Substance Use, Harm Reduction & Values

Skip anything

Every question is optional. No one has to retell painful events, name a diagnosis, or choose a religion or identity to begin.

Pause or stop

Stop at any point. Nothing is sent anywhere, and nothing is shared unless the person chooses it in the sharing review.

Whose words

Record who said each thing: the person, a caregiver or surrogate, or a professional. A caregiver's needs get their own field.

Support to take part

Extra time, a quieter place, pictures, an interpreter or a trusted person can help someone say what matters. Ask what helps.

Barriers are not preferences

Cost, travel, work, housing, caring for others and digital access are written down as barriers, not as what the person wants.

Meaning, religious or not

Hope, purpose, faith, relationships and identity can be part of the conversation if the person wants. None is assumed.

• Physician, nurse or pharmacist: Medicines, including treatment for opioid use, and how they fit with other care.
• Counselor or psychologist: Psychosocial treatment and support.
• Peer support worker: Lived experience of recovery, where such roles exist.
• Harm-reduction worker: Safer-use supplies and overdose prevention, where these services are legal and available.
• Social worker: Housing, income, legal and practical barriers.
• Chaplain or spiritual-care provider: Meaning, distress, hope and relationships, for people of any faith or none.
• People the person chooses: Family, friends, or a community or faith contact, only if the person wants them. Never assumed safe, available or wanted.

Roles, titles and training differ by country and service. Not every role exists everywhere.

A small set of places chosen for contrast, not a ranking or a representative survey: Global, Viet Nam, Iran, Portugal, Kenya, India, Brazil, France; United States, Multi-country. Each example states what its source establishes and what it does not. Policy on paper is not proof that a service is available.

Guidance, not outcomes:

Shows what is written or recommended. It does not show that it is followed or what results.

Abstract only:

Read from the abstract. The full paper may add or qualify this.

Policy, not outcomes:

Shows what is written or recommended. It does not show that it is followed or what results.

Service as described:

Describes a service when the source was written. Whether it still runs is not verified.

• Global · Guidance · 2020

  WHO/UNODC standards say people with drug use disorders should, as capacity allows, make treatment decisions, including when to start and stop and its nature, with informed consent and confidential records.

  Limits: Guidance, not outcomes

  What others could learn: The standards say people with drug use disorders should, to the extent they have capacity, decide whether to start and stop treatment and its nature.

  Conditions, limits and source

  Conditions that matter:

  Requires legal protection of health-record confidentiality (standard 2.3), staff ethics training (2.4), informed consent with a guaranteed option to withdraw (2.2), and treatment distinct from compulsory or detention centers.

  Cannot be inferred:

  Cannot infer any country complies, that consent practices are adequate anywhere, or that this principle improves clinical outcomes.

  Limits:

  Evidence level: normative ethical principle, not a graded recommendation or measured outcome. Non-binding; says nothing about whether services meet it. The same document distinguishes treatment from compulsory or detention centers that confine people without consent.

  Source: World Health Organization; United Nations Office on Drugs and Crime, International standards for the treatment of drug use disorders: revised edition incorporating results of field-testing (Chapter 2, Principle 2 (Ensuring ethical standards of care), description; printed p. 9 (PDF p. 17)). Where: Global. Population: People with drug use disorders. Published 2020; retrieved 2026-10-11.

• Global · Service described in 2024

  In WHO's 2019 survey (145 countries), only 16 reported drug and 17 alcohol treatment contact coverage; reported values ran from 0.3% to 35% for drug and up to 14% for alcohol use disorders.

  What others could learn: Where measured, contact with treatment was low, and most responding countries could not report it, so treatment access is hard to monitor.

  Conditions, limits and source

  Conditions that matter:

  Coverage depends on registered and reimbursed medicines, trained workforce, data systems and financing; the report links service capacity to country income level.

  Cannot be inferred:

  Cannot infer coverage in non-reporting countries, treatment quality, or whether people received the care they wanted.

  Limits:

  Evidence level: government-reported survey data, 2019. Contact coverage data exist for only 17 countries (alcohol) and 16 (drugs); about one third of countries do not collect epidemiological data. Contact with services does not equal effective treatment.

  Source: World Health Organization, Global status report on alcohol and health and treatment of substance use disorders (Executive summary, 'Treatment coverage and Service Capacity Index (SCI)'; printed p. xv (PDF p. 17); repeated in section 3.2.1, printed p. 107). Where: Global (145 countries responding to WHO SDG 3.5 survey). Population: People with alcohol and drug use disorders. Published 2024-06-25; retrieved 2026-10-11.

• Viet Nam · Measured outcome · 2018

  In a three-year Vietnamese observational study, voluntary community methadone was associated with larger reductions in heroin use and blood-borne virus risk behaviors than compulsory center-based treatment.

  Limits: Abstract only

  What others could learn: In this Vietnamese cohort, people in community methadone reported greater reductions in heroin use and risk behaviors than people in compulsory centers; the design cannot show the setting caused the difference.

  Conditions, limits and source

  Conditions that matter:

  Methadone requires legal authorization, supply, daily dosing sites and trained staff; compulsory centers reflect a criminal-justice legal framework.

  Cannot be inferred:

  Cannot infer causation, effects on overdose, outcomes beyond three years, or results in other countries.

  Limits:

  Evidence level: single non-randomized comparative cohort; groups differed at baseline (adjusted statistically); primary outcome was self-reported heroin use confirmed by urinalysis, other outcomes self-reported. No difference found for overdose. Abstract only reviewed.

  Source: Vuong T, Ritter A, Shanahan M, et al. (UNSW Sydney; FHI360 Vietnam; Haiphong and Hanoi medical universities), Outcomes of compulsory detention compared to community-based voluntary methadone maintenance treatment in Vietnam (Abstract, Conclusions). Where: Viet Nam (study sites not named in abstract). Population: Adults with heroin dependence (208 in compulsory centres, 384 in methadone treatment). Published 2018-04 (J Subst Abuse Treat 87:9-15; epub 2018-01-16); retrieved 2026-10-11.

• Iran · Policy · 2020

  A 2020 historical review describes Iran's addiction treatment system as combining drop-in harm reduction, opioid maintenance (methadone, buprenorphine, opium tincture), abstinence-based residential centers, and court-based compulsory residential programs expanded from 2010.

  Limits: Abstract only · Policy, not outcomes · Service as described

  What others could learn: Iran expanded harm reduction and opioid maintenance, including opium tincture, yet later extended compulsory programs; scale-up and coercion can coexist.

  Conditions, limits and source

  Conditions that matter:

  Shaped by HIV epidemic among people who inject drugs, a methamphetamine crisis, political and legal shifts, and courts' role in referral.

  Cannot be inferred:

  Cannot infer coverage, retention, outcomes, or that opium tincture is equivalent in evidence to methadone or buprenorphine.

  Limits:

  Evidence level: expert narrative review by authors involved in national programs; no outcome data in abstract. Describes availability of service types, not coverage or quality.

  Source: Ekhtiari H, Noroozi A, Farhoudian A, et al. (Iranian National Center for Addiction Studies and others), The evolution of addiction treatment and harm reduction programs in Iran: a chaotic response or a synergistic diversity? (Abstract, Methods). Where: Iran. Population: People with substance use disorders, including people who inject drugs. Published 2020-07 (Addiction 115(7):1395-1403; epub 2019-12-29); retrieved 2026-10-11.

• Portugal · Policy · 2021

  Portuguese authors argue that, two decades after decriminalization, drug policy remains contradictory, harm-reduction ambitions modest, and punitiveness toward people who use drugs rose in the last decade.

  Limits: Abstract only · Policy, not outcomes

  What others could learn: Portuguese authors argue decriminalization did not by itself end stigma and that harm-reduction implementation stayed modest. The abstract reports no health outcomes.

  Conditions, limits and source

  Conditions that matter:

  The authors describe a 2008 Supreme Court judgment treating use above an average 10-day supply as a crime, which they say might have affected penalization; they also cite modest harm-reduction implementation.

  Cannot be inferred:

  Cannot infer health or overdose outcomes of decriminalization, or that Portugal's model failed or succeeded overall.

  Limits:

  Evidence level: critical commentary/policy analysis; abstract does not report outcome measures. Author affiliations include APDES (Agência Piaget para o Desenvolvimento). Abstract notes a 2008 Supreme Court judgment re-criminalizing amounts above a 10-day supply.

  Source: Rêgo X, Oliveira MJ, Lameira C, Cruz OS (University of Minho; University of Porto; APDES; ISMAI), 20 years of Portuguese drug policy - developments, challenges and the quest for human rights (Abstract). Where: Portugal. Population: People who use drugs. Published 2021-07-17 (Subst Abuse Treat Prev Policy 16(1):59); retrieved 2026-10-11.

• Kenya · Reported experience · 2021

  In Kenyan qualitative interviews with 30 people receiving methadone, peer support among clients, family relations and outreach shaped access alongside time, travel and economic hardship.

  Limits: Abstract only · Service as described

  What others could learn: In one urban Kenyan methadone program, clients described peer support, family relations and outreach as shaping access. The authors suggest strengthening networks of people who use drugs and community projects; effects on retention were not tested.

  Conditions, limits and source

  Conditions that matter:

  Access involved time, travel and economic hardship and gender inequities; the program relied on a community drop-in center and an outreach project.

  Cannot be inferred:

  Cannot infer that peer support improves retention or outcomes, or that findings apply across Kenya.

  Limits:

  Evidence level: qualitative, single urban site, small sample; describes experiences, not effects. One author declared providing private methadone delivery in Kenya.

  Source: Ndimbii J, Guise A, Igonya EK, Owiti F, Strathdee S, Rhodes T (Kenya AIDS NGOs Consortium; University of Nairobi; King's College London; LSHTM; UCSD), Qualitative Analysis of Community Support to Methadone Access in Kenya (Abstract, Results). Where: Kenya (one urban area). Population: People who use drugs receiving methadone (30) plus 2 stakeholders. Published 2021 (Subst Use Misuse 56(9):1312-1319; epub 2021-05-24); retrieved 2026-10-11.

• India · Measured outcome · 2026

  In a Chandigarh randomized trial (n=138), buprenorphine induction with one in-person day, telemedicine follow-up and a day-7 visit was non-inferior to three days of supervised in-person induction for one-week retention.

  Limits: Abstract only

  What others could learn: In this single-center trial, replacing days 2-6 of supervised induction with telemedicine follow-up did not lower one-week retention. The abstract does not report travel burden.

  Conditions, limits and source

  Conditions that matter:

  Needs buprenorphine supply, a specialist center for day-1 and day-7 in-person visits, and phone or video access. Rules on remote prescribing are not discussed in the abstract.

  Cannot be inferred:

  Cannot infer long-term retention, overdose effects, or equivalence for fully remote initiation.

  Limits:

  Evidence level: single randomized trial, single center, open label, short follow-up (primary outcome at one week), almost all men. Not tested in women, rural clinics or other countries.

  Source: Dhillon HS, Ghosh A, Naik S, Nanjayya S, Verma A, Basu D (PGIMER Chandigarh), Telemedicine-assisted buprenorphine induction versus standard of care: A randomized controlled non-inferiority trial (Abstract, Findings). Where: India (Chandigarh). Population: Adults with opioid use disorder (ICD-11); mean age 28.2; 98.55% male. Published 2026-04 (Addiction 121(4):883-893; epub 2025-11-30); retrieved 2026-10-11.

• Brazil · Service described in 2025

  A review of 39 studies reports Brazil's CAPS-AD community centers use singular therapeutic plans and harm reduction, yet users describe limited autonomy and inadequate participation in care planning.

  Limits: Abstract only · Service as described

  What others could learn: Brazil's CAPS-AD model pairs open-door services linked to primary care with individual plans, yet the review reports limited user autonomy and participation in care planning. The abstract reports no outcome data.

  Conditions, limits and source

  Conditions that matter:

  Interdisciplinary staff; a 24-hour CAPS-AD III modality; structural deficits in resource-limited regions; stigma toward users and staff.

  Cannot be inferred:

  Cannot infer clinical effectiveness of CAPS-AD, national coverage, or availability of opioid agonist treatment.

  Limits:

  Evidence level: narrative-style review; search and appraisal methods not stated in abstract; underlying studies are mostly descriptive. Possible Portuguese-language literature not checked here.

  Source: Ramos A, Castaldelli-Maia JM (University of São Paulo), Key features and current challenges of the Brazilian Psychosocial Care Centers for alcohol and other drugs (CAPS-AD) (Abstract). Where: Brazil. Population: People who use alcohol and other drugs attending CAPS-AD. Published 2025 May-Jun (Int Rev Psychiatry 37(3-4):322-331; epub 2024-11-11); retrieved 2026-10-11.

• France; United States · Policy · 2024

  A 2024 France-US policy comparison says French methadone visit frequency, doses and drug testing are governed by clinical best practices and shared decision-making, within limits meant to minimize harms.

  Limits: Abstract only · Policy, not outcomes

  What others could learn: Dose, visit and testing decisions can follow shared decision-making within a service's limits. The authors contrast this with US rules that set minimum visit frequency and initial dose limits.

  Conditions, limits and source

  Conditions that matter:

  France: pharmacy dispensing without required supervised dosing, primary-care handoff. US, as the authors describe it in 2024: federal rules set minimum visit frequency and initial dose limits, states may add limits, and oversight includes law enforcement.

  Cannot be inferred:

  Cannot infer that French policy caused lower overdose rates, or how 2024 US rule changes have been implemented.

  Limits:

  Evidence level: expert policy comparison. The 87% France vs 13-20% US figures cover methadone or buprenorphine and are author-cited estimates. Overdose differences have many causes. SAMHSA's 42 CFR Part 8 final rule took effect April 2, 2024 (compliance date October 2, 2024) and may change US details.

  Source: Englander H, Chappuy M, Krawczyk N, Bratberg J, Potee R, Jauffret-Roustide M, Rolland B, Comparing methadone policy and practice in France and the US: Implications for US policy reform (Abstract (describing France)). Where: France; United States. Population: People with opioid use disorder. Published 2024-07 (Int J Drug Policy 129:104487; epub 2024-06-14); retrieved 2026-10-11.

• Multi-country · Service described in 2022

  A mixed-methods systematic review of 13 studies found access, care and skills problems in end-of-life care for people who use alcohol or drugs, and called for cross-training.

  Limits: Abstract only

  What others could learn: The review names inclusive policies, staff sensitization and training exchanges between drug and alcohol services and palliative care as challenges to address. It did not test whether they improve outcomes.

  Conditions, limits and source

  Conditions that matter:

  Population may face homelessness, mental health problems and comorbidities; needs flexible, multidisciplinary services and staff exchanges across sectors.

  Cannot be inferred:

  Cannot infer that any model of care improves outcomes, or the countries and settings the evidence comes from.

  Limits:

  Evidence level: systematic review of a small, mostly qualitative evidence base; no pooled outcomes; proposed model themes are not tested interventions.

  Source: Cook O, Doran J, Crosbie K, Sweeney P, Millard I, O'Connor M (Monash University; Melbourne City Mission), Palliative care needs and models of care for people who use drugs and/or alcohol: A mixed methods systematic review (Abstract, Conclusion). Where: Multi-country (countries not listed in abstract). Population: People who use drugs and/or alcohol with palliative care needs, and their formal and informal carers. Published 2022-02 (Palliat Med 36(2):292-304; epub 2022-02-20); retrieved 2026-10-11.

• The sourced examples include guidance, service description, measured outcome, policy, reported experience. Each quote was matched to the source text; that is not independent expert review.
• The prompts and fictional case are original. They have not been tested with patients, caregivers or clinicians.
• Whether this workflow helps anyone is an open research question.
• Content is in English. Interface translations are not reviewed for this topic.