"This tough love sh*t is just not love": Exploring harm reduction in Massachusetts homeless shelters.

BACKGROUND

Harm reduction can decrease negative consequences of substance use, but the extent to which harm reduction practices are implemented in emergency shelter settings is unknown.

METHODS

We conducted 55 semi-structured interviews at four shelters across Massachusetts to understand guest (40) and staff (15) experiences with harm reduction practices. We conducted thematic analysis rooted in the Social Ecological Model (SEM).

RESULTS

Well-established harm reduction practices include naloxone distribution, bathroom checks, and safe-sex supplies. Less established practices include wound care supplies, bad-date lists for people engaging in survival sex work, "no questions asked" lockers, amnesty beds, and abolishing curfews. Recommended future practices include safer consumption spaces, drug checking, and a full suite of harm reduction supplies. Key findings at each SEM level were: At the individual level: guest and staff attitudes toward harm reduction were mixed and influenced by personal experience, or gender identity. At the interpersonal level: tensions between people who use drugs (PWUD) and others who are abstinent; stigma prevents guests from being candid with staff about substance use, and fuels tension between staff and guests. At the community level: Guests and staff have access to naloxone at shelters, carry it, and use it regularly; communication around the presence and availability of naloxone is essential; women innovate distinct interventions for themselves. Last, at the societal level: prohibitory policies do not stop people from using drugs but make people less safe; shelters can collaborate with community organizations to provide necessary harm reduction services.

CONCLUSIONS

Shelters are implementing increasingly creative programs of harm reduction practices.