"Who Else Is Going to Come Do This?": The Human Cost of Harm Reduction Work within the Non-Profit Industrial Complex

Background and Purpose: Harm Reduction Workers (HRWs) are helping paraprofessionals on the frontlines of the U.S. opioid crisis, providing life-saving services to marginalized people who use drugs. HRWs are commonly charged with rapidly adopting and implementing opioid-related evidence-based interventions (e.g., syringe service programs, naloxone/Narcan administration), often in life-or-death circumstances and contested policy environments. Though harm reduction services and strategies have increasingly gained political acceptance in the U.S., their implementation is severely hindered by socio-structural factors, such as inadequate funding, stigma, drug criminalization, and legal precarity. However, scant research on the occupational dynamics and well-being of this essential workforce is available. As such, this exploratory qualitative study aimed to understand occupational stressors and their impact on HRWs.

Methods: In-depth semi-structured virtual interviews were conducted with N=32 HRWs in Texas to explore various aspects of participants’ jobs as HRWs. The interview protocol included questions related to their role and responsibilities, training histories and needs, and experiences of occupational stress. Approximately two-thirds of participants were full-time employees working >31 hours/week. 85% earned an annual income of <$60,000. Applied Thematic Analysis was used to identify and examine emergent themes related to the a priori research questions. Transcripts were double-coded by a 3-member coding team, and discrepancies were resolved via consensus. Authors adhered to Tracy’s (2010) “big-tent” criteria for qualitative inquiry to ensure trustworthiness of findings.

Results: In their narratives, the nature of their role as HRWs and the layered context within which they do their work emerged as salient framing devices to describe and interpret participants' occupational dynamics. Data revealed four interrelated categories of stressors related to the role of HRWs: burdensome workloads, health and safety hazards (e.g., needle stick injuries, sexual harassment), emotional labor (e.g., client death due to overdose), and relational boundaries. Data also revealed stressors related to the multi-level context within which participants do their work. Specifically, participants described the inherent tension and resultant burden of doing harm reduction within the broader non-profit industrial complex in that competition for scarce resources contributes to understaffed organizations and inadequate pay and job insecurity for HRWs. Participants described stressors adversely affected their emotional, mental, social, and physical well-being, often leaving them to feel helpless, emotionally exhausted, burned out, jaded, and, in some cases, returning to use (relapsing).

Conclusion and Implications: As Shepard (2013) noted, though harm reduction programs produce significant results, they take a substantial toll on the HRWs who operate them. Chronic, unaddressed occupational stress can lead to burnout and turnover, and ultimately threatening the long-term sustainability of the workforce and exacerbating the already-fragmented care continuum. Despite mounting evidence of occupational stress and burnout among helping professionals, community-based workers such as HRWs remain largely excluded from such conversations, further perpetuating inequities within the substance use and behavioral health workforce. The ways in this study's findings have been leveraged to inform community advocacy efforts, community-university partnerships, and research agendas will be discussed.