Turning a blind eye: implementation of harm reduction in a transitional programme setting

Background: Substance use and homelessness often overlap. Harm reduction is an evidence-based response to reducing harms of use rather than preventing use per se. While harm reduction is a key principle of Housing First, there has been limited research related to the implementation of harm reduction within programmes that aim to end homelessness.Methods: As part of a community-based research study, we conducted 29 qualitative interviews with staff and residents in two transitional programmes. We used interpretive description to analyze the data and generate practice relevant recommendations.Results: Being abstinent was not a criterion for programme eligibility but participants identified “getting and coming clean” as a programme goal. While harm reduction was official policy and safer use supplies were available, there was a zero tolerance policy for substance use onsite and sanctions for use. In the wake of a persistent culture of abstinence and conflicting policies related to substance use and harm reduction, staff turned a blind eye to substance use in an effort to prevent harms.Conclusion: The findings of this study highlight tensions between abstinence and harm reduction policies and the problems associated with the implementation of harm reduction as waiving requirements for sobriety, distribution of clean supplies, and tolerating discrete use in an environment that restricts use as fulfilling harm reduction mandates. Partial or incomplete implementation of harm reduction and a failure to shift norms related to substance use and harm reduction may contribute to harms of overdose, intoxication and stigma as well as tensions between residents.