Making Harm Reduction Evidence-Based: Collaboration in a Randomized Controlled Trial to Prevent Overdose

Background: This presentation describes efforts at collaboration through a randomized clinical trial testing the Harm Reduction Peer Recovery (HaRP) intervention, a complex case management intervention to prevent opioid overdose among people exiting jail. The trial brought together a diverse set of institutions and types of actors, from sheriffs to grassroots harm reduction activists, to academic researchers. HaRP is also one element of a broader portfolio of federally funded initiatives which represented an unprecedented scientific investment both in the carceral system as well as in testing harm reduction interventions.Therefore, the trial brought together a novel set of stakeholders who have historically stood in tension. Certain elements of harm reduction are only uneasily integrated into formalized public health and criminal-legal venues. Actors hold different conceptions of the causes of harm, ideal behavioral change goals, the moral worth of drug users, as well as the role of the criminal-legal system and direct action in attending to the causes and consequences of drug overdose. This presentation pursues the question: How are the demands of scientific inquiry negotiated with activist commitments during a socio-behavioral clinical trial?

Methods: My findings draw from over two years of participant observation of the HaRP clinical trial, where I attended daily meetings including formal intervention trainings, clinical case consultations, community advisory board meetings, and various types of research team meetings. I supplemented this data by conducting semi-structured interviews with researchers, practitioners, as well as jail and community stakeholders. Throughout, I observed the micro-interactional dynamics of how researchers of various disciplines, as well as clinicians, activists, and carceral administrators, collaborate amidst diverging ethical and institutional obligations and professional commitments. As a participant and research assistant on the HaRP trial, I also helped to develop study instruments including surveys, interview guides, and manuals of procedure. This mode of participation allowed me to observe and participate in the reflexive processes of researchers and implementation actors as they negotiated the ethical, epistemological, and political tensions of their work.

Results: I argue that the imperatives of the clinical trial, and the institutional obligations to which it was tethered, overrode the aspirations of on-the-ground practitioners for how to reduce overdose deaths most effectively among people who use drugs in carceral contexts. This is because, I argue, trial actors operated within different temporal and scalar logics. That is, they had different ideas for how broad, and under what timeline, social change should occur stemming from different professional, disciplinary and activist commitments. I will show how principal investigators on the trial expressed their desire to pursue objectivity and to produce research that would establish generalizable findings for policymakers, and how this stood in tension with the activist goals of harm reduction actors.

Implications/Conclusion: As harm reduction becomes increasingly “evidence-based” this presentation sheds light on how researchers and providers might better negotiate divergent institutional and ethical commitments in translational research where the imperatives of research, clinical practice, and activism may converge.