https://orcid.org/0000-0002-3402-8189
Figures
Abstract
Background
People who use alcohol and/or drugs (PWUAD) are at higher risk of infectious disease, experiencing stigma, and recurrent hospitalization. Further, they have a higher likelihood of death once hospitalized when compared to people who do not use drugs and/or alcohol. The use of harm reduction strategies within acute care settings has shown promise in alleviating some of the harms experienced by PWUAD. This review aimed to identify and synthesize evidence related to the implementation of harm reduction strategies in acute care settings.
Methods
A scoping review investigating harm reduction strategies implemented in acute care settings for PWUAD was conducted. A search strategy developed by a JBI-trained specialist was used to search five databases (Medline, Embase, CINAHL, PsychInfo and Scopus). Screening of titles, abstracts and full texts, and data extraction was done in duplicate by two independent reviewers. Discrepancies were resolved by consensus or with a third reviewer. Results were reported narratively and in tables. Both patients and healthcare decision makers contributing to the development of the protocol, article screening, synthesis and feedback of results, and the identification of gaps in the literature.
Findings
The database search identified 14,580 titles, with 59 studies included in this review. A variety of intervention modalities including pharmacological, decision support, safer consumption, early overdose detection and turning a blind eye were identified. Reported outcome measures related to safer use, managed use, and conditions of use. Reported barriers and enablers to implementation related to system and organizational factors, patient-provider communication, and patient and provider perspectives.
Conclusion
This review outlines the types of alcohol and/or drug harm reduction strategies, which have been evaluated and/or implemented in acute care settings, the type of outcome measures used in these evaluations and summarizes key barriers and enablers to implementation. This review has the potential to serve as a resource for future harm reduction evaluation and implementation efforts in the context of acute care settings.
Citation: Crowther D, Curran J, Somerville M, Sinclair D, Wozney L, MacPhee S, et al. (2023) Harm reduction strategies in acute care for people who use alcohol and/or drugs: A scoping review. PLoS ONE 18(12): e0294804. https://doi.org/10.1371/journal.pone.0294804
Editor: Ricky N. Bluthenthal, Keck School of Medicine, University of Southern California, UNITED STATES
Received: September 12, 2022; Accepted: November 9, 2023; Published: December 15, 2023
Copyright: © 2023 Crowther et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: This review relies on data from publicly available published literature. Included articles can be identified through the reference list.
Funding: This project is funded by the Strategy for Patient-Oriented Research Evidence Alliance in partnership with the Canadian Institutes of Health Research (https://sporevidencealliance.ca/ Grant number: Q80-21). The grant was awarded to JC. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Substance use is a global health concern, with drug and/or alcohol misuse contributing to over 5% of the global burden of disease [1]. People who use alcohol and/or drugs (PWUAD) are at an increased risk of infectious disease, recurring hospitalizations and death [2, 3]. A recent cross-Canadian study highlighted the increasing potency, unpredictability, and poor quality of unregulated substances placing PWUAD at a greater risk of serious health outcomes, such as poisoning [4]. While better management of substance use is recognized as a priority by national and international governing bodies, there are challenges in supporting PWUAD in the health care system. The complex social and health care needs of PWUAD create significant barriers in accessing care [5]. A 2010 report from the World Health Organization found that mental health care services, which provide substance use supports, are underutilized by PWUAD [1]. In addition to poor access to substance use support across the health and social care system, PWUAD often face stigma when seeking treatment for substance use disorders from health care providers [6]. Improved health system supports are urgently needed to ensure all PWUAD receive adequate care.
Harm reduction is an approach that emphasizes working with people where they are at, rather than focusing solely on drug and alcohol abstinence [7]. Harm reduction strategies are a promising approach for health care providers and health systems to improve the care of PWUAD. Harm reduction strategies such as safe injection sites, needle exchange programs and methadone maintenance treatment have led to reduced deaths from overdose [8], a decrease in human immunodeficiency virus (HIV) infections [9], and fewer hospitalizations [3]. Additionally, the recent decision by the U.S. Department of Health and Human Services’ to remove the X-waiver requirement for the use of medication-assisted treatment for people who use opioids highlight that harm reduction strategies are increasingly being viewed as valid and necessary approaches to care [10]. Despite advances in our understanding of the effectiveness of harm reduction strategies, greater public buy in, and the need for enhanced access to health care services for PWUAD, there are gaps in how and when PWUAD receive care.
While the majority of harm reduction work for PWUAD has been conducted in the community, evidence suggests that hospitals represent an ideal setting for implementing harm reduction strategies [11]. Hospitals are an ideal point of care for PWUAD, with rates of hospital admission and emergency department (ED) utilization higher for PWUAD than the general population [12]. In a qualitative study, PWUAD reported that hospital-based harm reduction strategies would enhance patient-centred care by promoting a culturally safe environment, ensuring timely access to care and prioritizing substance use symptoms [2]. However, health care providers repeatedly report lack of training as being a barrier to providing quality care to PWUAD in the hospital setting [13]. Further, there is little known about how harm reduction strategies are implemented in the inpatient and ED setting, making it challenging to design effective and acceptable interventions for this population. Therefore, the aim of this study is to map the evidence related to the implementation of harm reduction strategies in inpatient and ED settings for PWUAD. This study will answer four research questions:
- What harm reduction strategies have been evaluated to help alleviate negative health outcomes associated with substance use within inpatient settings and EDs?
- What are the commonly reported outcome measures used to evaluate harm reduction strategies and their implementation in these settings?
- How are harm reduction strategies implemented in inpatient settings and EDs?
- What are the reported barriers and enablers to their implementation?
Methods
Study design
This review followed the JBI methodology for scoping reviews [14] and was registered with Open Science Framework (Registration DOI: 10.17605/OSF.IO/P7BHN). This review utilized an integrated knowledge translation (iKT) approach [15]. The methods of the review were previously reported [16] and are briefly summarized below.
Search strategy
The search strategy was designed by a JBI-trained information specialist (LB), in collaboration with the study team and the principle knowledge user (AC), and was peer reviewed by a second research librarian (S1 Table). Five electronic databases were searched for articles: Medline, Embase, CINAHL, PsychInfo and Scopus. An additional search of the grey literature was completed following the systematic approach of Godin et al. [17].
Inclusion criteria
The participants, concept and context framework [14] was used to characterize the research question. Participants included either PWUAD who were accessing acute care settings for any health condition, or participants who provided care to PWUAD in acute care settings. Participants of any race, age and gender were considered for inclusion. Any studies evaluating interventions or implementation of interventions with the goal of reducing harms related to alcohol and/or substance use were considered. Studies utilizing patient reported outcome measures, patient reported experience measures and health outcome measures we considered for inclusion. Studies which took place in acute care settings (e.g., inpatient settings, emergency departments) were also considered. Outpatient services, primary care, community settings, long term inpatient settings (e.g., nursing homes, prisons) were excluded. Opinion papers, commentaries, newspaper articles were not included. Evidence syntheses were not included, however, the reference lists of any relevant evidence synthesis were searched for applicable articles. Grey literature sources (e.g., policy documents, unpublished program evaluations) were searched and assessed for eligibility. Articles were only included if they reported in English and the full text was available.
Screening approach
Articles retrieved from the search were managed using Covidence [18]. Following de-duplication, articles were independently screened by two reviewers, starting with titles and abstracts, and followed by full text papers. Any disagreements between reviewers were resolved through discussion or by consultation with the research team.
Data extraction
Data were extracted from each included study using a predetermined data extraction form. The data extraction form was pilot tested with six team members using one of the included studies. The team met to review any discrepancies in data extraction and to refine the data extraction tool. The data from each study were independently extracted in duplicate. The team met regularly to discuss any concerns related to the data extraction process until data extraction was complete.
Extracted data included characteristic and demographic details such as country, year of publication, study design, objective, participant sample, and setting characteristics. Intervention details included the type and length of intervention, the population targeted by the intervention, what type of drug use the intervention addressed and the reported outcomes measures. Implementation details included whether provider training, sustainability, quality and performance, cost, communication or participant compensation was mentioned. Additionally, data related to reported barriers or enablers to implementation was extracted.
Data synthesis and presentation
Extracted data were synthesized into four major sections (population characteristics, intervention characteristics, characteristics of outcome measures and implementation characteristics) using tables, figures and narrative description. The reporting and presentation of this review followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses for Scoping Reviews (PRISMA-ScR) (S2 Table) [19].
To further elucidate the harm reduction principles present in each intervention approach, the interventions were coded by Hawk et al.’s [20] six harm reduction principles for healthcare settings. These include: humanism, pragmatism, individualism, autonomy, incrementalism and accountability without termination. Interventions which contained pharmacological approaches were coded under pragmatism. Interventions which provided multiple services, tailored their services to meet patient needs and allowed shared decision making in terms of goal setting were coded to individualism. Interventions which supported patients during readmission, provided follow-up and ongoing care and aimed to “meet patients where they are” were coded to incrementalism. Interventions which provided information and/or referrals to additional services and care and allowed patients to make decisions related to their care were coded under autonomy. Interventions which provided education to patients and caregivers related to risks associated with continued drug use and overdose were coded to accountability without termination. Finally, interventions which enacted system changes and emphasized empathy, support, understanding and compassion were coded under humanism.
Barriers and enablers to implementation were organized based on the following pre-defined categories: system and organizational factors, provider-patient communication, patient perceptions and provider perceptions. System and organizational factors encompass barriers/enablers related to law and policy, funding and resources, and structural and environmental factors such availability of hospital space and the physical location of a hospital. Provider-patient communication encompass barriers/enablers related to communication between providers and patients. Finally, patient perceptions and provider perceptions encompass barrers/enablers related to how patient and providers perceive the harm reduction strategy.
Patient, decision maker and community organization engagement
Patients and healthcare decision makers were engaged throughout this review to: a) ensure that our research questions aligned with priorities relevant to all partners; b) allow partners with lived experiences of harm reduction programs to contextualize our findings and; c) inform the identification of key gaps in the literature that may have been overlooked without their engagement.
In addition to patients and healthcare decision makers, the preliminary findings of this review were also shared with members of a community organization which provides harm reduction services as part of their community health promotion and disease prevention mandate. Individuals from this organization were given the opportunity to provide feedback and comment on the findings, drawing on their own experiences of receiving, providing and advocating for care. This feedback was used to interpret review findings and integrated into the discussion. Reporting of engagement adhered to the Guidance for Reporting Involvement of Patients and the Public revised short form (GRIPP2-SF) checklist (S3 Table) [21].
Critical appraisal
All studies were critically appraised by two independent reviewers using the Mixed Methods Appraisal Tool (MMAT) [22]. The MMAT can be applied to a range of study designs and is therefore useful for scoping reviews. Based on the quality of the report, each article received a score ranging from 0 to 5. Differences in scoring were resolved by consensus or a third reviewer. Scores are listed in Table 1.
Results
Included studies
The database search returned 36,264 records, with 14,580 titles remaining after deduplication. No additional relevant articles were found through the grey literature search. A total of 549 full texts were assessed for eligibility, with 59 studies meeting the inclusion criteria for this review. Our patient partner screened 982 titles and abstracts. An overview of the screening process can be found in Fig 1 (Preferred Reporting Items for Systematic and Meta Analyses (PRISMA) Flow Diagram).
General characteristics of included studies
Included studies utilized a range of study designs with retrospective chart reviews (n = 14) [23–36] being the most common, followed by randomized controlled trials (n = 10) [37–46], cross-sectional designs (n = 10) [47–56], case reports (n = 9) [57–65], qualitative studies (n = 5) [66–70], mixed methods studies (n = 5) [71–75], prospective cohort design (n = 2) [76, 77], prospective observational design (n = 1) [78], pre-/post-test design (n = 1) [79], interrupted time series design (n = 1) [80], and quasi experimental: non-equivalent group design (n = 1) [81]. The majority of included articles were conducted in the United States (n = 39) [24–42, 44, 45, 47–50, 52–54, 61, 63, 66, 70–73, 75, 77, 80, 81], followed by Canada (n = 14) [23, 51, 55–59, 62, 64, 65, 67, 68, 74, 79], Australia (n = 3) [46, 69, 78], Netherlands (n = 2) [43, 60], and Sweden (n = 1) [76]. The majority of articles were published between 2019–2021 (n = 39) [23–38, 42, 45, 48–50, 52–56, 58, 59, 61, 63, 66–68, 70, 72–74, 78, 79], while the remaining were published between 1999 and 2018 (n = 20) [39–41, 43, 44, 46, 47, 51, 57, 60, 62, 64, 65, 69, 71, 75–77, 80, 81] (Table 1).
The reported sample size across studies ranged from 1 to 30,263. The majority of studies targeted patient populations alone (n = 46) [23–28, 30, 32–42, 44–52, 55, 56, 58–60, 62–68, 74–79, 81], followed by both patients and health care providers (HCPs) (n = 8) [31, 43, 54, 61, 69–71, 80], patients and caregivers (n = 3) [29, 57, 73] and HCPs alone (n = 2) [53, 72].
Intervention characteristics
Thirty-two of the included articles reported delivering interventions in EDs [25, 27, 28, 30–34, 37, 40, 41, 44, 46, 47, 49, 51, 53–55, 61, 63, 66, 69, 71–76, 78, 80, 81], while twenty-two studies [23, 24, 26, 29, 35, 36, 38, 39, 43, 45, 50, 56–60, 64, 65, 68, 70, 77, 79] took place in inpatient settings and five studies [42, 48, 52, 62, 67] included both ED and inpatient settings. Of the articles that delivered interventions in inpatient settings, specific departments included general medicine (n = 15) [23, 24, 29, 35, 36, 38, 39, 45, 50, 56–58, 68, 70, 77], critical care (n = 2) [60, 65], psychiatric, mental health or pain programs (n = 3) [43, 59, 79], and rehabilitation programs (n = 2) [26, 64].
Interventions targeted several types of drug use, including opioid use (n = 31) [24–32, 35, 37, 39, 47–55, 57, 61–63, 65, 66, 70, 72, 74, 75], alcohol use (n = 8) [40, 41, 44, 56, 68, 69, 71, 76], amphetamine use (n = 1) [78] or cannabis use (n = 1) [60]. Interventions which were not targeted to address a specific drug or targeted poly-drug use were categorized under substance use and represented 18 of the included articles [23, 33, 34, 36, 38, 42, 43, 45, 46, 58, 59, 64, 67, 73, 77, 79–81]. Interventions targeting alcohol and opioid use were predominantly set in the ED, whereas interventions targeting substance use were predominantly set in inpatient settings.
Interventions which targeted patients and caregivers did not report adapting intervention components based on the presence of the caregiver, only that caregivers were welcome to participate in the intervention alongside patients. Interventions which targeted HCP populations primarily utilized education or clinical pathway decision support materials. Only two articles [31, 70] utilized policy change as a strategy, and those interventions were targeted at both patient and HCP populations.
This review identified interventions which used several different modalities to reduce harms associated with drug and/or alcohol use, these included pharmacological (n = 4) [56, 60, 65, 68], decision support (n = 22) [29, 34, 36, 38, 40–46, 52, 53, 69, 71–73, 76, 78–81], safer consumption (n = 3) [23, 58, 67], early overdose detection (n = 1) [61] and turning a blind eye (n = 1) [64]. Twenty-eight articles [24–28, 30–33, 35, 37, 39, 47–51, 54, 55, 57, 59, 62, 63, 66, 70, 74, 75, 77] combined pharmacological and decision support approaches, with most of these being related to naloxone education and distribution, and primarily occurring in the ED. Other pharmacological strategies included the use of buprenorphine, methadone, cannabinoid derivatives and alcohol.
Decision support covered a range of intervention approaches including education, training, counselling, referral, and clinical decision supports. The use of brief interventions was a common approach (n = 10) [40, 41, 44, 46, 69, 71, 73, 76, 80, 81] within the decision support category. These interventions exclusively occurred in the emergency departments and addressed either alcohol use (n = 6) [40, 41, 44, 69, 76, 81] or substance use (n = 4) [46, 73, 80, 81]. The use of peer recovery supports (n = 9) [30, 31, 34, 38, 52, 59, 63, 70, 75] and specialized teams (n = 4) [24, 36, 77, 79] were also common and targeted opioid and substance use exclusively.
Safer consumption approaches included supervised consumption sites (n = 2) [58, 67] and needle distribution programs (n = 1) [23]. Only one article [61] reported using early overdose protection and the intervention was in the form of an emergency department bathroom sensor that detected when individuals remained immobile for a period of time. Only one article [64] reported utilizing the turning a blind eye approach, which involved ignoring patient drug use at a park across the street from the facility. Table 1 presents a full overview of intervention characteristics.
All of the included interventions utilized at least two of Hawk et al.’s harm reduction principles, with pragmatism being the most common (n = 34) [23–28, 30–33, 35, 37–39, 47–51, 53–58, 60, 63, 66, 68, 70, 74–76, 78], followed by individualism (n = 33) [24, 25, 29–31, 33, 36, 38, 40–44, 46, 52, 57–59, 62–65, 67, 70–75, 77, 79–81], incrementalism (n = 24) [24, 28, 31, 34, 36, 38–43, 45, 53, 57–59, 61, 62, 65, 67, 71, 73, 77, 79], autonomy (n = 19) [27, 29, 30, 35, 37, 43, 44, 46, 47, 50, 54, 59, 64, 66, 67, 70, 75, 80, 81], accountability without termination (n = 19) [23, 24, 26, 30, 37, 39–41, 44, 46–48, 50, 55, 63, 64, 68, 76, 80] and humanism (n = 14) [28, 34, 36, 40, 41, 44, 45, 52, 58, 59, 61, 65, 72, 79] (Table 2).
Characteristics of outcome measures
Reported outcome measures were organized into four categories, based on those defined by G. Alan Marlatt (1996) and the National Harm Reduction Coalition: [82, 83] abstinence, safer use, managed use, and conditions of use and use itself (Table 3). Safer use was comprised of outcome measures related to pharmacological distribution and/or acceptance, syringe acceptance, treatment implementation and presence of safe consumption site. Safer use outcome measures were used most frequently in ED settings. Managed use was comprised of outcome measures related to referral to and/or acceptance of care, satisfaction and/or experience of care and HCP follow-up. Conditions of use and use itself included measures related to mortality, readmission rates, leaving against medical advice (AMA), adverse events, length of stay and frequency of use of drugs and/or alcohol. One article, Schreyer et al., 2020 [61], did not report outcome measures related to these categories, however they did report outcome measures related to implementation. No studies reported on abstinence.
Characteristics of intervention implementation
Twenty-one articles reported at least one study aim related to measuring intervention implementation, with two of these described as quality improvement studies. The most commonly reported factor related to implementation was provider training (n = 33) [24, 26–28, 31–33, 35, 37–41, 43–45, 47, 48, 50, 52–54, 57, 61, 64, 69–71, 73, 75, 78, 80, 81], followed by sustainability (n = 21) [26, 30, 32, 33, 35, 39, 40, 47, 48, 53, 54, 61–64, 67, 70, 72, 73, 80, 81], providing a honorarium/credit for participants (n = 15) [32, 37–41, 43–45, 51, 67–69, 74, 77], quality and performance (n = 15) [29, 31, 33–35, 40–42, 44, 54, 56, 61, 70, 73, 81], cost (n = 14) [32, 34, 35, 42, 47, 48, 53, 54, 61, 63, 66, 70, 80, 81], and communication and marketing (n = 6) [28, 54, 56, 66, 67, 72]. Less than half of the articles reported implementation factors related to cost, sustainability, communication and marketing, quality and performance, and honorarium/credit for participants.
Reported barriers and enablers to implementation
Thirty-eight (64%) of the included articles reported at least one barrier and/or enabler to implementation (Table 4). The most commonly reported barriers and enablers were related to system and organizational factors. Factors related to patient-provider communication, patient perspectives and provider perspectives were also reported.
Quality appraisal
Overall the quality of the included studies was moderate to high with 2% (n = 1) [66] scoring 0, 3% (n = 2) [39, 70] scoring 1, 8% (n = 5) [28, 43, 46, 71, 72] scoring 2, 36% (n = 21) [24, 31, 35, 38, 44, 50, 53, 56–62, 64, 65, 69, 74, 77, 79, 80] scoring 3, 29% (n = 17) [23, 25, 27, 29, 33, 34, 36, 37, 45, 47–49, 54, 63, 75, 76, 81] scoring 4, and 22% (n = 13) [26, 30, 32, 40–42, 51, 52, 55, 67, 68, 73, 78] scoring 5 (Table 1).
Partner reflections on gaps in the literature
The following provides additional reflections from our patient and decision maker community partners on gaps identified through our review (Table 5). This section aims to share further contextual details that may be useful to researchers and policy makers. Consultations with partners took place after the preliminary data chart was developed.
Discussion
Overall, this review identified a diverse range of harm reduction strategies, which had been evaluated and implemented in different types of acute health care settings. Strategies were primarily implemented in the ED, followed by a range of inpatient settings such as general medicine, rehabilitation, critical care, and mental health or pain teams. The identified outcome measures used for strategy evaluation were related to safe use, managed use and use itself. Finally, the included studies did not report detailed implementation strategies or the use of frameworks to guide implementation. Factors related to implementation were inconsistently reported across articles, however a range of barriers and enablers were reported, albeit primarily related to system and organizational level factors.
Our findings suggest that there is a growing interest in the implementation of harm reduction strategies within acute care settings, as publications on this subject have dramatically increased within the last three years. While EDs have typically not considered such programs to be part of their mandate, calls for the use of harm reduction strategies within EDs have begun to emerge [84–86]. This apparent willingness to implement such strategies in ED settings is promising for the success of future projects, particularly given that PWUD seeking health care are more likely to do so via EDs [87]. However, while there appears to be growing support within EDs, we identified a limited number of studies which were set in non-mental health inpatient units. Training and harm reduction programs within these health service settings have the potential to be a valuable resource and reduce stigma. As such, further research exploring implementing programs in non-mental health inpatient settings are needed.
While this review identified a diverse range of harm reduction strategies, additional strategies currently being used in other settings were notably absent. Managing and providing nutrition for PWUAD [88], providing housing resources [89], drug checking technology to allow PWUAD to ascertain unknown chemicals in their street drugs [90, 91], and providing off label prescriptions (i.e., safe supply) to PWUAD [92] are all increasingly being considered as important harm reduction approaches, yet to our knowledge they have not been evaluated for use in EDs and/or inpatient settings. Additionally, our patient partners noted that providing education to PWUAD that improves their understanding of the health services they access could help set appropriate expectations on what kind of care they can expect to receive, potentially mitigating instances of leaving against medical advice and/or distrust of HCPs and health services. In the context of other healthcare services, educational strategies focused on health literacy have been shown to strengthen patient engagement [93] and improve patient health outcomes [94] and should therefore be considered as a potential avenue for additional harm reduction approaches.
Most outcome measures included in this review were designed to capture data related to program uptake, adherence and real world efficacy. As such, these outcome measures have the potential to inform the allocation of program resources and the tailoring of programs to specific contexts, making them valuable in informing program implementation, program evaluation and quality improvement projects. Of note, measurement of the satisfaction/experience of care was utilized in only 22% (n = 13) of the included studies. PWUAD dissatisfaction and poor experiences of care has been associated with stigma related to drug use, and this type of stigma has been identified as a factor in increased risk of leaving against medical advice and poor health outcomes [6, 95]. Additionally, abuse and suffering experienced as a result of accessing healthcare is more likely among stigmatized populations, is poorly understood and often goes unreported [96]. Measures of satisfaction or experience of care which are patient-oriented could be a valuable tool in widening our understanding of and managing these issues during program implementation and evaluation, potentially leading to improved patient outcomes.
While there were studies included in this review that reported implementation factors related to communication and marketing, cost, quality and performance, sustainability, and provider training, none of the studies utilized validated frameworks to inform their approach to implementation. Given the myriad of factors that can influence effective implementation [97] (e.g., rural/urban setting, available resources, level of personnel training, and patient/provider beliefs and attitudes) a greater emphasis on developing implementation strategies prior to implementation could help improve the effectiveness of approaches. This review also identified a range of barriers and enablers to implementation, most of which related to system and organizational level factors. Absent from these barriers and enablers was public awareness and opinion of harm reduction approaches. Negative public opinion of PWUAD and of harm reduction strategies can negatively impact the perceived value of certain strategies [98]. Media reporting of harm reduction services has the potential to reduce stigma against PWUAD and increase acceptance of harm reduction approaches [99]. In settings where HCP buy-in is a barrier, utilizing public messaging and information campaigns of the benefits of harm reduction services could help improve uptake by HCPs.
Limitations
We included studies based on our definition of a harm reduction approach. Harm reduction is a broad philosophy encompassing a range of ideas and as such our definition may have limited the inclusion of some approaches. However, our team included a harm reduction specialist who was consulted throughout the process to ensure that we were comprehensive in our inclusion of approaches. This review sought to identify and describe the scope of the available literature and as such providing definitive recommendations related to the implementation and/or evaluation of specific programs was not possible. Further, this review is not a meta-analysis and as such, the generalizability of the results within each study was not assessed. Our approach to data synthesis involved coding extracted data into validated frameworks (e.g., Hawk’s harm reduction principles), this process involved some level of subjective interpretation. To mitigate these effects, coding was done independently by two reviewers who then resolved any discrepancies through consensus or consultation with the research team. Our partners were engaged throughout this review to help contextualize our findings and ensure that we maintained a patient-centered approach in our methodology and reporting. Partner reflections should only be considered as potential avenues for future research and not definitive conclusions.
Conclusion
This scoping review sought to map and describe drug and alcohol-related harm reduction strategies, which have been evaluated in inpatient settings and EDs, the outcome measures used to evaluate these strategies, and implementation characteristics. We identified several gaps in the types and targets of potentially beneficial strategies, outcome measures, and factors related to the implementation of harm reduction strategies for PWUAD. Patient partners provided valuable insight throughout the review process to enrich study findings. The findings of this review may inform future research and will serve as a resource for harm reduction evaluation and implementation efforts in the context of EDs and inpatient settings.
Supporting information
S2 Table. The Preferred Reporting Items for Systematic Reviews and Meta-analyses for Scoping Reviews checklist.
JBI = Joanna Briggs Institute; PRISMA-ScR = Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews.* Where sources of evidence (see second footnote) are compiled from, such as bibliographic databases, social media platforms, and Web sites.† A more inclusive/heterogeneous term used to account for the different types of evidence or data sources (e.g., quantitative and/or qualitative research, expert opinion, and policy documents) that may be eligible in a scoping review as opposed to only studies. This is not to be confused with information sources (see first footnote). ‡ The frameworks by Arksey and O’Malley (6) and Levac and colleagues (7) and the JBI guidance (4, 5) refer to the process of data extraction in a scoping review as data charting.§ The process of systematically examining research evidence to assess its validity, results, and relevance before using it to inform a decision. This term is used for items 12 and 19 instead of "risk of bias" (which is more applicable to systematic reviews of interventions) to include and acknowledge the various sources of evidence that may be used in a scoping review (e.g., quantitative and/or qualitative research, expert opinion, and policy document) [19].
https://doi.org/10.1371/journal.pone.0294804.s002
(PDF)
S3 Table. The Guidance for Reporting Involvement of Patients and the Public revised short form (GRIPP2-SF) checklist [21].
https://doi.org/10.1371/journal.pone.0294804.s003
(DOCX)
Acknowledgments
We would like to acknowledge the support of our research team, specifically Sharon Amey for her work on this project. We would like to thank our partners, Morgan Joudrey, Amanda Hudson-Frigault, Lesley Huska and Caroline Jose. We would also like to acknowledge the Nova Scotia Health Authority, IWK Health, St Michael’s Hospital, the Toronto Opioid Action Network Implementation Committee and the Strategy for Patient-Oriented Research Evidence Alliance for their support of this project.
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