BackgroundExtant literature is limited on adoption of evidence-based harm reduction strategies in hospitals. We explored patient perceptions of incorporating harm reduction supplies and education in hospital care with patients with opioid use disorder (OUD).MethodsQualitative descriptive study of hospitalized patients with OUD in Philadelphia, PA using semi-structured interviews conducted between April and August of 2022.ResultsThree major themes emerged from 21 interviews with hospitalized patients with OUD: (1) Applicability and Acceptability of Harm Reduction Practices for Oneself; (2) Applicability and Acceptability of Harm Reduction Practices for Others; (3) Perceptions of Harm Reduction Conversations. Most participants were familiar with harm reduction but varied in their perceptions of its relevance for their lives. We noted differences in how participants viewed the applicability and acceptably of harm reduction practices that they perceived as intended to help others (e.g., naloxone) versus intended to help themselves (e.g., syringes). Most participants reported that meaningful conversations about drug use did not happen with their care team but that these conversations would have been acceptable if they were conducted in a way consistent with their individual substance use goals.ConclusionsPatients' interest and perceived acceptability of harm reduction services during hospitalization varied by individual patient factors and the perceived user of specific interventions. Given their positive potential, harm reduction practices should be incorporated in hospitals, but this must be done in a way that is acceptable to patients. Our findings reveal ways to integrate concepts from a harm reduction approach within a traditional medical model. More work is needed to understand the impact of such integration.Supplementary InformationThe online version contains supplementary material available at 10.1186/s13722-023-00395-w.