Harm reduction services, such as overdose education and distribution of naloxone, help reduce opioid-related overdose and infectious disease transmission. However, expansion of harm reduction services into many non-urban communities that face increasing opioid and polysubstance use is limited. We conducted qualitative interviews with 22 professionals working with people who use drugs in Rhode Island and Massachusetts to understand challenges and strategies for engaging communities in accepting harm reduction services.

Our thematic analysis identified several challenges, including: (1) limited understanding of harm reduction practices, (2) community-level stigma against people who use drugs and agencies supporting them, (3) data reporting leading to inaccurate perceptions about substance use patterns and health consequences, and (4) a “prosecutorial mindset ”against drug use and harm reduction. From key informants’ narratives, we also identified strategies that communities could use to address these challenges, including: (1) identifying local champions to advocate harm reduction strategies, (2) educating communities about harm reduction approaches before implementation, (3) improving the visibility of harm reduction services, and (4) obtaining “buy-in ”from stakeholders.

These findings carry important implications for expanding harm reduction services, including syringe service programs and safe injection sites, into non-urban communities that need to reduce drug-related overdose and infectious disease transmission.