Key themes from a state-federal harm reduction roundtable
Drug-related overdose deaths — primarily driven by fentanyl, psychostimulants, and other illicit drugs — remain a public health crisis in the U.S, contributing to over 100,000 deaths per year. Harm reduction policies, programs, and practices are rooted in evidence and remain a key public health strategy for reducing overdose deaths and other harms associated with drug use.
While opioid settlement funds and new federal resources provide new opportunities to invest and expand community-centered harm reduction approaches, barriers such as stigma, limited resources, and variability of state laws pose practical challenges to the implementation of lifesaving harm reduction services. Despite these challenges, many states continue to make progress in implementing harm reduction services — working to expand evidence-based interventions such as syringe service programs, partnering with community-based organizations that are trusted by people who use drugs, and building support within different types of environments.
NASHP-NAM Action Collaborative Harm Reduction Roundtable
On July 31, 2024, the National Academy for State Health Policy (NASHP) and the National Academy of Medicine’s (NAM) Action Collaborative on Combatting Substance Use and Opioid Crises held a roundtable that brought together state health leadership across geographically and politically diverse states, as well as federal agency and research partners, to share promising practices, lessons learned, and solutions to shared challenges in implementing evidence-based overdose prevention and harm reduction activities. Participating states were Colorado, Georgia, Kentucky, Indiana, Michigan, Oregon, Rhode Island, Utah, Vermont, Washington, and Wisconsin.
To better understand how state policymakers are overcoming challenges related to the implementation of harm reduction — and how these examples can inform future progress — NASHP and NAM’s Action Collaborative convened state and federal leaders, research partners, and providers to identify innovative and promising practices, lessons learned, and key opportunities advancing harm reduction at the state level. Key takeaways shared by state leaders and invited experts during the roundtable include (with more detail to follow):
- Establishing common assumptions and definitions of “harm reduction,” including identifying what may be more responsive to specific communities
- Identifying opportunities for state policy and action such as aligning strategies and funding across state agencies, leveraging state data to inform efforts, and providing support to local providers
- Supporting community-centered efforts, including involving people with lived and living experience in decision making, removing barriers for community-based organizations, supporting whole-person approaches, and identifying messages and messengers that resonate with communities
SAMHSA Definition of ‘Harm Reduction’
The Substance Abuse and Mental Health Services Administration’s (SAMHSA) Harm Reduction Framework defines harm reduction as “a practical and transformative approach that incorporates community-driven public health strategies — including prevention, risk reduction, and health promotion — to empower people who use drugs (PWUD) and their families with the choice to live healthier, self-directed, and purpose-filled lives. Harm reduction centers the lived and living experience of PWUD, especially those in underserved communities, in these strategies and the practices that flow from them.”
Defining ‘Harm Reduction’
As was noted by a number of participants, differing interpretations of the meaning of “harm reduction” can complicate the development of shared goals and agendas among state officials, harm reduction organizations, and the people they serve. Depending on context, individuals may use the term “harm reduction” to refer to either a set of clinical services (e.g. naloxone, syringe services, drug-checking equipment, medical and behavioral services) that can vary based on resources, feasibility, or legality, and/or a philosophy that centers individual autonomy, the experience of people who use drugs, and low-barrier access to services. SAMHSA’s definition of harm reduction — which refers to both public health strategies as well as the principles that inform harm reduction approaches — is often cited as a common point of reference for harm reduction discussions, as it bridges both the service and philosophical dimensions of the term.
Establishing common definitions at the onset of a conversation can help lay the foundation for a more productive discussion. Further, recognizing diverging perspectives, power differentials, and stigma and fear of incarceration experienced by people who use drugs is necessary for the productive exchange of ideas and development of trust. As participants noted, the subjectivity of “harm reduction” as it is commonly used can offer both opportunities (e.g., potential for finding common ground) as well as risks (cooption or dilution of the goals of a harm reduction movement rooted in social justice).
“Harm reduction strategies certainly aren’t one-size-fits-all. But I think we can agree that the principles and the social justice framework of harm reduction is applicable to all spaces — that dignity, preservation of health, and autonomy is something that we can all get behind.”
Understanding the Role of State Agencies in Advancing Harm Reduction
While states have an array of legislative, regulatory, fiscal, policy, and programmatic tools to effectively support harm reduction strategies, most harm reduction services are ultimately delivered at the community level. Consequently, state officials — particularly in states with home rule or local control ordinances — often spoke about the important role of state agencies in providing the coordination, data, resources, and technical support to local service providers. Key priorities and elements of success that state agencies play in supporting local harm reduction initiatives included:
- Aligning strategy and funding across state agencies: State officials representing a range of agencies and roles shared successes in creating a holistic array of services to address the needs of people who use drugs by coordinating efforts across agencies and braiding funding streams. They also discussed the importance of thinking strategically across funding streams to address gaps and long-term sustainability, and effectively using both data and input from people who use drugs to effectively fund and sustain programs for individuals most at risk of overdose. Flexible state and opioid settlement funding was also identified as a key opportunity for balancing restrictive federal funds with broader allowability of settlement funding. In Rhode Island, an “emerging issues” set aside within opioid settlement funding allows state leaders to flexibly respond to emerging challenges posed by a changing drug supply, including enabling mobile outreach rescue teams to do wound care and updating naloxone trainings to respond to xylazine within the drug supply.
“Early on when our [State Opioid Response] grants could only address opioids, we were braiding state funding to ensure that regardless of an individual’s substance of choice, we were looking at a holistic continuum for that person. Harm reduction takes that same approach — we braid our funding together to provide as much sustainability as we can.”
- Leveraging data to inform harm reduction efforts: Accurate and timely public health surveillance data collected by state agencies — coupled with ground-level intel collected by harm reduction providers — are critical for deploying limited resources and marshalling effective responses to a rapidly changing drug supply. Several states highlighted overdose fatality reviews, which identify risk factors and circumstances leading to fatal overdoses, as an important resource for identifying opportunities for interventions. State leaders also discussed the importance of establishing meaningful bi-directional sharing of data. Providing timely state-owned data to service providers and actively engaging organizations that serve people who use drugs to understand shifts in the drug supply can support both state and local providers in shifting resources to meet emerging needs.
“I think the focus and attention to data as a common denominator and common focus for our syringe services programs and state injury prevention strategies has made for really impactful work, particularly through our [statewide overview fatality] report that never would have been possible without the dedicated funding for our data infrastructure.”
- Providing resources, guidance, and support to local providers: While each state spoke to unique challenges and roles in navigating political environments, public health authorities, and legal restrictions, state agencies play a common role in contracting with or administering federal grants to local organizations providing harm reduction services. These local organizations have established relationships in their communities, and they are often trusted providers with in-depth understanding of the strengths and complexities of the people they serve. Some states discussed actively moving toward a “clearing house” model — like those in place in California and Oregon — in which states serve as a central resource hub for naloxone, fentanyl test strips, and other harm reduction materials, while others highlighted the state’s role in providing technical assistance and building connections across providers.
“We do try to broker relationships on behalf of our community partners so that they don’t have to navigate quite as much as we do. You almost need to lean into some of the inherent incrementalism that is necessary at a state level so that the folks that we work with in the communities can actually do that radical pragmatic work on the ground.”
Key Strategies (and Lessons Learned) for Supporting Community-Centered Harm Reduction
Regardless of degree of local control or political receptivity to harm reduction, state officials consistently emphasized the importance of hyper-local approaches, coalition building, and community-based organizations in sustaining harm reduction efforts that work within their own communities. Much like harm reduction has a mantra of “meeting people where they are,” state officials described trying to meet communities “where they are,” looking to local leaders and organizations to build trust and support for public health interventions. Key lessons learned for supporting community-centered harm reduction approaches included:
- Involving people with lived and living experience in every step of the decision-making process: State officials consistently emphasized the importance of involving people with lived experience across every aspect of harm reduction — actively working to hire people with lived experience to administer state programs and working alongside people who use drugs to provide input and feedback on services through the lens of their pathways through services and individual encounters with providers. People with lived and living experience engage in state-level decision-making in a variety of ways, including serving on advisory boards, contributing to needs assessments, and working directly in government. Although the increased focus on state agencies hiring people with lived experience has helped build trust with community members, state leaders noted that hiring policies and infrastructure may need to be updated to adequately support people with lived experiences.
“The conversation [on harm reduction] has really started with and been informed all along by people who use drugs, understanding what their health needs are, understanding where the gaps are.”
- Removing barriers for community-based organizations (CBOs): One critical challenge for access to harm reduction services identified by states — particularly within rural areas — is that the small CBOs largely delivering the services generally have small budgets and limited capacity to apply for and manage grant funding. Several states shared ways in which they were working to lower barriers to funding, including examining funding announcements and grant processes for accessibility, allowing greater flexibility or upfront funding for CBOs on minimal budgets, and providing technical assistance to build CBO infrastructure and capacity.
“Oftentimes the organizations in frontier and rural communities are still building support or operating out of the trunks of their cars. They don’t have a full-time grant writer, or they don’t have additional staff to kind of cover all of these different things that a state level application might be asking for. Every decision we make changes the accessibility of those funds and the accessibility of those programs, and ultimately the health for people who use drugs across our state.”
Supporting whole-person approaches: Harkening back to harm reduction’s emphasis on empowering healthier and self-directed lives, state leaders emphasized the need to consider the physical, behavioral, and social needs of populations that may be otherwise disconnected from support systems. While centering the humanity of each individual as they interact with harm reduction services is a core tenet of harm reduction, specific state initiatives such as Washington’s “Health Engagement Hubs” (low-barrier HIV and sexually transmitted infections testing services, urgent primary care screening, and same-day medications for opioid use disorder) provide replicable models for low-barrier access to a range of behavioral, physical, and social services.
“Cultivating community can be really fun. I think food is really one of the big keys’ we bring food to every meeting we go to. That’s not evidence-based, but it was very effective. Sometimes we have to go beyond and really look at the human needs of individuals.”
Finding messages (and messengers) that resonate: State leaders described political and cultural climates that varied in their receptivity to harm reduction principles. However, even states considered progressive on harm reduction highlighted challenges related to community resistance at the local level, including “NIMBY” (not in my backyard) resistance to harm reduction efforts within well-resourced areas and community pushback to new initiatives in rural areas that typically have lower access to services. Many state leaders spoke about their role in building support for harm reduction, including finding ways to message and communicate the public health value in terms that resonate with the communities being served, including faith communities. Others spoke of their role in supporting harm reduction leaders and advocates to build trust and connections within their communities.
“It’s about meeting people where they are and understanding where they are. With some of our churches, the conversation is really about ‘You know that addiction is in your congregation. You know it’s in your neighborhood.’ So, it’s a conversation about how they can react and how they can respond. It’s got to be a grassroots effort. It’s got to be that peer effort. People have to see themselves in those who are talking to them.”
Conclusions
State leaders play a crucial role in shaping harm reduction strategies, and their continued efforts are essential for addressing the complex needs of people who use drugs. As discussions on how and when to implement harm reduction services evolve community by community, the organizations performing lifesaving work on the ground will continue to need robust support in the form of data, resources, and funding. State behavioral health, Medicaid, public health, and social service agencies have a wealth of tools and strategies that, when effectively leveraged, can help build and sustain the necessary infrastructure for harm reduction services. By embracing innovative evidence-based approaches and centering the needs and dignity of people who use drugs, states have the opportunity to significantly reduce overdose deaths, mitigate the harms associated with drug use, and create stronger, healthier communities.
More specific strategies and successful models can be found in NASHP’s case studies of harm reduction approaches in Georgia, Maryland, Utah, and Vermont, offering valuable guidance for states looking to adapt these practices to their unique environments.
Acknowledgments
NASHP and the NAM Action Collaborative would like to thank the state, federal, and expert partners who participated in the “Challenges and Opportunities at the State Level for Harm Reduction” roundtable, including experts from the National Academy of Medicine’s Action Collaborative; federal officials representing the Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services Office of the Assistant Secretary for Health (OASH), Office of National Drug Control Policy (ONDCP), Substance Abuse and Mental Health Services Administration (SAMHSA); as well as state officials from Colorado, Georgia, Indiana, Kentucky, Michigan, Oregon, Rhode Island, Utah, Vermont, and Washington. Comments or insights in this document are not attributed to individuals and do not necessarily represent the views of participating organizations.
NASHP would also like to thank the Foundation for Opioid Response Efforts (FORE) for its support of this roundtable and ongoing work to support state leaders.
Contributors
The following individuals contributed to the roundtable and the development of this report:
National Academy for State Health Policy
- Katie Greene, Director, Public Health
- Rebekah Falkner, Senior Policy Associate
- Maddy Hraber, Senior Research Analyst
National Academy of Medicine’s Action Collaborative on Combatting Substance Use and Opioid Crises
- Aisha Salman, Director
- Noah Duff, Associate Program Officer
