Harm Reduction Workforce, Behavioral Health, and Service Delivery: A Cross Sectional Study

doi:10.21203/rs.3.rs-3088323/v1

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Research Article

Harm Reduction Workforce, Behavioral Health, and Service Delivery: A Cross Sectional Study

https://doi.org/10.21203/rs.3.rs-3088323/v1

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Journal Publication

published 10 Feb, 2024

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Background

Despite recent financial and policy support for harm reduction, little is known about the harm reduction workforce—the specific types of workers within organizations who design, implement, and actualize harm reduction services. This exploratory mixed-methods study asked: (1) Who constitutes the harm reduction workforce? (2) Who provides behavioral health services within harm reduction organizations? (3) Do referrals differ by type of harm reduction worker?

Methods

Purposive sampling techniques were used to distribute an electronic survey to U.S.-based harm reduction organizations. Descriptive statistics were conducted. Multivariate binary logistic regression models examined the associations (a) between the odds of the referral processes at harm reduction organizations and (b) between the provision of behavioral health services and distinct types of organizational staff. Qualitative data were analyzed using a hybrid approach of inductive and thematic analysis.

Results

Data from 41 states and Washington D.C. were collected (N = 168; 48% response rate). Four primary types of workers were identified: community health/peer specialists (87%); medical/nursing staff (55%); behavioral health (49%); and others (34%). About 43% of organizations had a formal referral process; among these, only 32% had follow-up protocols. Qualitative findings highlighted the broad spectrum of behavioral health services offered and a broad behavioral health workforce heavily reliant on peers. Unadjusted results from multivariate models found that harm reduction organizations were more than 5 times more likely (95% CI=[1.91, 13.38]) to have a formal referral process and 6 times more likely (95% CI=[1.74, 21.52]) to have follow-up processes when behavioral health services were embedded. Organizations were more than two times more likely (95% CI=[1.09, 4.46]) to have a formal referral process and 2.36 (95% CI=[1.11, 5.0]) times more likely to have follow-up processes for referrals when behavioral health providers were included.

Conclusions

The composition of the harm reduction workforce is occupationally diverse. Understanding the types of services offered, as well as the workforce who provides those services, offers valuable insights into staffing and service delivery needs of frontline organizations working to reduce morbidity and mortality among those who use substances. Workforce considerations within harm reduction organizations are increasingly important as harm reduction services continue to expand.

Harm reduction

behavioral health

workforce

peer support

referrals to service

survey

organization

syringe services program

Harm reduction is an evidence-based approach to mitigate the effects of substance use through prevention, treatment, and recovery.^1–3 Harm reduction aims to reduce the negative personal, social, public health, and economic impacts associated with substance use at individual and community levels.^4,5 First implemented in the Netherlands and the U.K., harm reduction was later acknowledged by the U.S. as a public heath response to the AIDS epidemic and harms associated with injection drug use in the 1980s, which was and remains a controversial decision² with opponents primary concern being that harm reduction condones elicit behavior. As an alternative to the moralistic, punitive understandings of drug use and addiction, harm reduction has been described as a bottom-up, or grassroots approach to engaging people who use drugs (p. 779).²

Despite long-standing criticism towards harm reduction strategies and policies by some policy makers, administrators, and those enforcing U.S. drug-related policies⁶, harm reduction programs and policies have proven to be highly effective public health responses to reducing rates of infectious diseases, overdoses, morbidity, and mortality among those who use substances.^1,2,5 Moreover, harm reduction programs provide a critical gateway for important recovery resources, health, behavioral healthcare, and substance misuse treatment.^7–10 For instance, in a randomized control trial, Strathdee and colleagues found individuals who participated in a needle exchange program (now referred to as syringe service programs [SSPs]) and received case management were more likely to enter drug treatment within seven days of receiving a referral.¹⁰ Though such efforts have been met with resistance in the U.S., nationwide, harm reduction programs nationwide have increased substantially alongside growing recognition as cost-effective and evidence-based approaches to addressing individual and societal impacts of drug use.^10,11

Within the last five years, U.S. state and federal agencies have acknowledged harm reduction’s important role as part of national efforts to address the opioid epidemic and substance use disorders.^5,12 With more than 100,300 drug-related overdose deaths occurring in 2021 – a 28.5% increase from the previous 12-month period¹³ – harm reduction became an integral component of the U.S. Department of Health and Human Services’ (DHHS) Overdose Prevention Strategy, which includes four goals: (1) advancing research on and demonstrations of harm reduction innovation; (2) integrating harm reduction with health care delivery; (3) sustaining funding strategies for harm reduction services; and (4) reducing drug-use stigma.^14,15 In 2021, SAMHSA announced its inaugural harm reduction grant mechanism authorized by the American Rescue Plan to invest $30 million dollars into harm reduction services and providers.⁵ Moving forward, we can expect harm reduction research and programming to play an integral role in federal efforts to combat the opioid epidemic from service to policy levels.

Yet despite recent financial and policy support for harm reduction, and despite the growing literature on the role of advocacy and research evidence in advancing harm reduction interventions^16–20, little is known about the harm reduction workforce: that is, the specific types of workers working within communities to design, implement, and actualize harm reduction services. Even less is known about the behavioral health workforce involved in direct services within harm reduction community-based settings, a workforce that serves individuals with a variety of mental health and substance use needs. This exploratory study thus employed a mixed-methods approach to answer three research questions: (1) Who (i.e., which workforce types) constitutes the community-based harm reduction workforce? (2) Who provides behavioral health services at harm reduction organizations? (3) Do referrals differ by the type of harm reduction worker?

Survey Development

The survey developed for this study was created using extant literature and key informant expertise. Key informants included four individuals who worked or had prior experience working in community based SSPs, had lived experience with substance use, and/or had experience volunteering at a SSP. During survey development, the research team sought guidance from representatives of two national organizations: The National Harm Reduction Coalition and SAMHSA. In addition, cognitive interviews were conducted with three individuals who work in harm reduction services (an executive director of an SSP, a board member for a harm reduction SSP, and a behavioral health clinician). During the cognitive interview process, clarity on response options were sought to ensure survey items were understandable and easy to navigate using the Qualtrics online survey platform.

The survey consisted of 46 questions, some open-ended and some closed-ended, designed to gather information about the community-based harm reduction workforce. The survey included four primary domains: (1) characteristics of the harm reduction organization (e.g., services provided and staff composition); (2) harm reduction strategies (e.g., behavioral health treatment, disease and overdose prevention, and formal referral services); (3) challenges related to hiring and retaining staff/workforce; and (4) respondent demographics.

Sampling Techniques

Purposive sampling techniques were used to distribute an electronic survey to community-based harm reduction organizations in the U.S. These organizations were identified through the North American Syringe Exchange Network (NASEN) directory of SSPs throughout the U.S.²¹ While master list of NASEN organizations has not been shared or distributed, the online directory is publicly available and contact emails for each organization were compiled by a masters’ student working with the research team to create an email distribution list.

Survey Delivery

The electronic survey was created using Qualtrics²² and distributed by emailing all contacts identified with each harm reduction organization registered with NASEN. After removing duplicate emails, the survey was sent to 350 e-mail addresses in January 2023, followed by two additional reminder emails, and closed six weeks later. Qualtrics fraud protection services were used to prevent multiple survey attempts (e.g., bot detection and reCAPTCHA). The first 150 respondents were provided a $15 Amazon gift card for participation. The study was approved by the [BLINDED UNIVERSITY NAME] Institutional Review Board and electronic consent was obtained from respondents prior to starting the survey.

Sample

The survey was intended for respondents involved in harm reduction organizations in various capacities (e.g., director, program coordinator, board member) and only those listed on the NASEN directory were contacted. The survey yielded a 48% response rate (n = 168) and on average took participants 10 to 15 minutes to complete. Most participants reported being part of executive leadership or in the director role within their organizations (76%). Respondents’ mean age was 43 years. They had an average of nine years’ experience working in harm reduction services, and an average of seven years’ experience working within their organization.

Data Analysis

Closed-ended survey results were exported from Qualtrics into Stata, which we used to conduct all quantitative data management and analysis.²³ Though our survey received 168 responses, some questions had legitimate skip patterns and Tables 1–5 reflect the total number of responses for that question. Open-ended questions resulted from participants either (a) selecting “other” as a response option to a question and typing in additional information; or (b) answering a qualitative question asked directly in the survey. Qualitative data were analyzed using a hybrid approach of inductive and thematic analysis. First, preliminary codes were generated. Next, because codes were short responses, illustrative quotes were pulled. Second, two investigators from the research team independently coded the responses and collaboratively discussed codes and quotes. Microsoft Excel was used to organize and code open-ended responses and all coding discrepancies were resolved by the research team.²⁴ The codes were then organized into broader themes and integrated into quantitative findings.

Table 1

Respondent Characteristics
Variable (total responses)	Frequency	Percentage	Mean	SD
Respondent age			42.82	11.42
Role (168)
Executive Leadership	128	76.19
Participant Services Staff	21	12.50
Program Coordinator	19	11.31
Respondent gender identity (147)
Female/Woman	94	63.95
Male/Man	37	25.17
Transgender, genderqueer, gender non-conforming, or non-binary	15	10.20
Prefer not to disclose	1	.68
Respondent ethnicity (153)
Non-Hispanic or Latino	137	81.55
Hispanic or Latino	16	9.52
Respondent race (154)
White	129	76.79
Black or African American	10	5.95
Other*	15	8.92
Respondent educational attainment (152)		152
Master’s degree or Doctorate/PhD, MD, or JD	42	25.0
4-year degree	61	36.31
Some college	27	16.07
2-year associate degree/vocational degree	12	7.89
Up to a high school degree or GED	10	5.95
Has the respondent completed a certificate program related to harm reduction services? (153)
No	90	53.57
Yes	63	37.50
Years worked in harm reduction (152)			8.86	7.86
Years respondents has worked in their harm reduction organization (149)			7.51	7.28
* To ensure data are deidentified, the racial category “Other” was created to include Asian, American Indian, or Alaskan Native, and Pacific Islander/Hawaiian individuals.

Variables of Interest

Independent Variables

Behavioral Health Services. Survey respondents were asked to select all the types of behavioral health services their organization provides. From these responses, a binary variable was created to code all organizations with at least one behavioral health service offered as a 1 and all organizations without any behavioral health services as a 0.

Types of Providers in Harm Reduction Organizations. Survey respondents were asked to select all the types of providers who work at their organization. The types of providers were dummy coded into distinct binary variables representing four provider types: (1) behavioral health providers; (2) community outreach staff; (3) medical providers; and (4) others (e.g., grant writers and researchers). For example, organizations with at least one type of behavioral health provider (e.g., clinical social worker or licensed marriage family therapist) were coded as a 1, while organizations without any behavioral health providers were coded as a 0.

Dependent Variables

Data for the two dependent variables in this study were obtained by asking respondents the following questions: (1) “Does your organization have a formal referral process for participants?” and (2) “Do you have a follow-up process with referrals made?” Response options were dichotomous; thus, the variables were coded as a binary. A value of 1 indicated the organization had a formal referral process and/or a follow-up process while a value of 0 indicated there was no formal referral process and/or follow-up process.

Quantitative Data Analysis

Once data were downloaded and cleaned, descriptive statistics were conducted for all study variables. Next, two multivariate binary logistic regression models were conducted to examine the associations (a) between the odds of the referral processes at harm reduction organizations and (b) between the provision of behavioral health services and distinct types of organizational staff. The first multivariate model examined the association between behavioral health services, behavioral health providers, community outreach staff, and medical providers and the odds of organizations having a formal referral process. The second multivariate model examined the association between behavioral health services, behavioral health providers, community outreach staff, and medical providers and the odds of organizations having a follow-up process following a referral. Additionally, ordinal variables related to the number of participants served were created to assess if this number significantly predicted the types of behavioral health services provided at an organization, the work performed by volunteers, or the type of organization (e.g., non -profit, faith-based). However, none of these models yielded significant findings.

Descriptive Statistics

Table 1 provides demographic details about participating respondents. Organizations (N = 168) represented 41 states and Washington D.C.; organizations with the highest response rates were in California (n = 25) and North Carolina (n = 12). Two-thirds were non-profit SSPs and about one third (32%) were SSPs operating within public health departments. Sixty seven percent of the organizations offered services across multiple sites, 51% utilized mobile units, 33% relied on pop-up sites based on community needs, and 14% offered tele-harm reduction services. On average, participating organizations reported 350 unique individuals/participants encounters per month (Table 2).

Table 2

Organization Characteristics
Variable (total responses)	Frequency	Percentage	Mean (SD)
Syringe Services Program (SSP) has multiple sites (168)
Yes	111	66.97	7.08 (9.80)
No	57	33.93
Physical setting of the organization
Primary location (168)	132	78.57
Mobile unit (168)	86	51.19
Pop-up sites (168)	56	33.33
Tele-services (168)	23	13.70
Number of unique participants served per month			350 (607.32)
Organization affiliation
Non-profit (168)	111	66.07
Health department (168)	53	31.55
Faith-based (168)	11	6.55
Other (i.e., for-profit, tribal affiliation) (168)	7	4.17
Organization services offered		4.17
Overdose/disease prevention (168)	163	97.02
General service delivery (168)	163	97.02
Testing services (168)	162	96.43
Behavioral health services (168)	127	75.60
Case management (127)	88	69.29
Peer recovery (127)	78	61.41
Counseling (127)	34	26.77
Crisis counseling (127)	26	20.47
Other (127)	37	29.13
Types of providers/staff at organization
Behavioral health (168)	82	48.80
Community outreach (168)	146	87.0
Medical (168)	92	54.76
Other (168)	57	34.0
Is there a formal referral process? (168)
No	95	56.55
Yes	73	43.45
Is there a follow-up process for referrals? (168)
No	114	67.86
Yes	54	32.14
Are there specialty mental health services? (159)
No	80	50.31
Yes	79	49.70
Are volunteers essential in-service delivery (159)
No	70	44.02
Yes	89	55.97

Harm Reduction Team Composition

Among the harm reduction organizations surveyed, we observed four primary types of workers: (1) community health and peer specialists (87%; e.g., peers, outreach workers, promotoras); (2) medical and nursing staff (55%; e.g., nurses, doctors); (3) behavioral health workers (49%; e.g., clinical social workers, licensed counselors); and (4) other professions (34%; e.g., grant managers, legal support, administrative staff). Overall, 78% of organizations had two categories of providers, 56% had three categories of providers, and 29% had all four categories of providers. Table 3 offers a breakdown of the types of providers within each category.

Table 3

Harm Reduction Workforce—Four Primary Types
Variable (each type of provider out of 168)	Frequency	Percentage
Behavioral Health Providers
Clinical supervisors	46	27.38
Marriage and family therapists	43	25.60
Addiction counselors	38	22.62
Clinical social workers	19	11.31
Mental health/professional counselors	13	7.73
Psychiatric mental health nurse practitioners	13	7.73
Psychologists	9	5.35
Community Outreach Providers
Community outreach specialists	114	67.86
Peer support specialists	99	58.93
Social workers	62	36.90
Advocates	32	19.05
Housing specialists	27	16.07
Insurance specialists	20	11.90
Translators	17	10.12
Case Managers	16	9.52
Job trainers	13	7.74
Promotoras	6	3.57
Medical Providers
Physicians	40	25.0
Nurse practitioners	42	23.81
Pharmacists	16	9.52
Paramedics	8	4.76
Dentists	8	4.76
Other Types of Providers
Grant writers	50	29.76
Researchers	14	8.33
Lawyers	12	7.14

Less than 50% of the organizations had behavioral health staff and of those organizations, 50% reported that they offered specialty mental health services. The types of behavioral health providers varied across organizations. The most common types of behavioral health providers included licensed marriage and family therapists (LMFTs) (26%), addiction counselors (23%), and clinical supervisors (27%); clinical social workers comprised less than 12% of the behavioral health workforce among represented organizations. However, no specific behavioral health discipline or type is discernable within the ‘addiction counselor’ and ‘clinical supervisor’ response options. Additionally, more than half (56%) of organizations reported relying on volunteers as an essential part of harm reduction services.

Behavioral Health Services

About 75% of the organizations (n = 127) offered any type of behavioral health service even though less than half of the organizations (49%) reported having behavioral health staff. About two-thirds of behavioral health services offered included case management (69%) and peer recovery support (61%). These services were likely offered by community outreach providers who delivered a sizeable proportion of behavioral health services. The behavioral health services most likely to be delivered by clinically licensed staff (e.g., clinical social workers, LMFTs) included counseling (27%) and crisis counseling (20%) (Table 2). About 43% of the organizations surveyed had a formal referral process for SSP participants; among these organizations, only 32% had follow-up protocols.

Twenty nine percent of organizations indicated they delivered “other types of behavioral health services.” These responses were coded and analyzed to describe other behavioral health services delivered within these harm reduction organizations. As illustrated above, these organizations offer a broad spectrum of behavioral health services offered (Theme 1). For example, one participant described their organization’s mental health services as “peer-centered” and noted that, as needed, the organization will “contract with counselors and psychiatrists in the event that someone wants these services.” Another said, “our team mostly focuses on trauma care or short-term situational crisis that can be resolved in 10 sessions or less. Any longer-term behavioral health or addiction is referred to community resource.” Although some organizations indicated they provide onsite behavioral health services, these services are often either referred off-site immediately or after a brief period of treatment.

Workforce Providing Behavioral Health Services

Like quantitative results in Table 2, responses to the open-ended question “Who provides specialty mental health services in your organization?” represented a broad behavioral health workforce engaged in harm reduction services and one that was reliant on peers (Theme 2). For instance, one respondent reported that their organization relied most on “community outreach workers [who] are trained for micro counseling.” Another stated, “We have no employees we are totally a volunteer organization. However, we recently received opiate settlement money and we may be able to offer a paid position.” Another respondent described the utilization of the peer workforce in the following way: “We are a peer-run, Recovery Community Organization (RCO) that is comprised of individuals in active, long-term recovery from substance use, mental health, and trauma-related experiences. We are non-clinical and lead with our lived experience.”

Other types of behavioral health providers identified in open-ended responses included student interns (i.e., “we contract through a university and mental health interns”) and volunteers.

Association Between Behavioral Health Providers and Referral Patterns

In the first multivariate logistic regression model, both providing behavioral health services and having behavioral health staff within an organization were significantly associated with the odds of harm reduction organizations having a formal referral process. The second multivariate logistic regression model also showed that both providing behavioral health services and having behavioral health staff were significantly associated with the odds of organizations having a follow-up process following a formal referral. In neither of these models was having community outreach staff or medical staff significantly associated with the odds of an organization having a formal referral process or a follow-up process. Unadjusted results indicate that harm reduction organizations are 5.06 (95% CI = [1.91, 13.38]) times more likely to have a formal referral process and 6.11 (95% CI = [1.74, 21.52]) times more likely to have a follow-up process regarding referrals when they have embedded behavioral health services. Additionally, harm reduction organizations are 2.20 (95% CI = [1.09, 4.46]) times more likely to have a formal referral process and 2.36 (95% CI = [1.11, 5.0]) times more likely to have a follow-up process for referrals when they employ behavioral health providers (Table 4).

Table 4

Logistic Regression Models Assessing the Odds of Referral Supports within Harm Reduction Organizations
Variable OR		95% CI	p-value
Formal referral process
Behavioral health services	5.06	[1.91, 13.38]	< .001
Behavioral health providers	2.20	[1.09, 4.46]	.029
Community outreach providers	1.17	[0.65, 2.14]	.592
Medical providers	1.14	[0.90, 1.44]	.281
Follow-up referral process
Behavioral health services	6.11	[1.74, 21.52]	.005
Behavioral health providers	2.36	[1.11, 5.0]	.025
Community outreach providers	1.67	[0.86, 1.42]	.209
Medical providers	1.10	[0.86, 1.42]	.430

The composition of the harm reduction workforce is occupationally diverse and includes many types of workers, including those with lived experiences, behavioral health providers with formal education, health professionals, and those who serve in other roles, many of which are administrative. Findings highlight the wide array of behavioral health services being offered within harm reduction organizations (Theme 1) and the broad composition of the behavioral health workforce involved in harm reduction services within U.S.-based community SSPs, with a heavy reliance on the peer workforce (Theme 2). Further, we found that having behavioral health workers as part of the harm reduction team facilitates organizations’ formal referral and follow-up processes.

Prior literature on harm reduction services has described how harm reduction organizations have served as a bridge to service delivery^2,25 and as a “low-threshold gateway to welcome anyone who is willing to ‘come as they are’” (p. 788).² Findings from this study not only confirm that this bridging to additional services occurs; they also indicate that the composition of the harm reduction workforce can enhance how these referrals and follow-up protocols are actualized. Specifically, having behavioral health on staff within SSPs facilitates significantly more referrals to additional community, social, and health supports compared to other groups of workers (e.g., medical staff and community outreach workers). However, our analyses also showed that the behavioral health workforce is occupationally diverse and includes those with lived-life experience, varied levels of education, and professional training.

While making behavioral health as a diverse service category may increase the number of people working to address behavioral health needs, it may also produce greater variation in what services are offered and by whom. Variation in scope of practice, training, and skills vary by workforce type along with payment mechanisms that reimburse or financially support different types of work performed.²⁶ As such, investigating the variation and scope of practice within the behavioral health workforce, as well as how this workforce is reimbursed and paid for harm reduction services, is necessary to determine how to scale behavioral health supports for SSP participants to improve service delivery and to other supports as need. Future research should also unpack whether the type(s) of behavioral health providers in a harm reduction organization result in different referral and follow-up processes within SSPs and how this impacts SSP participant outcomes.

Notably, our findings highlight the organization’s adherence to a central premise of harm reduction philosophy and practices: “meeting people where they are.”^27,28 Community outreach specialists were the most common type of providers identified within this study (87%), and peer recovery services were the most offered behavioral health service. Given that peer recovery services comprised almost two-thirds of all behavioral health services offered, future research should unpack who these peers are, what training they have, and how they are prepared to work in the harm reduction field given the severity of use and life-threatening consequences related to substance use. Prior research has documented the benefits of leveraging the peer workforce to address behavioral health needs and the recent nationwide proliferation of the peer behavioral health workforce^29–30, especially in light of the behavioral health challenges and social vulnerabilities associated with COVID-19^31,32 and increasing rates of overdose deaths.¹³ Recently, the Biden-Harris Administration identified peer supports as essential to accelerating the mental health workforce and improving health care delivery.^33,34 However, understanding how the harm reduction field and SSP organizations attract, train, and retain peers is a critical yet unexplored aspect of harm reduction workforce projections and planning. Determining how best to strengthen the harm reduction workforce, and the peer support specialist workforce specifically, is essential to effectively delivering harm reduction services.

Increasing the behavioral health workforce within the field of harm reduction could also increase the provision of specialty mental healthcare (i.e., evidence-based mental health interventions, brief treatment) that would continue to meet people in their own community, rather than requiring them to attend mental health treatment in a different locale/setting. The relatively smaller percentages of licensed behavioral health providers (e.g., psychologists and clinical social workers) we observed may stem from reimbursement allowances and policy restrictions on what types of behavioral health providers can bill for clinical behavioral health services.³⁵ Specifically, while this survey did not explore the funding models of each program, it is plausible that these types of behavioral health providers are less prevalent in these settings because behavioral health service reimbursement (i.e., insurance access and billing) is not a common funding mechanism used to sustain harm reduction and SSP community-based programming. In the future, as harm reduction services and behavioral health supports become more commonly understood, funding and reimbursement may emerge as an increasingly important source of revenue for SSPs. More research is needed to further understand what policy drivers may be impacting the types of behavioral health workforce hired by SSPs.

Strengths and Limitations

To the best of our knowledge, this is the first national survey assessing behavioral health issues among harm reduction organizations in the U.S. Findings from this study may have significant implications for future funding and policy changes – specifically, for increased funding for staff positions and the expansion of behavioral health services in harm reduction organizations. However, our findings should be interpreted considering study limitations. First, while our survey comes from a national sample of registered organizations within the NASEN network and achieved a 48% response rate, its findings have limited generalizability. First, not every SSP is part of the NASEN network and was therefore excluded. Among the organizations that responded, there is considerable variation in organizations’ size and geographic location. This means that, for example, unique considerations for SSPs in urban vs. rural areas of the U.S. or based on state policies that may inhibit or enhance harm reduction services may have potentially skewed our findings. Additionally, when looking at types of providers and services, the specific types of behavioral health provider (i.e., addiction counselor) was not always distinguishable and could include someone with a social work degree, a peer support specialist, among others. Finally, researchers assessed if organizations had a referral process, without noting which services were referred to and the outcome of these referrals.

Notwithstanding these limitations, this study calls attention to the essential and lifesaving services provided by harm reduction organizations across the U.S. This study also calls for future research to examine the challenges and barriers to hiring and sustaining the harm reduction workforce, and the ways in which organizations rely on peers and volunteers to carry forward harm reduction services with vulnerable populations. Future research and evaluative efforts could assess sustainable streams of funding for harm reduction organizations to ensure there is adequate staff to deliver a variety of services (e.g., SSPs, behavioral health, and medical care).

The workforce diversity of harm reduction organizations highlights how interdisciplinary teams are working together to engage individuals seeking harm reduction services. The behavioral health workforce within harm reduction varies by provider types (i.e., lived-life, professional, and educational experiences) and by the type of behavioral health services offered. Nonetheless, including behavioral health providers within SSPs significantly increases an organization’s number of referrals and follow-up protocols to extend the harm reduction continuum of care. Given that harm reduction organizations serve individuals with a multitude of needs including physical health concerns, behavioral health, crisis situations, social and basic needs, further analysis of the harm reduction workforce can help ensure that comprehensive and coordinated services are delivered to participants accessing SSPs. Understanding the types of services offered, as well as the workforce provides those services, offers organizations valuable insights into staffing and service delivery strengths, and needs by frontline organizations working to reduce morbidity and mortality among those who use substances.

CDC = Centers for Disease Control and Prevention; CI = confidence interval; DHHS = U.S. Department of Health and Human Services; LMFT = licensed marriage and family therapist; NASEN = North American Syringe Exchange Network; RCO = recovery community organization; SAMHSA = Substance Abuse and Mental Health Services Administration; SSP = syringe service program

Ethics approval and consent to participate: The Institutional Review Board at the University of North Carolina at Chapel Hill reviewed and approved this study (IRB# 22-3035). Participant consent was granted before the survey was initiated.

Consent for publication: All authors consent to publication and approve the submission of this manuscript.

Availability of data and materials: The survey and data collected was done so by the research team and is not publicly available.

Competing interests: All authors have no competing interest to declare or financial disclosures to report.

Funding: This project is supported by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U81HP46529‐01‐01 Cooperative Agreement for a Regional Center for Health Workforce Studies for $1,121,875. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by SAMHSA, HRSA, HHS or the U.S. Government.

Authors’ contributions: Lisa de Saxe Zerden led the project from inception to completion. She helped draft the survey, conducted interviews with content experts and was the primary author on the paper. Orrin Ware helped with the research proposal. He created the Qualtrics survey, assisted with the content expert interviews, and contributed to the manuscript. Brooke Lombardi’s primary contribution includes data cleaning, analyses, and table construction. She also assisted with writing up the findings and reviewing the entire manuscript. Brianna Lombardi contributed to the project proposal, survey design and sampling strategy. She reviewed the paper and provided feedback on earlier iterations of the manuscript.

Acknowledgements: The research team would like to acknowledge Kristina E. Smith, a dual degree MSW and JD candidate at the University of North Carolina at Chapel Hill who assisted compiled email addresses for survey dissemination and Jordan Wingate, PhD who provided editorial assistance to this manuscript. We also acknowledge Lucas Vrbsky, LCSW, Chase Holloman, MSW, and Dianne Carden for sharing their harm reduction expertise with our research team.

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No competing interests reported.

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Harm Reduction Workforce, Behavioral Health, and Service Delivery: A Cross Sectional Study

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Journal Publication

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Abstract

Background

Methods

Results

Conclusions

Introduction

Methods

Survey Development

Sampling Techniques

Survey Delivery

Sample

Data Analysis

Variables of Interest

Independent Variables

Dependent Variables

Quantitative Data Analysis

Results

Descriptive Statistics

Harm Reduction Team Composition

Behavioral Health Services

Workforce Providing Behavioral Health Services

Association Between Behavioral Health Providers and Referral Patterns

Discussion

Strengths and Limitations

Conclusions

Abbreviations

Declarations

References

Additional Declarations

Status:

Journal Publication

Version 1