Background: Harm reduction includes treatment and prevention approaches rather than abstinence, as a public health strategy for mitigating the opioid epidemic. Harm reduction is a new strategy for many healthcare professionals, and gaps in knowledge and practices may lead to barriers to optimal treatment. Our objective was to identify and describe gaps in physicians’ knowledge, education, and practice in harm reduction strategies related to opioid overdose. Methods: We searched the PubMed, CINAHL, and Web of Science databases for articles published between 2015 and 2021, published in English, containing empirical evidence, addressing opioid harm reduction, and identifying gaps in physicians’ knowledge, education, or practice. Results: Thirty-seven studies were included. Studies examined how physicians’ perceptions or stigma influenced harm reduction efforts and addressed clinical knowledge gaps in overdose treatment and prevention and OUD treatment. Less than half of the studies addressed access issues at the system level, above the individual healthcare professional. Conclusion: Individual-level interventions should be addressed with professional continuing education and curricular-based changes through experiential and interprofessional education. System-level gaps can be remedied by increasing patient access to care, creating policies favorable to harm reduction, and extending resources to provide harm reduction strategies.
Provisional Drug Overdose Death Counts. Centers for Disease Control and Prevention website. Published October 13, 2021. Accessed October 28, 2021.
2.
WilsonN, KariisaM, SethP,et al. Drug and opioid-involved overdose deaths – United States, 2017–2018. MMWR Morb Mortal Wkly Rep.2020;69(11):290–297.
3.
MahonLR, HawthorneAN, LeeJ, BlueH, PalombiL.Assessing pharmacy student experience with, knowledge of and attitudes towards harm reduction: illuminating barriers to pharmacist-led harm reduction. Harm Reduct J.2018;15(1):57.
4.
PittAL, HumphreysK, BrandeauML.Modeling health benefits and harms of public policy responses to the US opioid epidemic. Am J Public Health.2018;108(10):1394–1400.
5.
BeletskyL, DavisCS.Today's fentanyl crisis: prohibition's iron law, revisited. Int J Drug Policy.2017;46:156–159.
6.
LarochelleMR, BernsonD, LandTMedication for opioid use disorder after nonfatal opioid overdose and association with mortality: a cohort study. Ann Intern Med.2018;169(3):137–145.
7.
HillLG, EvoyKE, RevelesKR.Pharmacists are missing an opportunity to save lives and advance the profession by embracing opioid harm reduction. J Am Pharm Assoc.2019;59(6):779–782.
8.
Andraka-ChristouB, CaponeMJ.A qualitative study comparing physician-reported barriers to treating addiction using buprenorphine and extended-release naltrexone in U.S. office-based practices. Int J Drug Policy.2018;54:9–17.
9.
Methadone. Substance Abuse and Mental Health Administration website. Published August 19, 2020. Accessed August 19, 2020.
10.
Naltrexone. Substance Abuse and Mental Health Administration website. Published August 19, 2020. Accessed September 10, 2020.
11.
ThompsonEL, RaoPSS, HayesC, PurtillC.Dispensing naloxone without a prescription: survey evaluation of Ohio pharmacists. J Pharm Pract.2019;32(4):412–421.
12.
MaguireMA, PavlakosRN, MehtaBH, SchmuhlKK, BeattySJ.A naloxone and harm reduction educational program across four years of a doctor of pharmacy program. Curr Pharm Teach Learn.2018;10(1):72–77.
FreemanPR, HankoskyER, LofwallMR, TalbertJC.The changing landscape of naloxone availability in the United States, 2011–2017. Drug Alcohol Depend.2018;191:361–364.
15.
XuJ, DavisCS, CruzM, LurieP.State naloxone access laws are associated with an increase in the number of naloxone prescriptions dispensed in retail pharmacies. Drug Alcohol Depend.2018;189:37–41.
16.
Prescription Opioids Prescribing Practices. Centers for Disease Control and Prevention website. Published August 13, 2019. Accessed September 11, 2020.
17.
TongS, SaboR, AycockRAssessment of addiction medicine training in family medicine residency programs: a CERA study. Fam Med.2017;49(7):537–543.
18.
BarryDT, IrwinKS, JonesESIntegrating buprenorphine treatment into office-based practice: a qualitative study. J Gen Intern Med.2009;24(2):218–225.
19.
DeFlavioJR, RolinSA, NordstromBR, KazalLAJr.Analysis of barriers to adoption of buprenorphine maintenance therapy by family physicians. Rural Remote Health.2015;15:3019.
20.
WalleyAY, AlperenJK, ChengDMOffice-based management of opioid dependence with buprenorphine: clinical practices and barriers. J Gen Intern Med.2008;23(9):1393–1398.
21.
The ASAM national practice guideline for the treatment of opioid use disorder: 2020 focused update. J Addict Med.2020;14(2S):4.
22.
WilsonJD, BerkJ, AdgerH, FeldmanL.Identifying missed clinical opportunities in delivery of overdose prevention and naloxone prescription to adolescents using opioids. J Adolesc Health.2018;63(2):245–248.
23.
KiraneH, KetteringhamM, BereketSAwareness and attitudes toward intranasal naloxone rescue for opioid overdose prevention. J Subst Abuse Treat.2016;69:44–49.
24.
MartinoJG, SmithSR, RafieS, RafieS, MarienfeldC.Physician and pharmacist: attitudes, facilitators, and barriers to prescribing naloxone for home rescue. Am J Addict.2020;29(1):65–72.
25.
PeckhamAM, NiculeteME, SteinbergH, BoggsDL.A survey of prescribers’ attitudes, knowledge, comfort, and fear of consequences related to an opioid overdose education and naloxone distribution program. J Public Health Manag Pract.2018;24(4):310–317.
26.
PenmJ, MacKinnonNJ, LyonsMS, TolleE, SneedGT.Combatting opioid overdoses in Ohio: Emergency Department Physicians’ prescribing patterns and perceptions of naloxone. J Gen Intern Med.2018;33(5):608–609.
27.
WilsonJD, BerkJ, MatsonPA cross-sectional survey using clinical vignettes to examine overdose risk assessment and willingness to prescribe naloxone. J Gen Intern Med.2019;34(4):507–509.
28.
DevriesJ, RafieS, PolstonG.Implementing an overdose education and naloxone distribution program in a health system. J Am Pharm Assoc.2017;57(2S):S154–S160.
29.
HanJK, HillLG, KoenigME, DasN.Naloxone counseling for harm reduction and patient engagement. Fam Med.2017;49(9):730–733.
30.
WinogradRP, DavisCS, NiculeteM, OlivaE, MartielliRP.Medical providers’ knowledge and concerns about opioid overdose education and take-home naloxone rescue kits within Veterans Affairs health care medical treatment settings. Subst Abus.2017;38(2):135–140.
31.
WilsonJD, SpicynN, MatsonP, AlvanzoA, FeldmanL.Internal medicine resident knowledge, attitudes, and barriers to naloxone prescription in hospital and clinic settings. Subst Abuse.2016;37(3):480–487.
32.
BinswangerIA, KoesterS, MuellerSR, GardnerEM, GoddardK, GlanzJM.Overdose education and naloxone for patients prescribed opioids in primary care: a qualitative study of primary care staff. J Gen Intern Med.2015;30(12):1837–1844.
33.
ImDD, CharyA, CondellaALEmergency Department Clinicians’ attitudes toward opioid use disorder and emergency department-initiated buprenorphine treatment: a mixed-methods study. West J Emerg Med.2020;21(2):261–271.
34.
VarleyAL, LappanS, JacksonJUnderstanding barriers and facilitators to the uptake of best practices for the treatment of co-occurring chronic pain and opioid use disorder. J Dual Diagn.2020;16(2):239–249.
35.
SobelHG, GoeddeM, MarutiS, Hadley-StroutE, WahlbergE, KennedyAG.Primary care residents delivering care: integration of office-based opioid treatment into an internal medicine residency curriculum. Acad Psychiatry.2019;43(5):499–502.
36.
TesemaL, MarshallJ, HathawayRTraining in office-based opioid treatment with buprenorphine in US residency programs: a national survey of residency program directors. Subst Abuse.2018;39(4):434–440.
37.
TongST, HochheimerCJ, PetersonLE, KristAH.Buprenorphine provision by early career family physicians. Ann Fam Med.2018;16(5):443–446.
38.
SuzukiJ, EllisonTV, ConneryHS, SurberC, RennerJA.Training in buprenorphine and office-based opioid treatment: a survey of psychiatry residency training programs. Acad Psychiatry.2016;40(3):498–502.
39.
KoJY, TongVT, HaightSC, TerplanM, SneadC, SchulkinJ.Obstetrician-gynecologists’ practice patterns related to opioid use during pregnancy and postpartum-United States, 2017. J Perinatol.2020;40(3):412–421.
40.
McGintyEE, StoneEM, Kennedy-HendricksA, BachhuberMA, BarryCL.Medication for opioid use disorder: a national survey of primary care physicians. Ann Intern Med.2020;173(2):160–162.
41.
HoltSR, SegarN, CavalloDA, TetraultJM.The addiction recovery clinic: a novel, primary-care-based approach to teaching addiction medicine. Acad Med.2017;92(5):680–683.
42.
ChouinardS, PrasadA, BrownR.Survey assessing medical student and physician knowledge and attitudes regarding the opioid crisis. WMJ.2018;117(1):34–37.
43.
GuerreroE, OberAJ, HowardDLOrganizational factors associated with practitioners’ support for treatment of opioid use disorder in the emergency department. Addict Behav.2020;102:106197.
44.
Kennedy-HendricksA, BarryCL, StoneE, BachhuberMA, McGintyEE.Comparing perspectives on medication treatment for opioid use disorder between national samples of primary care trainee physicians and attending physicians. Drug Alcohol Depend.2020;216:108217.
45.
SamuelsEA, DwyerK, MelloMJ, BairdJ, KelloggAR, BernsteinE.Emergency Department-based opioid harm reduction: moving physicians from willing to doing. Acad Emerg Med.2016;23(4):455–465.
46.
SzottK.Contingencies of the will: uses of harm reduction and the disease model of addiction among health care practitioners. Health.2015;19(5):507–522.
47.
Kennedy-HendricksA, BuschSH, McGintyEEPrimary care physicians’ perspectives on the prescription opioid epidemic. Drug Alcohol Depend.2016;165:61–70.
48.
WangL, CunninghamCO, BrowderC, IyerS.Internal medicine residents’ feelings of responsibility, confidence, and clinical practice in opioid overdose prevention and naloxone prescribing. J Addict Med.2020;14(5):e147–e152.
49.
LinLA, LofwallMR, WalshSL, KnudsenHK.Perceived need and availability of psychosocial interventions across buprenorphine prescriber specialties. Addict Behav.2019;93:72–77.
50.
MartinA, KunzlerN, NakagawaJGet waivered: a resident-driven campaign to address the opioid overdose crisis. Ann Emerg Med.2019;74(5):691–696.
51.
SellJ, ViscontiA.Harm reduction: assessing the educational needs of family medicine residents in care of persons who inject drugs. Fam Med.2020;52(7):514–517.
52.
AppelG, AveryJJ, HoK, LivshitsZ, RaoRB, AveryJ.Improved emergency medicine physician attitudes towards individuals with opioid use disorder following naloxone kit training. Am J Emerg Med.2020;38(5):1039–1041.
53.
KermackA, FlanneryM, TofighiB, McNeelyJ, LeeJD.Buprenorphine prescribing practice trends and attitudes among New York providers. J Subst Abuse Treat.2017;74:1–6.
54.
LinLA, LofwallMR, WalshSL, GordonAJ, KnudsenHK.Perceptions and practices addressing diversion among US buprenorphine prescribers. Drug Alcohol Depend.2018;186:147–153.
55.
AndrillaCHA, CoulthardC, PattersonDG.Prescribing practices of rural physicians waivered to prescribe buprenorphine. Am J Prev Med.2018;54(6 Suppl 3):S208–S214.
56.
KnudsenHK, StudtsJL.Physicians as mediators of health policy: acceptance of medicaid in the context of buprenorphine treatment. J Behav Health Serv Res.2019;46(1):151–163.
57.
DavisCS, CarrD.Physician continuing education to reduce opioid misuse, abuse, and overdose: many opportunities, few requirements. Drug Alcohol Depend.2016;163:100–107.
58.
HillLG, SanchezJP, LaguadoSA, LawsonKA.Operation naloxone: overdose prevention service learning for student pharmacists. Curr Pharm Teach Learn.2018;10(10):1348–1353.
59.
SchartelA, LardieriA, MattinglyA, FeemsterAA.Implementation and assessment of a naloxone-training program for first-year student pharmacists. Curr Pharm Teach Learn.2018;10(6):717–722.
60.
MonteiroK, DumencoL, CollinsSAn interprofessional education workshop to develop health professional student opioid misuse knowledge, attitudes, and skills. J Am Pharm Assoc.2017;57(2):S113–S117.
61.
BuringSM, BhushanA, BroesekerAInterprofessional education: definitions, student competencies, and guidelines for implementation. Am J Pharm Educ.2009;73(4):59.
62.
CooperHLF, CloudDH, YoungAM, FreemanPR.When prescribing isn't enough – pharmacy-level barriers to buprenorphine access. N Engl J Med.2020;383(8):703–705.
63.
MosesTE, ChammaaM, RamosR, WaineoE, GreenwaldMK.Incoming medical students’ knowledge of and attitudes toward people with substance use disorders: implications for curricular training. Subst Abuse.2020;9:1–7.
64.
KomaromyM, DuhiggD, MetcalfAProject ECHO (Extension for Community Healthcare Outcomes): a new model for educating primary care providers about treatment of substance use disorders. Subst Abuse.2016;37(1):20–24.
65.
BerlandN, LugassyD, FoxAUse of online opioid overdose prevention training for first-year medical students: a comparative analysis of online versus in-person training. Subst Abuse.2019;40(2):240–246.
