U.S. substance use harm reduction efforts: a review of the current state of policy, policy barriers, and recommendations

Abstract

A wealth of research demonstrates that harm reduction interventions for substance use (SU) save lives and reduce risk for serious infectious diseases such as HIV, hepatitis C, and other SU-related health conditions. The U.S. has adopted several harm reduction interventions at federal and state levels to combat SU-related harm. While several policy changes on the federal and state levels decriminalized interventions and further support their use, other policies limit the reach of these interventions by delaying or restricting care, leaving access to life-saving interventions inconsistent across the U.S. Federal and state policies in the U.S. that restrict access to medications for opioid use disorder (MOUD), criminalize possession of drug paraphernalia, prevent syringe service programs and overdose prevention centers from operating, and limit prescribing of pre-exposure prophylaxis (PrEP) pose significant barriers to harm reduction access and implementation. This paper aims to bridge publications and reports on current state and federal harm reduction intervention policies and discuss policy recommendations. Federally, the DEA and SAMHSA should expand certification for methadone dispensing to settings beyond dedicated opioid treatment programs and non-OTP prescribers. Congress can decriminalize items currently categorized as paraphernalia, permit purchasing of syringes and all drug checking equipment using federal funds, amend the Controlled Substances Act to allow for expansion of overdose prevention centers, protect Medicaid coverage of PrEP, and expand Medicaid to cover residential SU treatment. At the state level, states can reduce regulations for prescribing MOUD and PrEP, decriminalize drug paraphernalia, codify Good Samaritan laws, and remove restrictions for syringe service program and overdose prevention center implementation. Lastly, states should expand Medicaid to allow broader access to treatment for SU and oppose Medicaid lock-outs based on current SU. These changes are needed as overdose deaths and serious infectious disease rates from SU continue to climb and impact American lives.

Keywords: Drug checking equipment; Medications for opioid use disorder; Naloxone; Overdose prevention centers; Pre-exposure prophylaxis; Syringe service programs.

Fig. 1

Possession of Drug Checking Equipment Policy by State as of August 2024 [117]

Fig. 2

Free Distribution of Drug Checking Equipment Policy by State as of August 2024 [117]

Fig. 3

Syringe Service Program Authorization and Operation Status by State as of April 2025 [64]

Fig. 4

Possession of Syringes Policy by State as of April 2025 [64]

Fig. 5

Summary of Federal Policy Recommendations

Fig. 6

Summary of State Policy Recommendations