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Opioid overdose deaths have skyrocketed over the past two decades, with nearly 500,000 deaths from 1999-2019, and over 107,000 deaths in 2021 alone (CDC, 2020). Due to the complex nature of the epidemic, a range of interventions that span socio-ecological levels have been implemented (e.g., medication treatments, peer recovery support services, prescription drug monitoring programs; Dugosh et al., 2016; Gormley et al., 2021; Fink et al., 2018). Recently, response efforts have increasingly integrated harm reduction strategies, programs, and policies; however little is known about the harm reduction interventions that have been implemented. As such, this systematic review aimed to 1) identify the range of harm reduction interventions for opioid misuse implemented at policy, community, and individual levels, and 2) summarize intervention outcomes relative to the level at which they were implemented.
Methods
We conducted a systematic review of academic literature published between 2011-2021 following PRISMA guidelines. Five databases were systematically searched (CINAHL, MEDLINE, PsycINFO, PubMed, SocINDEX) using an expert-informed search string. To concentrate our search on articles that examined harm reduction interventions aimed at reducing opioid-related harm, we excluded articles that reported on research that was not specific to opioids, did not report the effects of an intervention, or focused on medical treatments for opioid use disorder. Risk of bias was assessed (Higgins et al., 2011). The original search yielded 4,730 articles which, upon deduplication (n=2,538), were entered into a systematic review software for title/abstract screening and full-text review. Two coders independently extracted data and reconciled discrepancies prior to synthesis.
Results
26 articles met inclusion criteria. 5 articles examined policy-level harm reduction interventions, such as Good Samaritan laws, Naloxone Access Laws, and recreational cannabis laws. 6 articles examined community-level harm reduction interventions, such as overdose education and naloxone distribution programs, syringe service programs, and overdose monitoring facilities. 15 articles examined individual-level interventions, such as HIV/HCV education and fentanyl test strips. Evidence for individual- and community-level harm reduction interventions is largely consistent (i.e., interventions significantly associated with outcomes that reduce opioid-related harm), whereas evidence for policy-level interventions is mixed.
Conclusions and Implications
Review findings provide insight into the current state of scientific literature related to what harm reduction interventions have been implemented and effective in addressing the opioid epidemic. The majority of included articles reported on individual-level interventions (58%, n=15), revealing an age-old emphasis on individual behavior change as opposed to social and structural change. Findings also reveal a dearth of culturally-relevant interventions, as most interventions reported reaching White individuals (69%, n=11 of 16 studies), despite Black and Latinx communities being disproportionately impacted by the epidemic in recent years (Cano, 2021; El-Bassel et al., 2021). Finally, while the broad scope of the review prevents comparing intervention effectiveness across socio-ecological levels, findings reveal a lack of multi-level interventions and suggest a need for researchers to develop and examine harm reduction interventions designed to impact at least two socio-ecological levels, which may produce synergistic effects and therefore greater benefits.