However, a subset of participants, particularly those with a history of hospitalisations and withdrawal attempts, felt that discontinuation was preferable to a maintenance approach, fearing that continued dependence would hinder their treatment decisions. However, other approaches as the Risk Of Bias In Systematic Reviews (ROBIS) could yield similar results. The conclusions of the systematic reviews were considered as presented by Reducing injection harm authors, meaning that evidence may not be immediately transposed to different scenarios/settings and geographical regions.
In recent years, there has been a growing recognition of the social determinants of drug use and related health disparities. This broader understanding acknowledges that substance use is influenced by complex social, economic, and structural factors 29–31. Consequently, research on harm reduction interventions has expanded to examine the intersecting issues of poverty, inequality, stigma, mental health, and access to healthcare. This multidimensional approach has likely contributed to the increased research interest and the steeper growth observed in recent years. This growth signifies the ongoing commitment to addressing the complex challenges faced by individuals who inject drugs and the continuous efforts to develop effective interventions that prioritize harm reduction and public health.
This method is used for its immediate effects, as the injected substance is rapidly distributed throughout the body via the circulatory system. The rapid onset is because the drug bypasses the digestive system and liver metabolism (first-pass metabolism), allowing the active compounds to reach their target sites without being altered. Authors conducted a bridge to conduct a bridge search from their original search period (database inception to January 26, 2014) to updated search dates (January 26, 2014 to September 23, 2019). All data presented in this manuscript are available on the Scopus database () using the search query listed in the methodology section. This work was supported by the Cooperative Agreement Number 5 (grant number NU50CK000574), funded by the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention.
This work was supported by grant U54 GM from the National Institutes of Health for the Northern New England Clinical and Translational Research network.
While there are a limited number of literature overviews (i.e., systematic reviews of systematic reviews) available, they tend to focus on specific interventions (e.g., NSEP) and outcomes (e.g., HIV-related harms). These overviews are often outdated (last publications from 2022 including primary studies published until 2019–2020) and tend to concentrate on the broader category of people who use drugs. Furthermore, they may not thoroughly evaluate the roles of PWID and stakeholders on harm minimization initiatives (e.g., barriers to implementation and upscale) 11–16. Furthermore, they may not thoroughly evaluate the roles of PWID and stakeholders on harm minimization initiatives (e.g., barriers to implementation and upscale) 11,12,13,14,15,16. Approaches to care for people prescribed benzodiazepines vary significantly, reflecting differences in how harm reduction is interpreted and applied.
However, areas with less robust resources may need to seek creative solutions to gaps in care, such as telehealth 37 or the creation of localized treatment algorithms or electronic medical record bundles. Other allied health professionals, such as peer recovery specialists, nurse educators, and pharmacists, may also be able to provide counseling, education, and vaccinations. Integrated care teams have been successful in both inpatient and outpatient settings and provide a model for hospitals looking to improve the care of PWID 38–40. Initially, established in Europe, drug checking has expanded across North America in response to the opioid crisis and fentanyl contamination in the drug supply 79. A common finding across the included drug checking studies was the detection of unexpected substances. Etizolam was most frequently identified, and in some instances was co-detected with fentanyl, posing significant overdose risk 44.
By reviewing a comprehensive set of scholarly articles, this study identifies research hotspots, knowledge gaps, and future directions in the field. The findings provide valuable insights for researchers, policymakers, and practitioners to guide future research efforts and inform evidence-based harm reduction interventions. Seven studies29,31,33,36,39,44,54 reported outcomes relevant to access to addiction treatment programs. Review authors deemed four studies to be of greatest suitability of study design, with one of these studies (Wood and colleagues54) rated good quality of execution and the rest (Lloyd-Smith et al.,39 DeBeck and colleagues,29 and Kimber et al.36) rated fair.
The risk of IDU-related outbreaks can be significantly reduced with sterile injection equipment, safer injection technique, PrEP, PEP, and OUD treatment. Three studies examined the impacts of the rescheduling of medications, including benzodiazepines 59,60,61. A 2021 review included five studies that explored the rescheduling of alprazolam in Australia from Schedule 4 to Schedule 8 in 2014 59. Four of the studies reported declines in alprazolam use, with reductions in prescribing, dispensing, overdose deaths, and calls to poison centres. Further restrictions in 2017, such as removing 2 mg pills from public subsidies and limiting pack sizes, had no substantial impact.
This indicates an ongoing need for innovation and investment to improve drug checking technologies that can meet accuracy and speed requirements when detecting emerging substances. Current treatment approaches for benzodiazepine dependence primarily involve deprescribing through initial stabilisation and/or conversion to prescribed benzodiazepine followed by stepwise dose reduction with the goal of eventual abstinence 14, 37. A reduction plan often includes replacing short-acting, more potent benzodiazepines (e.g., alprazolam) with longer-acting options (e.g., diazepam) guided by standardised dose equivalence protocols 37. However, traditional dose equivalence tools prove challenging for novel and counterfeit benzodiazepines owing to their largely unknown composition and relative potencies, complicating treatment planning. In parallel, regulatory responses, such as medication rescheduling, have been used to address broader issues related to benzodiazepine harm and dependence 38. Remember, every step taken in the realm of harm reduction is a step towards a healthier, safer community.
This sample was chosen by selecting every 10th article after sorting the articles based on the year of publication. Harm reduction is an important strategy for preventing infections among people who inject drugs (PWID). We attempted to evaluate the harm reduction counseling that infectious diseases physicians provide to PWID presenting with infections. One study reported that users discussed optimal dosing for desired effects and safety, drug formulation alterations, routes of administration, and effect durations 69.
It is important to identify safer sites versus dangerous sites that should not be utilized. For IV injection, preferred sites include the forearms, followed by the backs of the hands 2, 34. Dangerous sites that should not be utilized due to high risk for complications or potentially fatal outcomes include the neck, groin, tops of the feet, ankles, ventral wrists, and palms 2, 34.
The size of each node in the map corresponds to the frequency of occurrence of the respective keyword in the literature. Among the identified keywords, the ones related to harm reduction and IDU were the most frequent followed by those related to HIV, hepatitis C (HCV), and opioid overdose. VOSviewer visualization technique was also used to map frequent terms in the titles and abstracts of the retrieved articles. The map (Fig. 4) shows the frequent terms distributed into three major clusters based on node colors.
A common misconception about harm reduction is that its interventions are dichotomous to abstinence-oriented strategies. This belief stems from many sources, including 2 landmark prospective cohort studies in the 1990s that found an association between SSP and higher risk of HIV seroconversion 19, 20. Follow-up studies in the same settings, conducted after addressing the aforementioned concerns, found no such increase in risk or decrease in HIV prevalence 21. The effectiveness of SIS in improving public health and safety, while controversial to some, is supported by a substantial body of evidence. By addressing the immediate health needs of PWID and providing pathways to treatment and support, SIS embody a critical component of comprehensive harm reduction strategies. Their role in saving lives, reducing the spread of infectious diseases, and improving community well-being underscores the importance of expanding these services as part of a holistic approach to drug policy and health care.
Pills marketed as pharmaceutical benzodiazepines, such as Valium and Xanax, were also found to lack the expected active ingredients and/or contain unexpected substances 48, 50, further highlighting the value of drug checking services. Two qualitative studies explored individuals’ perceptions of benzodiazepine use and treatment 57, 58. The first study found participants preferred prescribed benzodiazepines over illicit use, citing benefits such as reduced costs, criminal activity, and the risk of contaminated pills 57. Notably, some participants in this study reported treatment termination from their prescriber if nonmedical benzodiazepine use was suspected or disclosed. The second study found most participants saw the benefits of agonist treatment, such as reduced criminal behaviour and greater stability 58.
