We’ve been writing Substance Use Disorder / Opioid Use Disorder (SUD/OUD) treatment grant proposals since 1993, so we’ve been at it for long enough to see waves of funder preferences around approaches come and go. SUD/OUD are hard problems, and made harder because of the misinformation and disinformation about Oxycodone and Oxycontin that Purdue Pharma and its subsidiaries spread for decades, in a way that’s likely worse than the way the cigarette companies once marketed their wares.
For the first 20 years or so in business, the SUD/OUD treatment grant proposals we wrote were usually based on the standard “Step-Down” paradigm, in which people with addiction receive treatment along a continuum of care from a high level of care and then “step down” to lower care levels in increments, leading to eventual recovery and self-care. Following engagement, referral, or self-presentation and development of an individual treatment plan (ITP), the step-down levels are more or less like this:
- Inpatient treatment
- Intensive outpatient treatment
- Outpatient treatment, often including 12-Step peer support groups and, for those with OUD, medication assisted treatment (MAT)
- Recovery and self-care
The levels can be further broken down, but the above is a common schema. As patients move down the treatment continuum, they usually receive case-managed wraparound supportive services—like legal assistance, workforce development, primary/dental care, affordable housing, etc.— at least until they are in recovery and have been “clean and sober” for six to twelve months. The “affordable housing” part has gotten much harder, though, because most cities use zoning laws to restrict the supply of housing, which causes prices to rise, which makes a given housing unit difficult for a grant-funded organization, or a person with drug addiction, to afford. Also, it’s an unfortunate reality that most people with SUD/OUD will relapse multiple times, sending them to the top of the treatment pyramid again. In this way, step-down treatment is something like the classic board game Chutes and Ladders I played as a kid. “Step down” was the main “treatment game” available for decades, although methadone was sometimes used for what we now call OUD.
About ten years ago, we began noticing a difference in SAMSHA, HRSA, and other RFPs for SUD/OUD: those agencies now want usually applicants to augment treatment to include “harm reduction.” As defined and described by SAMHSA, “Harm reduction is critical to keeping people who use drugs alive and as healthy as possible, and is a key pillar in the multi-faceted Health and Human Services’ Overdose Prevention Strategy.” Most of our clients resisted this shift but have gradually gotten on board the harm reduction train as pure harm reduction RFPs, like SAMHSA’s “FY ’22 Harm Reduction NOFO,” began to appear. The shift isn’t surprising, because in grant seeking it pays to follow the golden rule. No, not that golden rule, this one: “The people with the gold make the rules.”
Harm reduction projects usually involve a van-based outreach model in which Peer Support Workers (PSWs) go in teams to what are termed “hot spots” to engage people living with SUD/OUD. “Hot spots” include places like homeless encampments, shelters, parks, etc. The outreach effort can be either obvious (e.g., signage on the van and PSWs in logo t-shirts) or on the down low (e.g., plain white van and PSWs in street clothes), or a hybrid version using magnetic signs placed on the van, or removed from it, depending on the needs of a particular location on a given day. The PSWs distribute harm reduction supplies like clean syringes (with or without exchange), alcohol swabs, sterile water ampules, spoons, fentanyl test strips, sharps containers, and condoms, along with emergency food, clothing, hygiene items, and so forth. The outreach van is also used to provide some direct services in the field like wound care, rapid HIV tests, and naloxone administration.
The most extreme version of harm reduction are safe injection sites: while these are illegal in most of America because the drugs themselves are technically illegal, if widely available, three safe injection sites have recently and prominently opened, two in NYC and one in San Francisco. One key problem with a safe injection site initiative is that few businesses or residents want one near them, much like no one wants to be in proximity of a methadone clinic, so permitting is a real challenge. We’ve yet to write a safe injection site proposal but likely soon will.
A key difference between the standard treatment model and the harm reduction model is that clients are typically not tracked (when Joe or Mary shows up for supplies, their identity isn’t verified and they aren’t entered into a client database for tracking), and, most significantly, services aren’t case-managed. PSWs will offer “warm handoffs” for follow-up treatment like MAT and other center-based services, but there’s no automated follow-up from the harm reduction team.
We’re just grant writers, so we don’t have an immediate opinion as to whether step-down treatment or harm reduction is more efficacious, and most studies on the subject are somewhat questionable, although every treatment/harm reduction proposal we write claims the project design uses “evidence-based practices” (EBPs). When in doubt, claim both “evidence” and “innovation” for your program, leaving aside that those two are often mutually exclusive. If your agency provides SUD/OUD treatment, consider adding a harm reduction component, as this is clearly where the feds are going with grant funds. A cynic might conclude that the feds are pushing harm reduction because it’s much cheaper than providing longitudinal case-managed treatment, but we’ll leave that conclusion to others.