Editor’s note: Elizabeth Salisbury-Afshar, MD, MPH, is an Associate Professor in the Department of Family Medicine and Community Health at the University of Wisconsin School of Medicine and Public Health and Medical Director of the Compass Program, a low-barrier walk-in clinic for substance-related health concerns.

Sarah Mossburg: Welcome, can you please tell us a little bit about yourself and your current role?

Elizabeth Salisbury-Afshar: I am board certified in family medicine, addiction medicine, and preventive medicine/public health. My current clinical practice is predominantly in addiction medicine. I work in an outpatient setting and on an addiction consult service at a hospital.

Sarah Mossburg: Thank you. Can you talk briefly about your practice?

Elizabeth Salisbury-Afshar: In the outpatient setting, I work at the Compass Program, a walk-in clinic that provides healthcare services for people who use substances. We provide same-day access to medications like buprenorphine for opioid use disorder (OUD). We can also prescribe medications for alcohol use disorder and provide an array of services that people who use substances often need but have trouble accessing, such as wound care, hepatitis C treatment, sexually transmitted infection (STI) testing and treatment, basic contraceptive services, vaccinations, and other acute care services.

In the hospital, I work on an addiction consult team. We typically see individuals admitted for another medical indication who, once hospitalized, appear to have challenges related to substance use. Our team provides consultation to assess for substance use disorder and explore interest in a variety of options, including harm reduction education, medication treatments, counseling services, etc. 

Sarah Mossburg: When do people who use substances typically come to see you?

Elizabeth Salisbury-Afshar: In the outpatient setting, people usually come when there's something they need or want. Most of the folks we see come in specifically hoping to get started on medication for opioid use disorder (MOUD), and then they realize there are other services they are open to receiving. We've also recently had some referrals for hepatitis C treatment because we partner with a lot of local community organizations like syringe service programs, the jail, and other places that test for hepatitis C but can't offer treatment. 

Sarah Mossburg: What are the most frequent substance use disorders (SUDs) among the patients that you treat?

Elizabeth Salisbury-Afshar: In the outpatient setting, we mostly see patients with OUD. Many patients with OUD are also using cocaine, methamphetamine, and/or alcohol. 

In my hospital-based work, we see a lot of patients with alcohol use disorder, often because they are coming in for treatment of severe and complicated alcohol withdrawal. We also see individuals with opioid and methamphetamine use disorders, who are often hospitalized for injection-related infections.

Sarah Mossburg: How have substance use patterns changed over the past decade? How does the current landscape shape the need for prevention, treatment, and harm reduction? 

Elizabeth Salisbury-Afshar: On a national scale over the last three decades, we've seen a few things. We've seen overdose rates continue to rise, although in 2023, there seemed to be some plateauing in terms of total number of overdose deaths. The Centers for Disease Control and Prevention often describes three waves of the overdose epidemic. The first wave was associated with prescription pain medications. Then, for a very short time, we saw an increase in heroin-related overdoses, and for over one decade, we’ve seen continual increases in fentanyl-involved overdoses. We now have what some are calling the 4th wave, which is polysubstance overdose, with a combination of illicitly manufactured fentanyl and stimulants like cocaine or methamphetamine. Those are the high-level trends nationally, but I would add that this looks really different in different places. For example, I used to work in Baltimore City and then in Chicago, and neither of those cities saw high rates of overdose deaths from prescription pain pills. They historically had endemic heroin markets and relatively limited access to prescribed pain medications. When we think about interventions, it's important that we understand our local trends so that interventions can be tailored appropriately.

Evidence-based prevention, treatment, and harm reduction services should be available everywhere. However, because of the changing landscape and regional variability in use trends, it’s critical that strategies match community needs. For example, if you're working in a community that doesn't have a lot of opioids and predominantly uses stimulants, you should meet the needs of the population. Evidence-based interventions can look a bit different for different substances. Some interventions show promise across multiple substances—for example, prevention strategies like skills-based education in schools. Evidence-based treatments look different for different substances. It’s similar for harm reduction services. For example, if you're in a community where very few people inject substances, it’s still important to have access to syringes. But if most people are smoking substances, it may make more sense to provide tools that will allow them to use more safely, including things like smoking supplies.

Sarah Mossburg: What are the main safety concerns for people who use substances?

Elizabeth Salisbury-Afshar: At a high level, one of the biggest safety concerns is the variability in the illicit drug market. These aren't regulated substances coming through a monitored supply chain. Someone could think they're buying cocaine, and it ends up having fentanyl in it. That can be life-threatening, particularly for people who are opioid-naive. We're seeing different types of synthetic substances being cut into the drug supply. Even if someone generally knows how much they can safely use, it can be very dangerous if they’re exposed to something they weren't expecting.

Sarah Mossburg: Could you talk a little bit about the issue of stigma in healthcare settings and how it could impact the patient experience of seeking SUD care? 

Elizabeth Salisbury-Afshar:  There is absolutely stigma in health care against people who use substances because there's stigma across society as a whole. This often makes people who use substances feel anxious about stepping forward and asking for help. We live in a society where health care is mostly paid for by employers, so some folks are nervous to seek help because they're worried that their employer will find out. We also have a very punitive child protective services system in our country and there's a lot of racial and ethnic discrimination in that system. Black and Indigenous individuals who have children are often afraid to disclose substance use to healthcare providers out of fear they will be reported, even if they are taking great care of their kids. So there are a lot of ways that stigma can make people afraid to step forward and ask for help. 

Then, once folks do step forward and ask for help, there are varying levels of awareness among healthcare professionals of how to support someone with concerns related to substance use. I think training is improving, but it is common for healthcare clinicians to have not had much, if any, education on addiction. If we did, it was more like a neurobiology lecture, not on how to talk to people about their substance use or how to help them navigate to appropriate services. 

Finally, I have heard countless stories from my own patients about how terribly they have been treated in a variety of healthcare environments. People are often treated poorly or blamed for negative health outcomes associated with substance use. Past negative experiences in health care make people very hesitant to go back. 

Another way stigma plays out in hospitals is in under-treatment of pain and withdrawal symptoms. When they are not adequately addressed, we see high rates of self-discharge (leaving before medically advised), and that can lead to a whole range of other negative health outcomes.

Sarah Mossburg: Harm reduction is one of the things we'd like to talk about today. Could elaborate on the concept of harm reduction?

Elizabeth Salisbury-Afshar: At its core, the goal of harm reduction is to meet people where they are and support them in reducing the harms associated with substance use. I think it is always important to acknowledge that harm reduction started as a movement during the HIV/AIDS epidemic. Rates of transmission of HIV were exceedingly high, and we knew that it could be transmitted through sharing injection equipment, which people still couldn’t access. Activists were tired of losing their friends and loved ones, so they started giving out injection equipment, whether it was legal or not. People took tremendous risks then and have continued to take risks for the last few decades to make sure that people who use substances have the tools they need to stay as safe and healthy as possible.  

Sometimes when people hear the term “harm reduction” they only think of naloxone or syringe service programs, which are specific harm reduction services. However, I think of harm reduction very broadly, more like a philosophy that can be applied across many settings and that is inclusive of a variety of services. This broader approach and philosophy include using non-stigmatizing language, treating people who use substances with respect and dignity, and advocating for substance-related policy changes that offer more support and are less punitive. This broader approach recognizes that people who use substances have rights. We should support them in their health the way we support all of our patients, including those who have a chronic condition that may have some behavioral associations. 

Sarah Mossburg: How does harm reduction differ from a traditional treatment strategy for somebody with a SUD?

Elizabeth Salisbury-Afshar: It's important to recognize that a lot of the SUD treatment infrastructure that exists today has historical and existing ties to the legal system. For example, methadone treatment was created to try to reduce recidivism. A lot of our treatment system has used strict and often punitive approaches toward people who use substances, with the idea that abstinence was the only acceptable outcome. If people were not able to comply with that goal or weren't interested, they didn't fit in and were discharged from care. This is a big problem. In the US, approximately three-fourths of people who have SUD don't engage in treatment. When asked why, people will typically say they don't think they need it. In my clinical experience, many people have been mandated to treatment in the past, often through the legal system. They felt like being in treatment was akin to being in jail. People may feel that treatment, with its deep connections to the legal system, is not welcoming, patient-centered, or safe. 

So how do we work to embed harm reduction philosophies? In addiction treatment, harm reduction aims to be welcoming and patient centered. It’s not a one-size-fits-all approach, and we don’t discharge people from treatment if they continue to show symptoms of their substance use disorder. For example, someone comes to me and says, “Hey Doc, I really want to stop using fentanyl, but I don't think I'm going to be able to give up cocaine” or “I want to stop using cocaine but don't think I'll be able to give up having a couple drinks on Friday night.” I’ll say, “OK, then let's work on a plan to help you meet that goal.”That’s the same way I’d work with someone who has high blood pressure and says, “Doc, look, I changed my diet most of the time. But on the weekends, I'm going to eat my favorite foods with my family.” I would say those are some great successes. Let’s continue to work together on your goals to improve your health and well-being.  

Embedding these harm reduction principles into treatment does not mean that abstinence has no place. Abstinence absolutely is part of harm reduction, but it is not the only acceptable goal or outcome. It is about really being inclusive, patient-centered, and listening to where people are and supporting them in their own goals.

Sarah Mossburg: Could you talk about some common harm reduction strategies that are implemented outside of healthcare settings?

Elizabeth Salisbury-Afshar: I'll just say at the onset, there are some really cool pilot programs pushing the edges of what we can do in different settings. We want to meet people where they are. Sometimes that means taking health care out of the clinic, and sometimes it means bringing harm reduction programming or services into healthcare settings. 

In the community, the most common services are things like naloxone distribution and syringe service programs. Naloxone distribution has gained a lot of steam in recent years because we have strong evidence that naloxone saturation reduces deaths from opioid overdose. We also have decades of literature on how effective syringe service programs are at reducing transmission of HIV and hepatitis C. They also reduce soft tissue skin infections and things like infective endocarditis, yet uptake and legality vary around the country. We are also seeing some newer programs in the community like drug-checking services that allow people to test their substance and have a better sense of what is in it before they use it. Several overdose prevention sites have opened in the US. These are places where people can bring substances they have already purchased and use them in an environment where there are people able to respond clinically if there is a negative event. 

I would argue that all healthcare clinicians working with patients should be offering overdose prevention education, and we should all be comfortable talking about it. In 2018, guidance from US Surgeon General Jerome Adams said that we should prescribe naloxone to people who are actively using substances, including those prescribed opioids for pain. That is an important first step, but we need to similarly embrace talking to patients about safer substance use and knowing how and where people can access harm reduction services in our communities.

Sarah Mossburg: Now that naloxone is available over the counter, has that strategy changed?

Elizabeth Salisbury-Afshar: Naloxone is available over the counter but cost-prohibitive for many people. Our community distribution plans need to continue to identify ways to get naloxone into the hands of individuals most at risk of overdose, who are also the individuals most likely to save someone’s life. In many states, Medicaid covers naloxone, often with no copay. This is important because we know that the higher the cost, the less likely people are to purchase it.

There is a movement to try to reduce barriers to initiating methadone and buprenorphine, two medicines that we use to treat OUD. Examples include clinicians working in emergency departments (EDs) and on ambulances administering buprenorphine. Similarly, hospitals start the medication while someone's hospitalized and then link them to treatment immediately upon discharge. Our goal should be that regardless of where you are seen — at a community harm reduction site, in the ED, in the field after an overdose, or at an addiction treatment program — all of the clinicians know where harm reduction services exist and how to link you to necessary services. Similarly, we should work to co-locate medical services at harm reduction sites so that people can access medical care and medications for addiction treatment if needed.

Sarah Mossburg: You mentioned the Compass Program. Please tell us about how you're utilizing harm reduction there. 

Elizabeth Salisbury-Afshar: Harm reduction is not just the services we offer, it’s how we work with patients. Much of the impetus for opening the clinic was knowing that it’s difficult for patients and families to find evidence-based, patient-centered services. We heard from a variety of community partners that patients who were interested in buprenorphine had trouble accessing it for several reasons. We also knew that some programs had long waits for the first appointment. 

So we worked to obtain a grant that allows us to see people regardless of their ability to pay, and our clinic offers walk-in services. This allows any individual to come during hours of operation to obtain a medical assessment and start medications. 

We had also heard from our syringe service program and street outreach partners that people who inject drugs often have wounds but are too afraid to go to urgent care, the ED, or primary care, so we incorporated other services into our care model. At Compass, we offer wound care, contraceptive access, hepatitis C treatment, STI testing and treatment, overdose prevention education, naloxone distribution, and fentanyl and xylazine test strips. We also support people by linking them to food pantries, clothing vouchers, housing opportunities, and transportation support. 

Before we opened Compass, we spent a lot of time with team members who answer the phones and sit at the front desk to ensure they had a good understanding of how the clinic would operate. We also had to make sure everyone felt comfortable working with people who use substances. It drives people away if they call and don't get the right information or show up and don't feel welcomed at the front desk. Some people won't stay long enough to get to the visit. 

Finally, our team makeup is also important. We have a peer support specialist, a nurse care coordinator, medical assistant, and physician assistant on our team, and we meet regularly to talk about service delivery. Our goal is to ensure that patients feel as comfortable as possible. We formally and informally ask patients if there are other things they wish we would offer. We will try to implement whatever we can. 

Sarah Mossburg: That is wonderful. It sounds like you're doing a lot of work to decrease barriers for patients to access services and care. Can you talk about harm reduction in the inpatient care setting?

Elizabeth Salisbury-Afshar: First I’ll say there is still a huge need for hospital-based clinicians to learn how to work with people who use substances. It certainly depends on when people trained. My impression is that in recent years more medical, nursing, and other health professional schools have included substance use disorder education. But there is still a lot of work to be done to reduce bias against folks who use substances. 

Some of the challenges in patients with substance use disorder face include undertreated pain, undertreated withdrawal symptoms, movement and visitor restrictions, and feeling stigmatized by hospital staff. Harm reduction in the inpatient setting includes ensuring that clinical teams are not using stigmatizing language, that pain and withdrawal symptoms are adequately addressed, that patients with SUD have the same freedom for guests and movement as other patients, and that we are offering evidence-based medications for addiction treatment, with linkage to appropriate and desired clinical and harm reduction services as an outpatient.

Sarah Mossburg: You just spoke to how clinicians on the inpatient side can integrate some harm reduction strategies into their current approach to care. Are there other suggestions that you would recommend for clinicians on the outpatient side?

Elizabeth Salisbury-Afshar: I think we've covered a lot of them, offering medications for OUD in the clinic environment and then either providing or linking people to other harm reduction services like test strips and syringes. If you can't offer those in your environment, then make sure you know what's available in your community.Provide education about using appropriate terminology, using non-stigmatizing terms, and making sure that people feel welcomed. That education should happen across the entire system, not just for the prescribers. 

Sarah Mossburg: What advice do you have for organizations that want to implement strategies like naloxone distribution?

Elizabeth Salisbury-Afshar: Distributing (vs prescribing) gets tricky because it comes down to local factors, such as how your state is using grant funds, pharmacy laws, and regulations, and whether your organization will allow you to hand it out or if it has to go through a pharmacy as a prescription. I would start with the state public health department and ask whether the state is donating naloxone to community clinics for distribution. They can let you know about local options. If direct distribution isn’t possible, prescribing is a good second choice, though there can be barriers such as cost and copays. It’s also one extra step for patients, but if you're prescribing other meds and you know your patient is going to the pharmacy anyway, it can be a great way to provide access to naloxone. That is primarily what we do in my clinic. Most people coming to see us are also getting a prescription for buprenorphine, so we co-prescribe naloxone. It is important to know what the copays are, at least for the primary payers. Medicaid often covers naloxone with limited, if any, copay, but Medicare and private payers can be different. For individuals with a bigger copay, donated supply from state or local public health departments and knowing about access points in the community can be really helpful.

Sarah Mossburg: Are there any particular harm reduction strategies that you find to be the most effective, or is it very contextual?

Elizabeth Salisbury-Afshar: Again, I think of harm reduction in a very broad way, so trauma-informed care is a piece of harm reduction as well. It’s always helpful if clinicians recognize that if a patient has SUD, it's very likely they have a history of trauma. Rates of adverse childhood experiences and adult trauma are extremely high among people with SUDs. Next, I never assume that someone wants to stop using. For example, if someone came in for heartburn and I find out that they drink alcohol, I don’t jump to the conclusion that they will be interested in abstaining from drinking. If I jump there, but they're not with me, that is going to shut the conversation down. So utilizing harm reduction techniques like motivational interviewing and trauma-informed care can fit into all clinical environments. In terms of the specific services that have been shown to reduce risk of death, we have naloxone distribution and medications for OUD, specifically methadone and buprenorphine. But at its core, harm reduction treats people with respect and makes sure they can access evidence-based services that support health and well-being.

Sarah Mossburg: Thank you. I want to shift directions a little bit. I'm curious how policies and regulations related to substance use have changed over your years of practice.

Elizabeth Salisbury-Afshar:  Many of the relevant policies are at the state level, so there is tremendous variability. Naloxone is a great example, where we've seen tremendous improvements across most states. At a high level, we've seen a lot of policy changes to increase availability of naloxone. First, we had standing orders, now we have some over-the-counter availability. Syringes are more accessible in some states, but there are still 13 where syringes are considered drug paraphernalia, and syringe service programs are not available. That is a lot given that we have decades of data supporting the efficacy of these programs for reducing transmission of infectious conditions. We've seen some states change legislation to make drug-checking legal. In some states, drug-checking remains in a gray zone as to whether or not the checking equipment is considered paraphernalia. Rhode Island passed legislation to pilot overdose prevention centers.  

I also want to acknowledge federal legislation that has increased access to methadone and buprenorphine. Historically, medical clinicians had to have a special add-on to their DEA (Drug Enforcement Administration) license to be able to prescribe buprenorphine. Federal regulation recently got rid of that requirement. Now anyone with a Schedule III DEA license can prescribe buprenorphine. Methadone regulations also recently changed to increase the ability of people to take their medication home earlier during their care. 

Finally, over the last few years, we've seen the federal government speak much more openly in support of harm reduction. The Substance Abuse and Mental Health Services Administration (SAMHSA) put out a harm reduction framework for the first time ever. That was a multi-year process with stakeholder engagement. Dr. Rahul Gupta from the Office of National Drug Control Policy speaks about harm reduction as part of the strategy from the White House.  We continue to see shifts in the conversation at the federal level to be more inclusive of harm reduction as part of a broader strategy.

Sarah Mossburg: What policy changes should be explored to reduce harms related to SUDs?

Elizabeth Salisbury-Afshar: At the highest level, I think we should move away from policies that punish people who use substances. We know that SUDs are chronic health conditions, and we want to create an environment where people can seek supportive, evidence-based services without fear of punitive responses. There are many ways to start this work. In my personal opinion, we need to shift away from the current approach of incarcerating people with substance use disorders and instead work to provide evidence-based treatments and support. For example, instead of incarcerating individuals caught with small amounts of an illegal substance or paraphernalia, we could instead direct those resources toward substance use and mental health treatment, housing, job training and placement, and other trauma-informed, recovery-oriented services.  

Sarah Mossburg: What opportunities do you see for research about harm reduction?

Elizabeth Salisbury-Afshar: There are many opportunities, particularly related to some of the newer services being implemented, such as overdose prevention sites and drug-checking. The overdose prevention sites in New York City and opening soon in Rhode Island offer great chances to build our understanding of service delivery models and associated health outcomes. We need to understand what's working and if there are things that need to be tweaked. Drug-checking services are also a newer intervention, with much to be learned about various technologies, messaging for individuals utilizing the service, and associated behavior changes and health outcomes. We also need to understand how to optimize these services in ways that are most helpful to the people who are using them.

Sarah Mossburg: That is really interesting. Thank you so much for your time.