall, the majority of participants expressed comfort in accepting supplies they perceived to be for use on other people regardless of their own individual plans and many felt empowered to help others in active use with these interventions.

While harm reduction supplies to meet basic needs and naloxone were nearly ubiquitously acceptable to patients, some participants were more hesitant about syringes and other supplies to facilitate safer drug administration. As one participant shared, “Well, syringes I wouldn’t want because I don’t have the plans on using them. But the Narcan, yeah, because you never know, you might see a fellow or a young lady falling out from it and have to flip them on their side and give them the Narcan.” [8]. Relatedly, one participant simultaneously noted discomfort with harm reduction for others and its necessity, stating, “It bothers me that [harm reduction] has to be the answer. But then again, it’s like telling your kids not to have sex. You have to give them the condom and tell them what happens.” [9]. Many participants recognized that having a broad menu of harm reduction supply offerings (e.g., naloxone, syringes, pipes, straws, tourniquet, alcohol wipes, fentanyl test strips) would be helpful for others, if not specifically for themselves. However, some felt less comfortable with distribution of syringes and other supplies that they associated with their own ongoing drug use.

Theme 3: Perceptions of Harm Reduction Conversations

We explicitly asked all participants if their hospital care team discussed harm reduction strategies or how to stay safe if they returned to substance use following discharge, and we found that discussions between the care team and patients about drug use were rare. It is worth nothing that while participants differentiated how they felt about the applicably and acceptability of harm reduction practices (e.g., use of naloxone, use of syringes) for themselves compared to others, most (though not all) participants responded to queries about harm reduction education in the hospital specifically for themselves. There was a range of reactions to the idea of harm reduction conversations in the hospital, with some participants supportive and others more hesitant, and responses were strongly influenced by the context of the discussion.

The limited clinical discussions about harm reduction that were reported by participants often happened during clinical history-taking, rather than being initiated by the care team for the purposes of exploring patient goals about drug use. For example, one participant shared that hospital providers “always ask you questions that I think are weird, but I just answer them. People ask do you share needles? Do you lick the tips? Do you use bleach? Do you dip them in bleach? Stuff like that. So, I’ve been asked them questions in the hospital every time I’ve come.” [7]. In the absence of conversations being initiated by the care team, one participant shared their history of drug use with their care team out of fear that the care team would make inappropriate clinical decisions without that information: “They wouldn’t ever know nothing about [my history of using drugs]. I mentioned it. The only reason I mentioned it was I thought it might have had something to do with my [clinical] situation.” [2]. Both of these participant reflections point to clinicians’ lack of understanding about drug use and harm reduction. They also reveal a missed opportunity for clinicians to engage with patients about harm reduction and drug use in a way that is meaningful for patients.

Support for harm reduction conversations in the hospital

Despite the fact that most participants reported a lack of discussion about harm reduction strategies with their care team, many patients thought the hospital setting was a suitable place for harm reduction conversations. One patient whose care team did not talk to them about drug use stated, “I’m willing to learn anything. And any kind of advice or something, you know, I’m willing to hear any of it.” [5]. Another participant shared that “I’m very familiar with [harm reduction practices] myself. But it still would have been nice to hear it again.” [20]. One participant shared a desire for harm reduction education and open discussion about drug use, stating “I would feel safe. You know, I would love that.” [14]. For these participants, open discussion did not happen, but they felt that it could have facilitated a supportive and open dynamic with the care team.

Some participants supportive of hospital-based harm reduction education highlighted the importance of tailoring such offerings based on individual goals and factors, something that is core to the harm reduction philosophy. One participant noted the contextual considerations for having these conversations based on the length of hospitalization, stating “For me, I’ll be in the hospital for over a month. So, my mind is not using. So, if they offered [harm reduction supplies] to me, I would say no. If I was in the hospital for a week, and I know I’m gonna use again, all right, give it to me.” [8]. One participant who reflected on the importance of tailoring hospital-based harm reduction conversations both for themself and for others stated: “I would suggest that they’d let [me] dictate [my] own life, like everybody should be able to dictate their own life and what direction they want they life to go into and what they want to do.” [17]. These participants conveyed the importance of patient autonomy in care and harm reduction education that is concordant with patient goals.

Hesitancy around harm reduction conversations in the hospital

Other participants were hesitant to have conversations about harm reduction strategies for themselves with their care team during hospitalization. Some noted discomfort about bringing substance use up to their care team because of fears about how this would be perceived. As one participant noted, “Once you’re in the hospital, I can’t see why they would ask me that because I’m here, it’s supposed to be end game. So, why tell me how I’m supposed to inject if I’m trying to stop injecting. It’s like a catch-22.” [7] Others expressed ambivalence about discussing a potential return to substance use because they were not planning to return to use substances following their hospitalization. As another participant shared: “They know that I’m trying to get out of that life. So I don’t think that they think that I need [harm reduction] anymore.” [6]. While some participants were aware of the possibility of returning to drug use after discharge, those who intended to remain abstinent from substance use after discharge were often more hesitant about the idea of harm reduction teaching and distribution of supplies in the hospital because of their optimism for recovery and perception that harm reduction supplies were not applicable to them.