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Background: There is a great diversity of traditions, practices, and experiences among the Indigenous Peoples of North America and Oceania. However, Indigenous Peoples across these regions are affected by the historical and ongoing violence of settler colonialism, resulting in disproportionately heightened drug-related harms. 'Harm reduction' refers to both an ethos and a set of strategies intended to lessen negative social and/or health effects associated with drug use. While harm reduction could therefore be valuable to Indigenous people who use drugs, important concerns remain regarding the culturally specific implementation and outcomes of such strategies. A clearer picture of research regarding harm reduction in Indigenous communities is needed.

Method: We conducted a scoping review of primary studies regarding drug use harm reduction approaches among Indigenous communities in Australia, Canada, New Zealand, and the United States. We included studies that (1) reported on harm reduction principles or strategies; and (2) either reported disaggregated results for Indigenous participants or were based on a sample in which at least half of the participants identified as Indigenous. Medline and PsycINFO were searched in March 2024; screening by two independent reviewers was completed in April 2024.

Findings: Screening 578 references generated a corpus of 28 studies, 16 (57 %) of which were conducted in Canada. Indigenous people who use drugs generally reported favourable attitudes towards harm reduction initiatives; other community members and healthcare providers were more hesitant. A variety of harm reduction strategies were discussed, most commonly needle-syringe programs (n = 8, 29 %). Barriers included the availability and acceptability of harm reduction services. Community members expressed concerns regarding cultural appropriateness, but also offered possibilities for improved integration of harm reduction into Indigenous traditions and practices.

Interpretation: This review indicated an emerging, wide-ranging, and somewhat disparate body of literature. While barriers remain, there are promising possibilities for reconceptualizing harm reduction from an Indigenous ethos.