Perspectives on harm reduction kit implementation in heterogeneous outpatient clinics

The evolving U.S. drug market has fueled a public health crisis with rising drug use-associated morbidity and mortality, revealing a mismatch between current abstinence-based addiction care and the needs of people who use drugs (PWUD) to access evidence-based harm reduction services (HRS). Co-locating HRS into outpatient clinics could reduce mortality and improve clinical outcomes. We investigated barriers and facilitators of HRS implementation through kit distribution at three heterogenous outpatient addiction clinics using pre- and post-implementation focus groups. Using a qualitative description approach, we conducted 1-hour virtual focus groups and individual interviews with clinic staff and providers both pre- and post-implementation of kit distribution. Interview guides were based on the Consolidated Framework for Implementation Research to assess anticipated and actual implementation barriers and facilitators. Interviews were analyzed using thematic analysis. Five providers and six staff participated in pre-implementation data collection. Dominant themes pre-implementation included participant enthusiasm for HRS integration and anticipated barriers of personal knowledge and external stigma against PWUD. Six providers and five staff participated post-implementation. Participants reported successful kit implementation with few actual barriers, though external stigma at the individual, health system, and community levels, along with issues related to patient use and interactions with child protective services, law enforcement, and pharmacies, occasionally disrupted the process. The lack of sustainable funding for supplies and labor emerged as a primary concern for long-term sustainability, with clinics actively seeking alternative funding sources. Implementation of HRS in outpatient addiction clinics was well-received by providers and staff and supported by pre-implementation trainings, site champions, and favorable implementation environments. Further efforts are needed to reduce stigma in the greater community and achieve sustainable funding for HRS. Harm reduction kits were implemented in three outpatient addiction clinics to examine barriers and facilitators to integrating harm reduction services (HRS). Pre-implementation, clinic providers and staff were eager to integrate HRS at their sites, though they anticipated logistical challenges incorporating these into existing busy workflows. External stigma from health care systems, law enforcement, and public towards people who use drugs remained significant post-implementation barriers; however, education and advocacy from site champions and clinic providers and staff helped mitigate these challenges. While clinics were keen to continue and expand HRS, a key post-implementation challenge was securing the financial sustainability for the services.