Enhancing the Care Continuum for Veterans Who Inject Drugs Using Harm Reduction Approaches

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Project Goals: The long-term goal of this Innovation Project is to implement comprehensive harm reduction services in VA that will reduce high and unacceptable rates of fatal overdoses and prevent viral (HCV, HIV) and invasive bacterial (sepsis, endocarditis) infections associated with the rise in opioid and other drug injection among Veterans. The Phase I goal is to work collaboratively with multiple VA Medical Centers (VAMCs), VA operational partners, community agencies and Veterans to develop comprehensive harm reduction “bundles” that are adaptable for use in different service lines (i.e., inpatient, outpatient) and geographic areas (i.e., urban, suburban, rural). These “bundles” will include options for accessing and providing sterile syringes, Narcan and overdose prevention education, skin cleaning education, and recommendations for infectious disease screening and other prevention resources. We will develop a Harm Reduction Community of Practice to collaboratively explore and address social, logistical and policy barriers to implementing harm reduction approaches in VA, develop harm reduction delivery models that include recommendations for who, when and how “bundles” are provided, and develop supporting resources (e.g., provider training, model community contracts) for implementation of harm reduction approaches). Our second goal is develop an implementation study for Phase II, including identification of participating VAMCs, implementation strategies, and outcomes. The Long-term Aim of the Phase II Project is to conduct a multi- site implementation study assessing the impact of providing harm reduction services, including access to sterile syringes, on Veterans’ health outcomes, VAMCs financial burden of care, and the culture of healthcare for Veterans who inject drugs. Innovation: Despite the strong and overwhelming evidence-base for harm reduction approaches, healthcare systems in the U.S. have been slow to adopt them into practice. Recent changes in federal policies and a 2018 National Ethics in Healthcare opinion allow healthcare agencies to develop comprehensive harm reduction services in the interest of public health. Continued restrictions on the use of federal funding to purchase sterile syringes require partnering with state or community agencies to support access. This creates opportunities to bridge care for vulnerable and hard-to-reach Veterans and assist them in accessing needed resources to protect their health and engage in self-care. If successful, VA will be among the first healthcare systems in the U.S. to offer these critical services to IVDUs. Impact: Increasing access to sterile syringes, Narcan and other harm reduction resources will prevent fatal overdoses and costly viral and bacterial infections. If implemented in accordance with principles of patient-centered care, it will also help reduce stigma associated with IVDU and engage this vulnerable population of Veterans in VA care. Phase I Accomplishments include the formation of a robust Harm Reduction Community of Practice that allows us to work collaboratively across disciplines and setting types to develop reasonable and feasible harm reduction “bundles” that can be implemented and tested in Phase II. This work includes addressing real and perceived policy barriers to implementing comprehensive harm reduction approaches in VA, socio-cultural challenges associated with stigma of injection drug use, development of guidance for how to partner with community agencies to access sterile syringes and options for making them available to Veterans, and implementation resources (e.g., training materials, CPRS consult templates, example community contracts). Next Steps: Findings from the Phase II multi-site study will inform refinements to the Harm Reduction Implementation Package, which will be disseminated to VAMCs across the country and improve the quality and responsiveness of care for Veterans with opioid dependency.