Fifteen interviews were conducted across five different VAMCs. Participants served a variety of roles within the VA, including clinical pharmacists (n = 3), primary care clinicians (n = 3), hospitalists and emergency room clinicians (n = 2), social workers (n = 5), and directors of addiction and mental health services (n = 2). Relevant findings were identified in each of the PRISM domains (Table 1).
Barriers: Multiple barriers were identified within the external environment. Most significantly, participants cited long-standing federal and state policies prohibiting key elements of harm reduction services, including SSPs, as having slowed uptake of harm reduction services and influenced organizational attitudes around harm reduction. Providers thought that current policies reinforced stigma around substance use and the culture emphasized treatment and abstinence rather than safe substance use.
Participants also described limited knowledge of local, community-based harm reduction resources. Only one participant reported existing relationships with community-based harm reduction organizations and relied on referrals to these outside programs to get Veterans access to SSPs and other resources. No other participants reported similar relationships. Additionally, several providers noted that community outreach to Veterans was scarce; all participants serving a predominantly rural population noted this challenge.
Facilitators: Participants described few facilitators from the external environment. Some were encouraged by recent policy changes, such as those that allow federal funds to be used to purchase harm reduction resources, and the inclusion of harm reduction in federal drug policy. One participant with existing relationships to community-based harm reduction programs cited these relationships as significant facilitators for the provision of harm reduction services to their patients.
Potential Solutions/Suggested Strategies to Improve Uptake: Communication and education about the changes in federal policies regulating the use of federal funds to purchase harm reducing resources, like sterile syringes, was thought to be critical. One participant also recommended additional policy changes to ease restrictions around the prescription of buprenorphine and create systemic infrastructure to support the distribution of naloxone, syringes, and other harm reduction resources. Participants also recommended identifying points of contact within healthcare settings to build relationships with community-based harm reduction services.
Implementation and Sustainability Infrastructure
Barriers: Participants described limited infrastructure and a lack of dedicated funding and time to support provision of harm reduction services within the VA. Lack of processes and mechanisms to systematically identify and track Veterans who would be most likely to benefit from harm reduction services were frequently noted as a significant barrier. Moreover, if Veterans were identified, access to harm reduction services was further hindered by care fragmentation and the limited availability of integrated services. Participants explained that access to harm reduction resources, such as sterile syringes or the prescription of MOUD, was highly variable, both within the VA and in local communities, and the lack of a streamlined referral process was burdensome. As such, while most providers reported the ability to offer naloxone, they reported that the prescription workflow was repetitive and cumbersome. Finally, many participants noted that stigma around substance use needed to be addressed at a systemic level.
Facilitators: The VA’s initiative to become a High-Reliability Organization (HRO)(33) was identified as a facilitator, in that programs could leverage existing infrastructure provided by the HRO initiative to address substance use-related stigma at both the system and provider levels. For example, at one site, HRO patient safety goals were framed in terms of “safety for all”, including access to naloxone and MOUD. One site also reported the benefits of integrating a brief drug use screening questionnaire into routine workflows to identify patients who could potentially benefit from intervention.
Potential Solutions/Suggested Strategies to Improve Uptake: Multiple participants highlighted the need for workload credit for the provision of harm reduction services. Participants also recommended standardized workflows and clear role delineation, including the use of peer support specialists, to facilitate patient engagement and follow up. Several recommended leveraging existing information technology within the VA, including the ability to mine electronic medical records to create dashboards and the use of automated reminder systems, to facilitate outreach and engagement efforts for at-risk Veterans. Utilizing information technology to identify patients using substances and to streamline the provision of harm reduction services, such as order sets for infection screening, automating naloxone prescription refills, and quick referrals for MOUD was highlighted as a potential solution.
Overall, participants identified few harm reduction resources currently available to Veterans, with naloxone prescriptions and access to social work resources to help address some social determinants of health the most common themes. A few participants also cited relatively easy access to behavioral health services, which can facilitate access to MOUD or other treatment options if the Veteran is interested in treatment. Clinical pharmacists and social workers were most likely to mention that they provide some basic substance use education and harm reduction information to Veterans, but typically as part of a more traditional substance use treatment program. Some clinical pharmacists also described the role they play in educating providers about substance use and use behaviors and in supporting providers around the prescription and distribution of medications that can reduce harms associated with use, such as naloxone and MOUD.
Barriers: Providers identified many organizational characteristics as barriers. Organizational complexity and lack of standardized processes within the VHA was identified as a barrier. Participants reported that access to various harm reduction services varied significantly within the organization; for example, services and supplies available at the main hospital are not always available at community-based outpatient clinics. Most providers also reported little experience and training around harm reduction and substance use in general, which limited the care and resources that they were able to offer patients.
Facilitators: Participants from a few sites cited local level clinical champions and early adopters who were taking the initiative to provide harm reduction services at their local facility. Some sites also described initiatives to increase the number of buprenorphine-naloxone prescribers to expand access to MOUD. Participants also noted the robust social support resources that the VHA provides, including housing resources, comprehensive behavioral health care, job training, and other programs to address social determinants of health.
One site described a novel program designed to identify and support Veterans at risk for acute withdrawal during their hospitalization as a significant facilitator. This site offered Veterans an opportunity to utilize MOUD during their hospitalization to address acute withdrawal and to initiate MOUD in a monitored setting. Veterans at this site also had the opportunity to meet with a behavioral health social worker who would come to bedside to discuss Veterans’ goals and treatment preferences.
Potential Solutions/Suggested Strategies to Improve Uptake: Participants highlighted the need for provider training and educational initiatives around substance use, harm reduction, and patient-centered care, and recommended that these trainings be dynamic and interactive to encourage participation.
Organizational Perspective of the Intervention
Although some providers identified personal values that conflicted with the ethos of harm reduction, most participants were generally supportive of offering a comprehensive bundle of harm reduction services to Veterans who use substances to help protect Veterans’ health, prevent fatal overdose, and support engagement in care.
Barriers: Many participants discussed an overall lack of ownership of harm reduction services at the organizational level and that harm reduction services were not prioritized. Some of the physician participants reported a reluctance to discuss substance use with Veterans due to their own limited knowledge of harm reduction, unfamiliarity with local resources, and time constraints. Other participants raised concerns that some care providers may not support harm reduction strategies and may prefer to offer abstinence-only substance use treatment, and that existing mechanisms were focused on medication and abstinence-based treatment, which may not be consistent with Veterans’ goals. Finally, some providers identified concerns regarding potential liability if patients were to overdose or incur other harms after utilizing sterile syringes or accessing SSPs.
Facilitators: A few participants identified their own knowledge of substances, substance use behavior, and risk reduction strategies as facilitators at the provider level. Additionally, the few participants currently providing harm reduction services highlighted the strong evidence base surrounding both harm reduction services and SUD treatment.
Potential Solutions/Suggested Strategies to Improve Uptake: Participants recommended a multi-pronged and dynamic approach to implementing harm reduction programming, including in-person, interactive trainings for frontline staff, incorporating program rollout into departmental provider meetings, and improving communication between patients and providers, with a goal of building capacity for both parties.
Barriers: Participants highlighted the impact of many social determinants of health, including neighborhood and physical environment, employment and associated financial instability, access to transportation, and social support networks, in addition to history of trauma or competing medical needs. Notably, some participants underscored patients’ possible mistrust of the VHA or perceived institutional betrayal by the VHA and/or military as potential barriers for patients to utilize harm reduction services or medical care in general.
Facilitators: Participants noted that many Veterans are already well-connected to healthcare and other services within the VHA and thought that positive relationships with healthcare providers and with the VHA as a whole could be leveraged to facilitate patients’ utilization of harm reduction services. Additionally, providers suggested that many Veterans found value in protecting their own health and that those values would facilitate utilizing harm reduction services.
Potential Solutions/Suggested Strategies to Improve Uptake: The providers interviewed recommended that future harm reduction programs emphasize outreach to particularly marginalized communities, such as patients experiencing homelessness or living in rural areas. Several providers also suggested that peer support specialists could help to bridge the gap between patients and the healthcare system.
Patient Perspective of the Intervention
Barriers: Providers suggested that the inconvenience and inaccessibility of existing harm reduction services likely serve as barriers for Veterans, as current programs are mostly concentrated at larger, mostly urban VAMCs and few services are available in rural areas. Additionally, participants postulated that some Veterans may be concerned that disclosure of substance use could potentially jeopardize Veterans’ access to housing or other benefits within the VHA or that it would impact the quality of care that the Veteran received.
Facilitators: Providers reported that patients’ own experience and knowledge around substance use and their potential willingness to discuss substance use and harm reduction with their care providers would be facilitators from the patient perspective.
Potential Solutions/Suggested Strategies to Improve Uptake: Providers recommended that future harm reduction interventions be low-barrier, patient-centered, incorporate patient feedback, and address potential concerns around service eligibility. Likewise, providers posited that patient navigation support and coordinated outreach and follow-up efforts would facilitate patient engagement and retention.
The Consolidated Framework for Implementation Research - Expert Recommendations for Implementing Change (CFIR – ERIC) tool was developed to identify appropriate implementation strategies to address contextual barriers.(31) Potential solutions identified by participants mapped to implementation strategies are presented in Table 2. Coalition-building and involvement of executives and opinion leaders could address many of the political and regulatory barriers to the integration of harm reduction services into the VHA. Likewise, the revision of professional roles and changes to workflows and incentive structures would facilitate the integration and sustainability of harm reduction services into existing structures and the development of dynamic, collaborative trainings and educational materials would engage and coach staff. Tailoring the intervention to each local community, involving Veterans and their families in the design and the implementation of the intervention, and continuously eliciting feedback and making improvements could help to engage Veterans, promote uptake of harm reduction services, and build trust. Finally, executive leadership, local champions, and media campaigns could be utilized to begin to address stigma around substance use and to promote the integration of harm reduction services. By building capacity of local champions, leveraging existing structures within the VHA, and applying these implementation strategies, a comprehensive bundle of harm reduction services could be successfully integrated into the VHA.