Substance Abuse and Mental Health

Services Administration

Harm Reduction 

Framework
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framework

Recommended Citation

Substance Abuse and Mental Health Services Administration: Harm Reduction Framework. 

Center for Substance Abuse Prevention, Substance Abuse and Mental Health Services 

Administration, 2023.

Originating Office

Center for Substance Abuse Prevention, Substance Abuse and Mental Health Services 

Administration, 5600 Fishers Lane, Rockville, MD 20857.

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applicable Federal civil rights laws and does not discriminate on the basis of race, color, 

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of race, color, national origin, age, disability, religion, or sex (including pregnancy, sexual 

orientation, and gender identity). 
Harm Reduction Framework 3

Contents

Harm Reduction Framework for People Who Use Drugs (PWUD)...................................................... 4

Brief History and Background of Harm Reduction ........................................................................................5

Addressing Health Inequities .........................................................................................................................................6

Framework Overview ..........................................................................................................................................................6

• Framing Harm Reduction.................................................................................................................................7

• Pillars of Harm Reduction.................................................................................................................................8

• Table 1. Six Pillars of Harm Reduction.......................................................................................................8

• Supporting Principles........................................................................................................................................10

• Table 2. Principles of Harm Reduction...................................................................................................10

• Core Practice Areas.................................................................................................................................................. 12

• Table 3. Core Practice Areas...........................................................................................................................12

• Community-Based Harm Reduction Programs (CHRPs).........................................................17

Conclusion............................................................................................................................................................................17

References............................................................................................................................................................................18

Harm Reduction Steering Committee Members ......................................................................................... 25
4 Harm Reduction Framework

Harm Reduction Framework for People Who 

Use Drugs (PWUD)

The Biden-Harris Administration has identified harm reduction as a federal drug policy 

priority. The White House Office of National Drug Control Policy (ONDCP), in the 2022 

National Drug Control Strategy, notes that harm reduction is a public health approach 

designed to advance policies and programs in collaboration with people who use drugs 

(PWUD) and is supported by decades of evidence. Harm reduction strategies are shown to 

substantially reduce HIV and hepatitis C infection among people who inject drugs, reduce 

overdose risk, enhance health and safety, and increase by five-fold the likelihood of a person 

who injects drugs to initiate substance use disorder treatment.1, 2, 3

 In line with this, harm 

reduction is one of the four strategic priorities of the U.S. Department of Health and Human 

Services (HHS) Overdose Prevention Strategy developed to address the overdose public 

health emergency.4

In December 2021, the Substance Abuse and Mental Health Services Administration 

(SAMHSA) convened the first-ever federal Harm Reduction Summit, in partnership with 

the Centers for Disease Control and Prevention (CDC) and ONDCP. The Summit brought 

together more than 100 experts representing prevention, treatment, recovery, and harm 

reduction perspectives. Most importantly, Summit attendees included people with lived 

experience with substance use to help inform SAMHSA’s policies, programs, and practices 

as they relate to harm reduction. Additional partners included community members, 

advocates, harm reductionists, providers, funders, and others who are affected by these 

issues.

SAMHSA’s Harm Reduction Framework is one outcome of the Summit. This Framework is 

historic, as the first document to comprehensively outline harm reduction and discuss its 

role throughout HHS.

The Framework was developed and written in partnership with the Harm Reduction 

Steering Committee, composed of harm reduction leaders in the field from across the 

country. This group represents a broad array of backgrounds and experience, with most 

having lived experience of drug use. The Steering Committee synthesized findings from the 

Summit ― including a definition of harm reduction, pillars and principles supporting that 

definition, and core practices that SAMHSA can support. The Framework is adapted from 

the Committee’s final report.

This Framework will inform SAMHSA’s harm reduction activities moving forward, as well 

as related policies, programs, and practices. SAMHSA’s aim is to integrate harm reduction 

activities and approaches across its organizational Centers and initiatives, and to do so in 

a manner that draws on evidence-based practice and principles ― while also maintaining 

sustained dialogue with harm reductionists and people who use drugs (PWUD). The 

Framework will also inform SAMHSA’s thinking about opportunities to work with other 

federal, state, tribal, and local partners toward advancing harm reduction approaches, 

services, and programs.

SAMHSA defines harm reduction as a practical and transformative approach that 

incorporates community-driven public health strategies — including prevention, 

risk reduction, and health promotion — to empower PWUD and their families 

with the choice to live healthier, self-directed, and purpose-filled lives. Harm 

reduction centers the lived and living experience of PWUD, especially those in 

underserved communities, in these strategies and the practices that flow from them.
Harm Reduction Framework 5

Brief History and Background of Harm 

Reduction

Harm reduction has a long history in the United States. The field itself and harm reduction 

practice emerged decades ago, as direct community action and mutual aid in response 

to effects of the “War on Drugs,” an early and incomplete scientific understanding of 

substance use and substance use disorders, and government inaction to swiftly respond to 

the growing HIV/AIDS epidemic.5

In 1982, CDC published findings that the human immunodeficiency virus (HIV) is 

transmissible through the intravenous use of drugs.6 By 1983, PWUD began the 

distribution of sterile syringes to limit the transmission of HIV/AIDS.7 After the 1988 

restriction on federal funding for the purchase of syringes for needle and syringe 

exchange programs, PWUD and allies who operated syringe services programs 

(SSPs) across the country began to organize their work.8 In 1992, the first Harm 

Reduction Working Group meeting in the United States was held in San Francisco to 

create a unified definition of harm reduction. A major outcome of the group was the 

establishment of the National Harm Reduction Coalition.

9

Since the first Harm Reduction Working Group meeting in 1992, harm reduction has 

grown in scope and in practice. PWUD have innovated and sustained the movement 

despite criminalization of many harm reduction interventions and lack of financial and 

social support.

An important example is the advent of community naloxone distribution, which began 

in 1996.10 From 1996 through June 2014, 136 organizations reported distributing naloxone 

to 152,283 laypersons. Of the 109 organizations who collect reversal data, 26,463 overdose 

reversals were reported.11 Although the number of organizations distributing naloxone 

has doubled and since 2013 has included organizations other than SSPs, in 2014, SSPs 

still accounted for 80 percent of the distribution effort to PWUD, as well as 80 percent of 

overdose reversals.12

In 2019, SSPs distributed 702,232 doses of naloxone to 230,506 people in communities 

across the country.13 Studies have shown that communities may experience up to a 46 

percent reduction in opioid overdose mortality when more than 100 people who are likely 

to observe or experience an overdose per 100,000 population are enrolled into an Overdose 

Education and Naloxone Distribution (OEND) program.14 In addition, SSPs are associated 

with an estimated 50 percent reduction in HIV and hepatitis C incidence.15,16 When 

combined with medications that treat opioid use disorder (also known as medications for 

opioid use disorder or MOUD), hepatitis C virus and HIV transmission is reduced by more 

than two-thirds.17 The last few decades have solidified the evidence-based practices and 

individuals have become specialized subject matter experts in the field of harm reduction. 
6 Harm Reduction Framework

Addressing Health Inequities

In the spirit of Executive Order 13985,

18 SAMHSA is in the process of reviewing its policies to 

examine the intended and unintended impacts of its programs, policies, and procedures; 

incorporating racial justice and health equity into its policy goals; and advancing equitable 

support for Black, Latino, American Indian and Alaskan Native persons, Asian Americans, 

Native Hawaiians, and Pacific Islanders, and other persons of color; members of religious 

minorities; lesbian, gay, bisexual, transgender, queer, intersex (LGBTQI+) persons; persons 

with disabilities; persons who live in rural areas; and persons otherwise adversely impacted 

by persistent poverty or inequality. This is proactively undertaken to address past and 

present inequities.18 Integrating harm reduction principles and approaches throughout the 

agency is one strategy for advancing that commitment.

Deficient social determinants of health and structural inequalities contribute to and 

exacerbate substance use, substance use disorder, and mental illness, and can and do 

have a profound impact on some populations. Most notably, persons who have a history of 

familial, community or racial trauma may be particularly in need of compassionate services 

to support their pathways to improved health outcomes. Community practitioners and 

behavioral health providers must be culturally responsive and attentive to health equity 

to effectively improve individual and population level health. For this to be accomplished, 

community trust and buy-in must be earned, and that begins with truth and reconciliation 

of a community’s shared traumatic history and the structural racism that perpetuates 

inequities. On this foundation, trust and meaningful relationships can develop.19

“Formally acknowledging a community’s shared 

traumatic history is a fundamental step in preparing for 

and planning community engagement (CE) efforts that 

address health inequities.”19

This work is undertaken in partnership with SAMHSA’s Office of Behavioral Health Equity, 

which describes the work as: “Advancing health equity involves ensuring that everyone 

has a fair and just opportunity to be as healthy as possible. This also applies not only to 

behavioral health, but in conjunction with quality services, this involves addressing social 

determinants, such as employment and housing stability, insurance status, proximity to 

services, culturally responsive care — all of which have an impact on behavioral health 

outcomes.”20

Framework Overview

Harm reduction is practical in its understanding and acceptance that drug use and other 

behaviors that carry risk exist ― and responds in a compassionate and life-preserving 

manner. Harm reduction seeks to reduce the harmful impacts of stigma, mistreatment, 

discrimination, and harsh punishment of PWUD, especially those who are Black, 

Indigenous, and other People of Color.21 Building community partnerships with harm 

reduction organizations can positively shape beliefs and attitudes, reduce stigma, and 

ensure the well-being of the community at large.22
Harm Reduction Framework 7

Harm reduction also accounts for the intersection of drug use, other stigmatized behaviors, 

and people’s health. Fundamentally, a harm reduction approach meets people where they 

are, engaging with them and providing support.23

Harm reduction opens the door to more options for PWUD, for whom traditional treatment 

approaches are inaccessible, ineffective, or inappropriate — and who want to make safer, 

healthier choices with their life and health. Access to harm reduction services is consistently 

shown to improve individual and community outcomes. By viewing substance use on a 

continuum, incremental change can be made, allowing for risk reduction to better suit a 

person’s own individual goals and motivations.

Most importantly, harm reduction approaches save lives.

The SAMHSA definition of harm reduction contains six pillars, 12 principles, and six core 

practice areas that give life to harm reduction approaches, initiatives, programs, and 

services. The pillars are essential building blocks that are the foundation of what makes 

harm reduction effective. The pillars are further divided into supporting principles that are the 

specific concepts and ideals supporting each pillar. The SAMHSA Framework also describes 

the core components of community-based harm reduction programs.

Framing Harm Reduction

SAMHSA conceptualizes harm reduction as being a set of services, an approach, and a 

type of organization. Harm reduction has, at times, been reduced to a singular service or 

group of services, when in fact, its application goes well beyond this. Harm reduction as 

an approach — with supporting principles and pillars that can be applied to a variety of 

contexts — includes the provision of evidence-based treatment. An organization or an 

individual healthcare practitioner may not consider themselves as primarily providing 

harm reduction services but may adopt and apply practices and principles outlined in this 

Framework ― to enhance the services they offer and engage with PWUD in a manner 

informed by these principles. Any organization who works with PWUD can benefit from the 

integration of harm reduction as an approach.

Harm reduction is also part of the continuum of care and a comprehensive strategy that 

includes prevention, treatment, recovery, and health promotion. All of these elements are 

necessary — and people weigh them differently in different situations, at different points in 

their lives, and relative to a wide range of substances and behaviors.

Prevention, in particular primary prevention, seeks to prevent problems before they start. 

That means preventing exposure to substances (or screening and intervening with early 

misuse), reducing risk factors, and strengthening protective factors at the individual, 

relationship, community, and society levels. Prevention also seeks to stop or delay the 

progression of substance use to a substance use disorder, as well as prevent other harms 

associated with substance use.

Harm reduction recognizes the complex relationship people may have with substances, 

starting from first use, through the many possible intervention points from there. 

Harm reduction does not minimize the inherent harms associated with drug use and 

acknowledges that reducing harm can take different forms for different people at different 

points, including with the use of medications to treat substance use disorders. Harm 

reduction is also inclusive of abstinence as a chosen pathway but not inclusive of abstinence 

as a coerced pathway. 
8 Harm Reduction Framework

Harm reduction services must adhere to the harm reduction approach to maintain fidelity 

to the evidence base and lead to better outcomes. This is exemplified by the concept of 

Community-Based Harm Reduction Programs (CHRPs) described in this Framework.

Pillars of Harm Reduction

Table 1 summarizes the six pillars of harm reduction. Harm reduction initiatives, programs, 

or services should include these elements.

Table 1. Six Pillars of Harm Reduction

Harm Reduction...

1. Is led by people

who use drugs

(PWUD) and

with lived

experience of

drug use

Work is led by PWUD and those with lived and living experience 

of drug use. Harm reduction interventions that are evidence 

based have been innovated and largely implemented by PWUD. 

Through shared decision-making, people with lived experience 

are empowered to take an active role in the engagement process 

and have better outcomes.24 Put simply, the effectiveness of harm 

reduction programs is based on the buy-in and leadership of the 

people they seek to serve.

Organizations providing harm reduction services should have a 

formal mechanism to meaningfully include the voices of people 

with lived experience in the design, implementation, and evaluation 

of those services.25 Adopting at least two of the following specific 

mechanisms of inclusion is mission critical: employment of people 

with lived experience in both intervention and administrative roles, 

advisory boards of PWUD, and the consultation of CHRPs or any 

other peer-led organizations.

It is important to note that while people in recovery and people 

who formerly used drugs have valuable experience, centering 

the perspectives of people who currently use drugs (and the 

intersectionality with other historically marginalized individuals) and 

have a working understanding of the current, dynamic, and rapidly 

changing landscape of drug use in a particular community in which 

an organization is working, is essential to successful engagement 

and outcomes. This is exemplified in the provision of OEND 

Programs.26

2. Embraces the

inherent value

of people

All individuals have inherent value and are treated with dignity, 

respect, and positive regard.

Harm reduction initiatives, programs, and services are trauma 

informed, and never patronize nor pathologize PWUD, nor their 

communities. They acknowledge that substance use happens, and 

the reasons a person uses drugs are nuanced and complex. This 

includes people who use drugs to alleviate symptoms of an existing 

medical condition.
Harm Reduction Framework 9

Harm Reduction...(Cont.)

3. Commits 

to deep 

community 

engagement 

and community 

building

All communities that are impacted by systemic harms are leading 

and directing program planning, implementation, and evaluation.

Funding agencies and funded programs support and sustain 

community cultural practices, and value community wisdom and 

expertise. Agencies and programs develop through communityled initiatives focused on geographically specific, culturally 

based models that integrate language revitalization, cultural 

programming, and Indigenous care with dominant-society 

healthcare approaches.

4. Promotes 

equity, rights, 

and reparative 

social justice

All aspects of the work incorporate an awareness of (and actively 

work to eliminate) inequity related to race, class, language, sexual 

orientation, and gender-based power differentials.

Pro-health and pro-social practices that have worked well for specific 

cultural and/or geographic communities are aligned with organizing 

and mobilizing, providing direct services, and supporting mutual aid 

among PWUD.

CHRPs are often the best-placed organizations to respond to 

communities or individuals on racial justice and health equity 

issues, and provide services for Black, Latino, American Indian and 

Alaska Native persons, Asian Americans, Native Hawaiians, and 

Pacific Islanders, and other persons of color; members of religious 

minorities; LGBTQI+ persons; persons with disabilities; persons who 

live in rural areas; and persons otherwise adversely impacted by 

persistent poverty or inequality.

5. Offers most 

accessible and 

noncoercive 

support

All harm reduction services have the lowest requirements for access.

Participation in services is always voluntary, confidential (or 

anonymous), self-directed, and free from threats, force, and the 

concept of compliance. Any data collection requires informed 

consent and participants should not be denied services for not 

providing information. This means using low-threshold evaluation 

and data collection systems to measure the effectiveness of harm 

reduction programs.

6. Focuses on any 

positive change, 

as defined by 

the person

All harm reduction services are driven by person-centered positive 

change in the individual’s quality of life.

Harm reduction initiatives, programs, and services recognize that 

positive change means moving towards more connectedness to 

the community, family, and a more healthful state, as the individual 

defines it. There are many pathways to wellness; substance use 

recovery is only one of them. Abstinence is neither required nor 

discouraged.
10 Harm Reduction Framework

Table 2. Principles of Harm Reduction

Supporting 

Principles Principle Description

Respect

autonomy

Each individual is different. It is important to meet people where 

they are, and for people to lead their own individual journey. Harm 

reduction approaches, initiatives, programs, and services value and 

support the dignity, personal freedom, autonomy, self-determination, 

voice, and decision making of PWUD.

Practice 

acceptance and 

hospitality

Love, trust, and connection are important in harm reduction work. 

Harm reduction approaches, initiatives, programs, and services hold 

space for people who are at greatest risk for marginalization and 

discrimination. These elements emphasize trusting relationships and 

meaningful connections and understand that this is an important way 

to motivate people to find personal success and to feel less isolated.

Provide support Harm reduction approaches, initiatives, programs, and services provide 

information and support without judgment, in a manner that is 

non-punitive, compassionate, humanistic, and empathetic. Peer-led 

services enhance and support individual positive change and recovery; 

and peer-led leadership leads to better outcomes.

Connect with 

community

Positive connections with community, including family members 

(biological or chosen) are an important part of well-being. Community 

members often assist loved ones with safety, risk reduction, or 

overdose response. When possible, harm reduction initiatives, 

programs, and services support families in expanding and deepening 

their strategies for love and support; and include families in services, 

with the explicit permission of the individual.

Provide many 

pathways to 

well-being across 

the continuum of 

health and social 

care

Harm reduction can and should happen across the full continuum 

of health and social care, meeting whole-person health and social 

needs. In networking with other providers, harm reduction initiatives, 

programs, and services work to build relationships and trust with 

health and social care partners that embrace supporting principles. 

To help achieve this, organizations practicing harm reduction utilize 

education and encourage policies that facilitate interconnectedness 

between all parties.

Supporting Principles

The pillars are supported and reinforced by 12 core principles that guide the work. As with 

the pillars, the principles are vital. Programs that do not incorporate all 12 principles risk 

violating the spirit of harm reduction.
Harm Reduction Framework 11

Supporting 

Principles Principle Description...(Cont.)

Value practicebased evidence 

and onthe-ground 

experience

Structural racism and other forms of discrimination have limited the 

development and inclusion of research on what works in underserved 

communities. Harm reduction initiatives, programs, and services 

understand these limitations and use community wisdom and 

practice-based evidence as additional sources of knowledge.

Cultivate 

relationships

Relationships are of central importance to harm reduction. Harm 

reduction approaches, initiatives, programs, and services are relational, 

not transactional, and work to establish and support quality 

relationships between individuals, families, and communities.

Assist, not direct Harm reduction approaches, initiatives, programs, and services support 

people on their journey towards positive change, as they define it. 

Support is based on what PWUD identify as their needs and goals (not 

what programs think they need), offering people tools to thrive.

Promote safety Harm reduction approaches, initiatives, programs, and services actively 

promote safety as defined by the people they serve. These efforts 

also acknowledge the impact that law enforcement can have on 

PWUD (particularly in historically criminalized and marginalized 

communities) and provide services accordingly.

Engage first Each community has different cultural strengths, resources, 

challenges, and needs. Harm reduction approaches, initiatives, 

programs, and services are grounded in the most impacted 

and marginalized communities. It is important that meaningful 

engagement and shared decision making begins in the design phase 

of programming. Equally important is bringing to the table as many 

individuals and organizations as possible who understand harm 

reduction and who have meaningful relationships with the affected 

communities.

Prioritize

listening

Each community has its own unique story that can be the foundation 

for harm reduction work. When we listen deeply, we learn what 

matters. Harm reductionists engage in active listening ― the act of 

inviting people to express themselves completely, recognizing the 

listener’s inherent biases, with the intent to fully absorb and process 

what the speaker is saying.

Work toward 

systems change

Harm reduction approaches, initiatives, programs, and services 

recognize that trauma; social determinants of health, such as access 

to healthcare, housing, and employment; inequitable policies; lack of 

prevention and early intervention strategies; and social support have 

all had a responsibility in systemic harm.
12 Harm Reduction Framework

Core Practice Areas

Core practices are effective methods for harm reduction that reflect community 

understanding, experience, strengths, and needs. There are six core practice areas: (1) 

safer practices; (2) safer settings; (3) safer access to healthcare; (4) safer transitions to care; (5) 

sustainable workforce and field; and (6) sustainable infrastructure.

While not an exhaustive list, Table 3 provides key strategies and links to resources. 

Anyone in the United States can access free, direct technical assistance (in any of the 

core practice areas) from SAMHSA and CDC. SAMHSA’s harm reduction webpage offers 

resources, including allowable expenses for its grants that support harm reduction activities.

Table 3. Core Practice Areas

Examples of Practices Supporting Resources and Evidence 

(Research- and Practice-based)

Safer Practices: Education and support describing how to reduce risk; provision of risk 

reduction supplies and materials

Needs Based Syringe Services 

Programs (SSPs) — also referred 

to as syringe exchange programs 

(SEPs) and needle exchange 

programs (NEPs),* including 

secondary exchange.1,17,19,22,26,27,28,29

CDC Syringe Services Programs Technical Package

SAMHSA TIP 33 Treatment for Stimulant Use Disorders

SAMHSA TIP 63 Medications for Opioid Use Disorder

Safer smoking supplies/

distribution to reduce infectious 

disease transmission.* 29,30,31

*As permitted by law. No

federal funding is used directly

or through subsequent

reimbursement of grantees to

purchase pipes. Grants include

explicit prohibitions of federal

funds to be used to purchase

drug paraphernalia.

CDC Stimulant Guide

Overdose education, overdose 

detection services, and naloxone 

distribution.10,13,26,29,32

CDC Lifesaving Naloxone Guide

SAMHSA What is Naloxone?

SAMHSA TIP 63 Medications for Opioid Use Disorder

SAMHSA Opioid-Overdose Reduction Continuum of 

Care Approach (ORCCA) Practice Guide 2023

Engaging Community Coalitions to Decrease Opioid 

Overdose Deaths Practice Guide 2023
Harm Reduction Framework 13

Examples of Practices Supporting Resources and Evidence 

(Research- and Practice-based)...(Cont.)

Drug-checking education, 

fentanyl test strips, xylazine 

test strips and other assay test 

strips, FTIR spectrometers, and 

other drug-checking technology 

at community drug-checking 

sites.

33,34

CDC MMWR: Rapid Analysis of Drugs: A Pilot 

Surveillance System to Detect Changes in the Illicit 

Drug Supply to Guide Timely Harm Reduction 

Responses

Overdose Data to Action: Surveillance Strategies | 

Drug Overdose | CDC Injury Center

SAMHSA Federal Grantees May Now Use Funds to 

Purchase Fentanyl Test Strips

Integrated reproductive health 

education, services and supplies, 

and sexually transmitted infection 

screening, prevention, and 

treatment.35,36,37,38

SAMHSA TIP 33 Treatment for Stimulant Use Disorders

Onsite access or immediate 

accessible referral to basic wound 

care supplies and services in the 

community.38

Wound Care & Medical Triage for People Who Use 

Drugs and the Programs That Serve Them | NASTAD

CDC Syringe Services Program Technical Package

Safer Settings: Access to safe environments to live, find respite, practice safer use, and 

receive supports that are trauma-informed and stigma-free

Day centers and social spaces 

that offer harm reduction 

services, are low barrier, and 

are led and maintained by the 

communities they serve.39

SAMHSA Peer Support Services in Crisis Care

Access to safe and secure 

housing.33,40

SAMHSA Homeless & Housing Resource Center

Public health programs as 

alternatives to arrest and any legal 

system involvement.20,41

SAMHSA Criminal and Juvenile Justice Resources

Hybrid recovery community 

organizations providing peerdelivered harm reduction and 

recovery support services.42

Peer Recovery Center of Excellence
14 Harm Reduction Framework

Examples of Practices Supporting Resources and Evidence 

(Research- and Practice-based)...(Cont.)

Safer Access to Healthcare: Ensuring access to person-centered and non-stigmatizing 

healthcare that is trauma informed, including FDA-approved medications

Low-barrier treatment services 

that offer a whole-person 

approach and rapid re-initiation, 

if needed.43

SAMHSA Practical Tools for Prescribing and Promoting 

Buprenorphine in Primary Care Settings

Flexible provision of services 

that offer medication starts at 

first visit or at home, choice of 

medications, and individualized 

dosages.44

SAMHSA Practical Tools for Prescribing and Promoting 

Buprenorphine in Primary Care Settings

Healthcare settings and providers 

are directly informed by harm 

reduction principles, pillars, and 

the people they serve.45,46,47

SAMHSA Engaging Community Coalitions to Decrease 

Opioid Overdose Deaths Practice Guide 2023

Nonpunitive care that 

consistently offers the standard 

of care in a nonstigmatizing, 

nonjudgmental manner and 

does not refuse healthcare based 

on stigma or personal beliefs 

about PWUD.48

Overcoming Stigma, Ending Discrimination

Mobile access and take-home 

methadone medication.49,50,51,52

SAMHSA Methadone Take-Home Flexibilities 

Extension Guidance

Mobile buprenorphine services, 

including telehealth options 

for initiation and continuity of 

care.53,54,55,56

SAMHSA The Physical Evaluation of Patients Who Will 

Be Treated with Buprenorphine at Opioid Treatment 

Programs

Access to new paradigms of care, 

including treatment specific to 

the use of all drugs and/or each 

drug.57,58

SAMHSA Treating Concurrent Substance Use Among 

Adults

Onsite or quick referral, lowbarrier oral health services that 

are informed by lived experience 

of substance use.

59

Oral Health, Mental Health and Substance Use 

Treatment
Harm Reduction Framework 15

Examples of Practices Supporting Resources and Evidence 

(Research- and Practice-based)...(Cont.)

Safer Transitions to Care: Connections and access to harm-reduction-informed and 

trauma-informed care and services

Health hubs for PWUD/ integrated 

HIV, viral hepatitis, and healthcare 

services.26,38,60,61,62,63,64

Center of Excellence for Integrated Health Solutions

CDC HIV Risk Reduction Tool

Expand telehealth, while also 

addressing low technology 

literacy and enhancing access in 

languages other than English.54

SAMHSA Telehealth for the Treatment of Serious 

Mental Illness and Substance Use Disorders

SAMHSA Culturally Competent LEP and Low-literacy 

Services

Warm hand-off to and from 

emergency department programs 

― with low-barrier MOUD 

initiation and post- overdose 

services.38,65

SAMHSA Connecting Communities to Substance Use 

Services: Practical Tools for First Responders

ACA Expanding Access to Medications for Opioid Use 

Disorder in Corrections and Community Settings 

Medication access and treatment 

on-demand (abstinence not 

required).26,66,67,68

SAMHSA Practical Tools for Prescribing and 

Promoting Buprenorphine in Primary Care Settings

CDC Linking People with Opioid Use Disorder to 

Medication Treatment

Onsite or immediate referral to 

accessible nutritional assistance, 

clothing, temporary shelter, and 

housing.65

SAMHSA Homeless & Housing Resource Center

SAMHSA Expanding Access to and Use of 

Behavioral Health Services for People Experiencing 

Homelessness

Seamless coordination of care 

for individuals leaving carceral 

settings and treatment settings 

that do not offer medications, 

because people are at greatly 

heightened risk for overdose 

fatality when back in the 

community.65

SAMHSA GAINS Center

ACA Expanding Access to Medications for Opioid Use 

Disorder in Corrections and Community Settings

SAMHSA Best Practices for Successful Reentry from 

Criminal Justice Settings for People Living With 

Mental Health Conditions and/or Substance Use 

Disorders
16 Harm Reduction Framework

Examples of Practices Supporting Resources and Evidence 

(Research- and Practice-based)...(Cont.)

Sustainable Workforce and Field: Resources for maintaining a skilled, well-supported, 

and appropriately managed workforce and for sustaining community-based programs

Organizational leadership from 

people with living and lived 

experience.26

ASPE Methods and Emerging Strategies to Engage 

People with Lived Experience

SAMHSA Participation Guidelines for Individuals with 

Lived Experience and Family

NHRC Peer Delivered Syringe Exchange (PDSE) 

Toolkit

SAMHSA TIP 64: Incorporating Peer Support into 

Substance Use Disorder Treatment Services

Living wages and essential 

benefits for harm reduction 

workers.69,70

SAMHSA National Model Standards for Peer Support 

Certification

Wellness services and support 

for harm reduction staff and 

volunteers without mandated 

abstinence.39,71

SAMHSA National Model Standards for Peer Support 

Certification

Training and technical assistance 

for community-based providers.38

SAMHSA Practitioner Training

Include harm reduction expertise 

and lived expertise in the selection 

process of reviewers for harm 

reduction grants and other 

competitive processes.72

SAMHSA Grant Review Process

Sustainable Infrastructure: Resources for building and maintaining a revitalized 

and community-led infrastructure to support harm reduction best practices and 

the needs of PWUD

Hire and appropriately compensate 

PWUD to inform policy at agencies 

that serve PWUD.73

SAMHSA National Model Standards for Peer Support 

Certification

Co-leadership of PWUD in 

organizational partnership in 

research.

74

SAMHSA National Model Standards for Peer Support 

Certification

Promote education on the value of 

harm reduction services.

26,75, 76,77,78,79

CDC/SAMHSA National Harm Reduction Technical 

Assistance Center

SAMHSA Harm Reduction

SAMHSA National Model Standards for Peer Support 

Certification
Harm Reduction Framework 17

Community-Based Harm Reduction Programs (CHRPs)

While integrating harm reduction (as an approach and as services) into a wide variety 

of settings is beneficial to the people who are served and impacted by them, SAMHSA 

is committed to supporting harm reduction organizations that are by and for their 

community ― as they are mission critical for connecting to our communities’ most 

marginalized individuals.

CHRPs describe harm reduction organizations where people with lived and living 

experience lead the planning and oversight, program development and evaluation, and 

resource/funding allocation for an organization’s harm reduction initiatives, programs, and 

services. CHRPs also offer the core practice areas, as permitted by law. Harm reduction 

activities may be integrated into a comprehensive, person-centered program of care that 

includes treatment services that meet the specific needs of the community in which the 

program is housed.

In addition to programs being consistent with all aforementioned principles and pillars, 

CHRPs should include people with lived experience as co-investigators in any research 

project. Boards, staff, and team members should be at least 51 percent those with lived 

experience. CHRPs demonstrate meaningful connection to PWUD in their community, 

especially to communities most marginalized, and provide lowest-barrier, core harm 

reduction practices.

Conclusion

The Harm Reduction Summit was a groundbreaking event that engaged a diversity of 

perspectives across the fields of prevention, treatment, recovery, and harm reduction. More 

than 100 participants attended the Summit, representing the private sector, communitybased organizations, health care, faith-based organizations, academia, researchers, funders, 

law enforcement, and leaders from federal, state, local, and tribal governments.

The subsequent Steering Committee synthesized and refined the Summit findings, 

providing guidance for this Framework. Moving forward, this Framework will inform 

SAMHSA’s harm reduction activities, as well as related policies, programs, and practices. 

SAMHSA’s aim is to integrate harm reduction activities and approaches across its 

organizational Centers and initiatives, and to do so in a manner that draws on evidencebased practice and principles — while also maintaining sustained dialog with harm 

reductionists and PWUD.

SAMHSA is committed to continued collaboration with PWUD and the field to put this 

Framework into practice, support and expand harm reduction approaches and services, 

and ultimately save lives.
18 Harm Reduction Framework

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20 Harm Reduction Framework

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Harm Reduction Framework 25

Harm Reduction Steering 

Committee Members

Mark Jenkins

Founder and Executive Director 

Connecticut Harm Reduction Alliance 

Hartford, CT

Elizabeth Burden

Senior Advisor

National Council for Mental Wellbeing

Phoenix, AZ

Jessica Tilley

Founder

HRH413

Northampton, MA

Hiawatha Collins

Community and Capacity Building Manager 

National Harm Reduction Coalition

New York, NY

Sherrine Peyton

State Opioid Settlement Administrator 

Illinois Department of Human Services 

Chicago, IL

Rafael A. Torruella 

Executive Director 

Intercambios Puerto Rico 

Fajardo, PR

Maya Doe-Simkins

Co-Founder

Harm Reduction Michigan 

Traverse City, MI

Chad Sabora

Vice President of Government and Public

Relations

Indiana Center for Recovery 

St. Louis, MO

Marielle A. Reataza

Executive Director

National Asian Pacific American Families

Against Substance Abuse

Alhambra, CA

Charles King

Chief Executive Officer 

Housing Works

New York, NY

Justine Waldman

Founder and Chief Executive Officer 

REACH Medical

Ithaca, NY

Rafael Rivera

Deputy Director

Bureau of Prevention Services, Illinois

Department of Human Services 

Chicago, IL

Louise Vincent

Executive Director

North Carolina Urban Survivors Union 

Greensboro, NC

Christine Rodriguez

Senior Program Manager 

AIDS United 

Washington, DC

Philomena Kebec

Economic Development Coordinator 

Bad River Tribe

Odanah, WI

Caty Simon

Leadership Team Member 

Urban Survivors Union 

Holyoke, MA

Stephanie Campbell

Behavioral Ombudsman Project Director 

New York State Office of Addiction Services

and Supports

Albany, NY

Anthony D. Salandy

Interim Executive Director, Managing Director

of Programs

National Harm Reduction Coalition 

New York, NY

Chase Holleman

Public Health Analyst

Substance Abuse and Mental Health Services

Administration (SAMHSA)

Greensboro, NC

Shannon Mace

Executive Director

Legal Assistance Project: A Medical-Legal Partnership

Philadelphia, PA
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Substance Abuse and Mental Health

Services Administration

SAMHSA’s mission is to lead public health and service delivery efforts that promote mental 

health, prevent substance misuse, and provide treatments and supports to foster recovery while 

ensuring equitable access and better outcomes.

1-877-SAMHSA-7 (726-4727) • 1-800-487-4889 (TTY) www.samhsa.gov