Implementation of harm reduction strategies in criminal-legal systems: a scoping review of the literature.

BACKGROUND: Harm reduction is a public health approach that emphasizes strategies to reduce the negative consequences of drug use. Rising overdose deaths in the United States have prompted integration of harm reduction strategies within criminal-legal systems (CLS), which have historically emphasized deterrence. However, the scope and nature of these strategies across the CLS remain poorly understood. METHODS: We conducted a scoping review, in accordance with PRISMA guidelines, to identify harm reduction strategies targeting illicit drug use that have been implemented within CLS settings in the United States. We searched seven databases for peer-reviewed articles published in the last 10 years. Eligible articles reported on implementation of a harm reduction strategy focused on reaching PWUD in a CLS setting. Using the Sequential Intercept Model as a guiding framework, we mapped strategies to law enforcement, initial detention/court hearings, jails and courts, reentry, and community corrections settings. We used DistillerSR to screen articles and abstract data. RESULTS: From 455 records, 99 articles met inclusion criteria, representing 51 discrete instances of harm reduction strategy implementation. Implementation was most common in custody settings (e.g., jails and courts) and frequently included initiation of medication for opioid use disorder, naloxone distribution, and CLS referral/diversion. Fewer instances of implementation were documented in early stage or community-based settings. CLS staff were directly involved in delivering over 75% of the harm reduction strategies, and one-third included partnerships with non-CLS government agencies. Nearly one-third of the strategies were implemented as part of research studies. CONCLUSIONS: Harm reduction strategies have increasingly been integrated into CLS, though unevenly and often with a narrow clinical focus. Expanding harm reduction within CLS will require broader definitions, system-level buy-in, and efforts to align practice with public health evidence.