Alcohol harm reduction entails pragmatic, compassionate strategies to reduce alcohol-related harm and improve quality of life, without requiring abstinence. Since the landmark reviews from Marlatt and Witkiewitz in 2002 and 2006, harm-reduction approaches for alcohol have expanded considerably. This narrative review synthesizes more recent evidence across policy-, population-, community-, and individual-level interventions. Policy interventions, including taxation, minimum unit pricing, and outlet density restrictions, consistently reduce alcohol consumption and associated harm. Population-level campaigns improve knowledge and attitudes; however, effects on drinking behaviors are mixed. At the community and individual levels, Housing First programs and harm-reduction treatment for alcohol have garnered empirical support. Managed alcohol programs and meaningful activity interventions show promise in nonrandomized studies. Building on grassroots, user-led efforts in the larger harm-reduction movement, the alcohol harm-reduction field has a growing empirical foundation. Future research should engage communities, expand RCTs, refine outcome measures, and explore technology-driven solutions to expanding the reach of harm reduction.

OBJECTIVES:American Indian (AI) people are disproportionately impacted by opioid use disorder (OUD) and its associated consequences. However, there is a dearth of published research about substance-use treatment and its efficacy for AI people with OUD. People with OUD, especially those with a longer substance-use history, often have widely variable experiences in their access to and engagement in substance-use treatment. Furthermore, there is a paucity of literature on AI people's perceptions of their substance-use treatment experiences. This study seeks to fill this research gap. METHOD:Conventional content analysis was used to document perceptions of substance-use treatment among AI people who have used opioids (N = 45) as well as their suggestions for the improvement of treatment moving forward. RESULTS:Participants highlighted the importance of connection to nonjudgmental counselors and peers with lived experience, challenges of logistical barriers to treatment (e.g., cost, distances to facilities), the importance of intrinsic versus extrinsic motivation for recovery, and a preference for treatment as respite versus punishment. Participants felt substance-use treatment could be enhanced through the incorporation of Native-centric cultural programming, the integration of social services into substance-use treatment (e.g., housing and vocational training), provision of robust individual and group counseling options, and healing settings that include nature and flexible structures. CONCLUSIONS:Findings should be taken into consideration when establishing and designing substance-use treatment for AI people who have used opioids to ensure appropriate accessibility, feasibility, and implementation concerns are addressed. (PsycInfo Database Record (c) 2026 APA, all rights reserved).

AIMS: The literature from Canada, the UK and the USA reports health inequities among people experiencing homelessness; however little is known about this population’s health in Switzerland. Our study is the first to comprehensively assess health needs, expectations and experiences of people experiencing homelessness in Switzerland. METHODS: We describe the health needs, expectations and experiences of people experiencing homelessness in French-speaking Switzerland, using both quantitative and qualitative methods. From May to August 2022, 123 people experiencing homelessness completed quantitative questionnaires about health needs, expectations and experiences. Recruitment took place in 10 homeless-serving institutions across four cities in the Canton of Vaud. A total of 18 people experiencing homelessness and 13 professionals involved in the homeless-serving sector completed qualitative interviews. For the qualitative strand, we selected people experiencing homelessness using quota sampling based on health insurance, residency status and sex representativeness according to the study population. For homeless-serving sector professionals, we used quota sampling by professions (i.e. night watcher in shelters; social/healthcare workers) ensuring balance. In addition, we aimed to recruit at least one homeless-serving sector professional from each of the ten institutions included in the parent research project. RESULTS: The most common health issues reported were musculoskeletal, dental and psychiatric. Thirty-one percent of people experiencing homelessness had visited emergency rooms and 27% a community health centre in the prior 6 months. People experiencing homelessness reported low quality of life according to the WHOQOL, especially in social and environmental domains; 33% reported moderate and 17% high grade of psychological distress. Findings indicated that up to 32% of participants reported facing difficulties in reaching out to the healthcare system. In qualitative interviews, people experiencing homelessness described positive perceptions about the Swiss healthcare system. However, people experiencing homelessness reported various barriers encountered while seeking healthcare (e.g., health insurance, financial barriers, appointment delays, hesitancy in accessing care, prioritising other needs). Both groups commonly reported that social situations impacted the health and healthcare use of people experiencing homelessness. CONCLUSION: People experiencing homelessness in Switzerland are not spared by the common health inequities reported in Canada, the USA and the UK. Our results provide interesting foundations on which to build public health actions towards health equity for people experiencing homelessness in Switzerland and suggest that they could benefit from additional medical follow-up and tailored interventions.

People experiencing homelessness (PEH) are disproportionately affected by health issues yet remain underserved by the health care system. Emerging findings suggest that complementary medicine (CM) approaches might help address the low access to earlier treatment and the complex needs of this population. Very little research has explored this topic in Europe. Thus, this study aimed to explore perceptions, experiences, and interests in CM among PEH in Switzerland. Participants (N = 123) were PEH in French-speaking Switzerland who completed a questionnaire assessing their use of and interest in CM. A subsample of the survey participants (n = 18) and 14 professionals working in the homeless-serving sector participated in semi-structured interviews exploring perceived utility of CM for PEH. Descriptive statistics and conventional content analysis were used to analyze quantitative and qualitative data, respectively. Quantitative findings showed that despite high levels of interest in CM, less than 30

BACKGROUND AND AIMS:In a prior randomized clinical trial (RCT), combined pharmacobehavioral harm-reduction treatment improved alcohol outcomes and physical health-related quality of life (PH-QoL). In this secondary analysis, we tested race, ethnicity and sex assigned at birth as predictors and moderators of these effects. DESIGN:Secondary study of a four-arm RCT. SETTING:Community settings serving people experiencing homelessness in the US Pacific Northwest. PARTICIPANTS:Adults aged 21-65 (N = 308) with alcohol use disorder (AUD) who experienced past-year homelessness. INTERVENTION:In the parent RCT, participants were randomized to brief behavioral harm-reduction treatment for AUD + extended-release naltrexone (HaRT-A + XR-NTX); HaRT-A + placebo; HaRT-A alone, or services-as-usual control. MEASUREMENT:We tested whether baseline outcomes, trial inclusion, data missingness, treatment adherence, side effects, and treatment effects on alcohol frequency, quantity, alcohol-related harm, urinary ethyl glucuronide, and PH-QoL differed by race, ethnicity, and sex assigned at birth. FINDINGS:Race, ethnicity and sex assigned at birth were not associated with differential trial inclusion, missingness, treatment adherence or side effects with one exception: the Multiracial/other people of color (POC) group attended fewer HaRT-A sessions than the white group (odds ratio [OR] = 0.49, p = 0.03, 95% confidence interval [CI] [0.25, 0.95]). There were no statistically significant moderators of the behavioral HaRT-A effect; however, Multiracial/other POC race (B = -3.34, p = 0.03, 95% CI [-6.35, -0.34]) and sex assigned at birth (B = 2.43, p = 0.04, 95% CI [0.14, 4.73]) moderated the XR-NTX versus placebo effect on one variable: PH-QoL. Simple slope analysis indicated the Multiracial/other POC group who received placebo showed improvement on PH-QoL (dy/dx = 2.61, p = 0.003, 95% CI [0.91, 4.31]); the XR-NTX group did not (dy/dx = -0.22, p = 0.79, 95% CI [-1.90, 1.45]). Among XR-NTX recipients, the female group (dy/dx = 2.89, p < 0.001, 95% CI [1.53, 4.25]) showed faster improvement rates than the male group (dy/dx = 1.19, p = 0.02, 95% CI [0.23, 2.16]) on PH-QoL. CONCLUSION:Race, ethnicity and sex assigned at birth were largely not associated with trial inclusion, data missingness, treatment adherence, side effects, or outcomes in a combined harm-reduction treatment and extended-release naltrexone randomised clinical trial for alcohol use disorder (AUD). Although Multiracial/other people of color (POC) participants attended fewer brief behavioral harm-reduction treatment for AUD sessions, they did not differ from white participants on alcohol and physical health-related quality of life outcomes. Among participants receiving extended-release naltrexone (XR-NTX), women showed greater improvement than men on physical health-related quality of life. Compared with white participants, Multiracial/other POC participants who received XR-NTX showed less improvement than those who received placebo. Given their post hoc nature and limited power, findings are hypothesis-generating. They suggest the equitable utility of behavioral harm-reduction treatment and the importance of assessing sociodemographic differences in AUD treatment response.

Safer use strategies (SUS) are behaviors before, during, and after drug use to moderate use and/or mitigate unwanted consequences. As treatment of substance use disorders becomes more common in primary care, offering SUS in primary care merits exploration. We explored acceptability and use of SUS in primary care using a convergent parallel mixed-method design consisting of patient and clinician semi-structured interviews and surveys. Participants were recruited from primary care clinics involved in a multi-state practice research network. Patients with lifetime stimulant and/or opioid and any SUS use were eligible. All clinicians were eligible. Qualitative data were analyzed using a rapid assessment procedure. Quantitative data were analyzed descriptively. Participants included patients (n = 10) and clinicians (n = 12) from multiple disciplines. More than half of patients indicated that every SUS surveyed should be offered in primary care. Patients reported using multiple SUS to stay safer, reduce consequences, and limit use. Clinicians reported that offering SUS to primary care patients is acceptable and supported SUS use by sharing informational resources (e.g., safer injection practices) and tangible resources (e.g., naloxone, medication for opioid use disorder [MOUD]). Some strategies recommended by patients were not currently being systematically offered (e.g., fentanyl test strips). Several clinicians expressed willingness to discuss SUS with patients but wanted more training and resources to facilitate SUS discussions to support patient goals. Offering SUS to primary care patients is acceptable to patients and clinicians. Clinicians supported some SUS use, though more SUS and harm reduction training and resources were desired. Providing SUS to patients who use stimulants and/or opioids could enhance patient-centered primary care, especially in clinics offering MOUD. More research is needed to optimize SUS support in primary care settings.

Objective: Both opioid misuse and overdose mortality have disproportionately impacted the American Indian population. Although medications for opioid use disorder, such as buprenorphine (BUP-NX), are highly effective in reducing overdose mortality, questions have been raised about the cultural acceptability of Western medical approaches in this population. Understanding patients' desired recovery pathways can lead to more culturally appropriate, patient-centered, and effective approaches to opioid use disorder (OUD) treatment. In this qualitative study, we document experiences with combined pharmacobehavioral treatment for OUD and suggestions for enhancing it. Method: Participants (N = 45) were American Indian patients and community members impacted by OUD. They participated in one-time, 45- to 60-min, semistructured interviews. Results: Findings from conventional content analysis indicated participants were grateful for a Tribally run combined pharmacobehavioral OUD treatment program, which made treatment more financially and geographically accessible over a large, rural area. Participants expressed satisfaction with BUP-NX and the accompanying behavioral health programming but were interested in making it more accessible through telemedicine appointments and mailed prescriptions. Participants noted the importance of clear communication about this kind of programming, which tends to be less structured than other substance-use treatment programs, but also appreciated its tailored, compassionate, and holistic approach. Participants were interested in robust counseling options; a low-barrier, acceptance-based, and harm-reduction orientation; as well as more culturally aligned programming that honored their Native heritage and traditional medicine. Conclusions: Treatment providers, researchers, and policymakers should consider integration of more patient-driven, compassionate, and culturally aligned means of intervention for American Indian patients with OUD.

Background Two, randomized controlled trials found harm-reduction treatment for AUD (HaRT-A) improves alcohol outcomes for adults experiencing homelessness. HaRT-A, which neither requires nor precludes abstinence, entails tracking alcohol-related harm, harm-reduction goals, and safer-use strategies. This secondary dual study qualitatively describes this last component, safer-use strategies, and their quantitative association with treatment outcomes. Methods Participants were people who experienced homelessness and AUD and were enrolled in the active HaRT-A treatment arms in 2 randomized control trials (Trial 1 N = 86; Trial 2 N = 208). Trial 1was a 2-arm study with randomization to HaRT-A or services as usual. Trial 2 was a 4-arm study combining HaRT-A and extended release naltrexone. In HaRT-A sessions, participants received a list of 3 categories of safer-use strategies (i.e., buffering alcohol's effects on the body, changing the manner of drinking to be safer and healthier, and reducing alcohol use). Mixed methods were used to qualitatively describe safer-use strategies implemented and quantitatively test their association with alcohol outcomes (i.e., peak quantity, frequency, alcohol-related harm). Results In Trial 1, but not Trial 2, participants committed to more safer-use strategies across time, which was associated with reductions in alcohol frequency over the past 30 days. In both trials, participants committing to reducing alcohol consumption drank on a quarter fewer days overall, and in Trial 2, experienced 15 % less alcohol-related harm. In Trial 1, participants who committed to changing the manner of drinking were heavier drinkers overall, and although they showed significant reductions in alcohol-related harm, their reduction rate was slower than for participants who selected other strategies. In Trial 2, strategies to buffer alcohol's effects were associated with a monthly 14 % decrease of alcohol-related harm. Conclusion This study replicated prior findings that people experiencing homelessness and AUD regularly adopt strategies to reduce alcohol-related harm. The implementation of safer-use strategies was favorably associated with alcohol outcomes, but specific associations differed by trial and outcome. Discussion of safer-use strategies appears helpful; however, further research is needed to firmly establish how this HaRT-A component works.

Background: Minoritized racial/ethnic and sex assigned at birth/gender groups experience disproportionate substance-related harm. Focusing on reducing substance-related harm without requiring abstinence is a promising approach.Objectives: The purpose of this meta-epidemiologic systematic review was to examine inclusion of racial/ethnic and sex assigned at birth/gender in published studies of nonabstinence-inclusive interventions for substance use.Methods: We systematically searched databases (PubMed and PsycINFO) on May 26, 2022 following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. Articles were eligible for inclusion if they: 1) reported in English language, 2) had a primary goal of investigating a nonabstinence-inclusive intervention to address substance use, 3) used human subjects, and 4) only included adults aged 18 or older. Two coders screened initial articles and assessed eligibility criteria of full text articles. A third consensus rater reviewed all coding discrepancies. For the remaining full-length articles, an independent rater extracted information relevant to study goalsResults: The search strategy yielded 5,759 records. 235 included articles remained. Only 73 articles (31.1%) fully reported on both racial/ethnic and sex assigned at birth/gender, and only seven articles (3.0%) reported subgroup analyses examining treatment efficacy across minoritized groups. Nine articles (3.8%) mentioned inclusion and diversity regarding both racial/ethnic and sex assigned at birth/gender in their discussion and four articles (1.7%) broadly mentioned a lack of diversity in their limitationsConclusion: Findings highlight that little is known about nonabstinence-inclusive interventions to address substance use for individuals from minoritized racial/ethnic and sex assigned at birth/gender groups.

"Substitute addiction" refers to the process of achieving abstinence or resolution of one addictive behavior and subsequently engaging in one or more additional addictive behaviors in its place. Substitute addiction, a concept in the abstinence-based recovery field for decades, is viewed as a cause for concern because resolving one addictive behavior might not fully remove harm or ensure recovery. Conversely, "harm-reduction treatment" refers to a counseling orientation that focuses on helping service users reduce substance-related harm and improve their quality of life without necessarily requiring abstinence or use reduction. Harm-reduction treatment assesses a constellation of addictive behaviors in the larger context of a person's life to holistically reduce harm in that constellation. In this commentary, we define and compare both constructs and point out their implications for addictions treatment.

Prior research suggests that culturally aligned, accessible and lower-barrier interventions are well-placed to align with the needs of American Indian and Alaska Native (AI/AN) people with alcohol use disorder (AUD). Taking into account community members' suggestions and the need for physical distancing during the COVID-19 pandemic, our team developed a protocol for virtual Harm Reduction Talking Circles (HaRTC) to incorporate these points. The aims of this 8-week, single-arm pilot were to initially document feasibility, acceptability, and outcomes associated with attendance at virtual HaRTC, which integrates the accessibility of virtual connection, a lower-barrier harm-reduction approach, and a culturally aligned intervention. Participants ( N  = 51) were AI/AN people with AUD (current or in remission) across 41 Tribal affiliations and 25 US states. After a baseline interview, participants were invited to attend 8, weekly virtual HaRTC sessions. At the baseline, midpoint and post-test assessments, we collected data on virtual HaRTC acceptability, cultural connectedness, quality of life, and alcohol outcomes. Of the 123 people approached, 63% were interested in and consented to participation. Participants attended an average of 2.1 (SD = 2.02) virtual HaRTC sessions, with 64% of participants attending at least one. On a scale from 1 to 10, participants rated the virtual HaRTC as highly acceptable ( M  = 9.3, SD = 1.9), effective ( M  = 8.4, SD = 2.9), culturally aligned ( M  = 9.2, SD = 1.5), helpful ( M  = 8.8, SD = 1.9), and conducted in a good way ( M  = 9.8, SD = 0.5). Although the single-arm study design precludes causal inferences, participants evinced statistically significant decreases in days of alcohol use and alcohol-related harm over the three timepoints. Additionally, both sense of spirituality, which is a factor of cultural connectedness, and health-related quality of life increased over time as a function of the number of HaRTC sessions attended. Virtual HaRTC shows initial feasibility and acceptability as a culturally aligned intervention for AI/AN people with AUD. Future randomized controlled trials will provide a test of the efficacy of this approach.

Approximately three fourths of the American Indian and Alaska Native (AI/AN) population lives in urban areas, and urban AI/ANs are disproportionately affected by alcohol-related morbidity and mortality. Although no studies have documented alcohol use disorder (AUD) treatment outcomes specific to urban AI/ANs, studies in other Native communities highlight concerns about the cultural acceptability of directive, abstinence-based approaches, such as cognitive behavioral therapy and 12-step programs. Understanding this population's desired recovery pathways in their own words may help providers create more culturally appropriate, patient-centered, and effective approaches. Participants (N = 31) were urban AI/ANs who screened positive for AUD using the AUDIT-C. They participated in semi-structured interviews eliciting their experiences in AUD treatment to date and suggestions for redesigning AUD treatment in their own vision. Conventional content analysis was used to create a thematic description. Findings indicated that intrinsic motivation and not extrinsic pressure (e.g., mandated treatment) was associated with positive treatment engagement and outcomes. Participants appreciated feeling safe and supported in AUD treatment, but also felt AUD treatment could be institutional and oppressive. Participants preferred compassionate counselors with lived experience who could provide insights into recovery; they largely did not appreciate a "tough love" approach or power struggles with counselors. Native-led treatment centers providing access to cultural practices were preferred. Moving forward, participants suggested AUD treatment providers should help patients meet basic needs, prioritize patient-driven versus provider-driven goal-setting, support patients' reconnection with meaningful activities, facilitate access to a supportive community network, and recognize cultural activities as important recovery pathways.

Harm reduction approaches are effective, patient-driven alternatives to abstinence-based treatment for people who are not ready, willing, or able to stop using substances. This volume outlines the scientific basis and historical development of these approaches, and reviews why abstinence-based approaches often do not work. The authors then share their expertise about harm reduction treatment (HaRT), an empirically based approach co-developed with community members impacted by substance-related harm – a first of its kind. The reader learns in detail about the pragmatic mindset and compassionate heartset of HaRT and the three treatment components: measurement and tracking of patient-preferred substance-related metrics, harm-reduction goal setting and achievement, and discussion of safer-use strategies. This volume walks practitioners through all components, provides example scripts for use in daily practice, and illustrates the work through case studies and input from community members. Handouts are available for use in daily practice. This is essential reading for clinical psychologists, psychotherapists, and researchers who encounter people who have substance-use problems.

ObjectivesA prior randomized controlled trial showed behavioral harm reduction treatment for alcohol use disorder (AUD), or HaRT-A, was effective in improving alcohol outcomes and quality of life for people experiencing homelessness and AUD when provided with or without pharmacotherapy (ie, extended-release naltrexone). Because nearly 80% of the sample also reported baseline polysubstance use, this secondary study tested whether HaRT-A also positively impacted other substance use.MethodsIn the parent study, 308 adults with AUD and homelessness were randomized to receive HaRT-A plus intramuscular injections of 380-mg extended-release naltrexone (HaRT-A + extended-release naltrexone), HaRT-A plus placebo (HaRT-A + placebo), HaRT-A alone, or community-based services as usual (control). In this secondary study, we used random intercept models to detect changes in other substance use after exposure to any of the HaRT-A conditions. For less prevalent behaviors, outcomes included past-month use (cocaine, amphetamines/methamphetamines, opioids). For more prevalent behaviors (polysubstance, cannabis), outcomes were past-month use frequency.ResultsCompared with controls, participants who received HaRT-A showed significantly reduced 30-day frequency of cannabis use (incident rate ratio = 0.59, 95% CI = 0.40-0.86, P = 0.006) and polysubstance use (incident rate ratio = 0.65, 95% CI = 0.43-0.98, P = 0.040). No other significant changes were detected.ConclusionsCompared with services as usual, HaRT-A is associated with reduced cannabis and polysubstance use frequency. The benefits of HaRT-A may thus extend beyond its impact on alcohol and quality of life outcomes to positively reshape overall substance use patterns. A randomized controlled trial is needed to further investigate the efficacy of such combined pharmacobehavioral harm reduction treatment for polysubstance use.

Objectives The use of extended-release naltrexone (XR-NTX) as treatment for alcohol use disorder (AUD) has been limited by a prior black box warning for hepatotoxicity. We performed a secondary analysis of data from a randomized clinical trial to compare serum liver enzyme levels for those randomized to XR-NTX versus placebo. Methods The parent study aimed to test the efficacy of combined pharmacobehavioral harm-reduction treatment in improving alcohol and quality-of-life outcomes for adults experiencing homelessness and AUD. We compared the 2 arms that received intramuscular injections of either 380 mg XR-NTX (n = 74) or placebo (n = 77). Outcomes included (a) liver enzyme levels and (b) liver enzyme values categorized as normal (<1× upper limit of normal [ULN]), elevated (1–3× ULN), or high (>3× ULN). We performed multinomial logistic regression and negative binomial generalized estimating equations modeling to assess the effects of treatment group and the time × treatment group interaction on liver enzyme outcomes. Results The mean age was 47.9 ± 9.9 years, and the mean baseline alcohol consumption was 23.2 ± 14.0 drinks per day. There were no significant differences in the development of liver enzyme elevations 1 to 3× ULN or more than 3× ULN (all Ps > 0.25) or in the change in liver enzyme values (all Ps > 0.41) between the placebo and the XR-NTX groups over the treatment course. Conclusions In our study of adults experiencing homelessness and AUD, receipt of XR-NTX was not associated with hepatotoxicity. These findings support the use of XR-NTX to treat AUD even in patients who are drinking heavily and physiologically dependent on alcohol.

OBJECTIVE:People experiencing homelessness are disproportionately impacted by alcohol-related harm. Racially minoritized groups are disproportionately represented in the homeless population and are likewise disproportionately impacted by alcohol-related harm. Most alcohol outcome measures have not been adequately psychometrically studied in this marginalized population and across racial groups. This study documents psychometric properties, including measurement invariance, reliability, and convergent validity, of a measure of alcohol-related harm, the Short Inventory of Problems (SIP-2R), across Black, North American Indigenous (NAI), and White adults experiencing homelessness and alcohol use disorder (AUD). METHOD:Adults experiencing homelessness and AUD who had participated in one of two randomized controlled trials of harm-reduction treatment (N = 493; NAI = 205, Black = 125, and White = 163) were included in this psychometric study of the 15-item SIP-2R. RESULTS:Multigroup confirmatory factor analysis (MGCFA) indicated that a model comprising one general alcohol-related harm factor overarching five factors, showed close fit and partial scalar invariance, χ²(329, N = 493) = 624.902, p < .001, comparative fit index (CFI) = .966, root-mean-square error of approximation (RMSEA) = .074, 90% CI [.066, .083], standardized root-mean-square residual (SRMR) = .063, confirming acceptable measurement equivalence across racial groups. The SIP-2R showed internal consistency (α = .94, ω = .95) and convergent validity, that is, positive correlation between the total SIP-2R score and the number of drinks consumed the heaviest drinking day, ρ(490) = .30, p < .001. CONCLUSION:This study provided support for the internal consistency, convergent validity, and cross-group measurement equivalence of the SIP-2R for NAI, Black, and White adults experiencing homelessness with AUD. (PsycInfo Database Record (c) 2023 APA, all rights reserved).