"We Do It Ourselves": Strengths and Opportunities for Harm Reduction Practice in Texas

Background and Purpose: Unprecedented increases in substance-related overdose fatalities have been observed in Texas and the U.S. since the onset of the COVID-19 pandemic and have made clear there is considerable need to reduce harms associated with drug use. At the federal level, initiatives have called for widespread dissemination and implementation of evidence-based harm reduction practices to reduce overdose deaths. Implementation of harm reduction strategies is challenging in Texas. There is a paucity of literature on understanding current harm reduction practices in Texas. As such, this qualitative study aims to understand harm reduction practices among people who use drugs (PWUD), harm reductionists, and emergency responders across four counties in Texas. We sought to answer the following research questions: (1) what barriers exist for PWUD to engage with the healthcare system following an overdose? (2) what strengths and challenges exist for harm reduction organizations in serving their clients in Texas? and (3) what are harm reductionists’ perspectives on how policy influences harm reduction philosophy and practice in Texas? This work will inform future efforts to scale and spread harm reduction in Texas.

Methods: Semi-structured qualitative interviews were conducted with N=69 key stakeholders in harm reduction practice (25 harm reductionists; 24 PWUD; 20 emergency responders). The sample is predominantly male (61% male; 39% female), White (78% White; 12% Other; 6% Asian; 6% African American or Black; 2% American Indian or Alaskan Native), and Non-Hispanic or Latino (Non-Hispanic or Latino 61%; 35% Hispanic or Latino; Other 4%). Stakeholders were recruited via snowball sampling methods, including in-person communications, flyers, e-mails, reaching out to known contacts via telephone, and word of mouth via community advisory boards. Secondary analysis of these qualitative interviews was carried out to better understand barriers to practicing harm reduction and providing evidence-based overdose prevention services in Texas. Interviews were transcribed verbatim, coded for emergent themes, and analyzed using Applied Thematic Analysis with Nvivo 12. A community advisory board defined the research questions, reviewed the emergent themes, and assisted with interpretation of the data.

Findings: Emergent themes highlighted barriers to harm reduction at micro and macro levels, from the individual experience of PWUD and harm reductionists to systemic issues in healthcare and the emergency medical response system. Specifically, (1) Texas has existing strengths in overdose prevention and response efforts on which to build, (2) PWUD are fearful of interacting with healthcare and 911 systems, (3) harm reductionists are in increasing need of support for reaching all PWUD communities, and (4) state-level policies may hinder widespread implementation and adoption of evidence-based harm reduction practices.

Conclusions and Implications: Perspectives from harm reduction stakeholders highlighted existing strengths, avenues for improvement, and specific barriers that currently exist to harm reduction practices in Texas. Findings demonstrated a need to improve state harm reduction infrastructure, including stable funding sources, tools for collecting and aggregating data to drive response efforts, and mental health supports for harm reduction service providers to combat burnout and staff turnover.