1.29: Harm reduction for people who use drugs- A life-saving opportunity
At the end of this case, students will be able to:
- Summarize how harm reduction improves the health of individuals and the community
- Identify best practices related to use of supportive language, provision of supplies for safer drug use, and connection to local harm reduction organizations
- Counsel a patient on harm reduction strategies and appropriate resources
Introduction
As defined by the Harm Reduction Coalition ® , harm reduction is “ a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use .” 1 Harm reduction is a core component of the treatment model of substance use disorders (SUD), especially during ongoing substance use or when individuals do not identify abstinence as a primary goal. The most common misconception is that harm reduction is synonymous with promoting drug use. 1 Contrarily, harm reduction recognizes that substance use can be associated with significant harm, yet also recognizes that substance use has long been, and will continue to be, part of our world. 1 Instead, harm reduction represents a person-centered alternative to punitive and prohibitionist measures which lead to adverse health outcomes and social isolation. 1 While this ideology may sound like a novel concept, harm reduction strategies are utilized in many other areas of our lives such as seatbelts for cars, condoms for sex, and, most recently, face masks for COVID-19, for example. These interventions aim to reduce negative consequences associated with activities that impose some level of risk, such as driving a car, engaging in sex, or gathering with others during a viral pandemic. Though harm reduction in the context of substance use commonly targets people who inject drugs, people who use drugs via other routes can also benefit from harm reduction interventions.
Harm reduction for people who use drugs (PWUD) applies to a range of services personalized to the individual, substance(s) used, route(s) of use, and other risk factors. 2 These services are centered around overdose prevention, infection prevention, and social justice for PWUD in order to decrease morbidity and mortality. 2 Harm reduction interventions that decrease risk of overdose and death include strategies such as fentanyl test strips, administration of small initial test doses, using in the presence of others who are prepared to administer naloxone, taking turns and staggering use by at least 30 minutes, avoiding concomitant use of multiple central nervous system depressants, and using via a less dangerous route (e.g., intranasal rather than intravenous). 2 Harm reduction interventions to decrease risk of infectious diseases may include access to sterile syringes and other equipment, education to avoid reusing or sharing syringes, safer injection technique including location and step-by-step guide, administration of indicated vaccinations, HIV pre-exposure prophylaxis (PrEP) or post-exposure prophylaxis (PEP), and provision of wound care. 2 Access to methadone and buprenorphine for alleviation of withdrawal and treatment of underlying opioid use disorder (OUD) has also been associated with reduced overdose and mortality risk, even when use of the medication is non-prescribed. 3-6 Use of these medications for treatment of OUD has also been shown to reduce risk for infectious disease. 7-16 Legal, policy, and regulatory changes are also essential to facilitate these harm reduction interventions; examples include naloxone access laws, overdose Good Samaritan laws, and removal of paraphernalia laws that impede syringe access. Harm reduction efforts to facilitate social justice for PWUD may go further to include public education, use of non-stigmatizing language, restructuring of SUD treatment models, decriminalizing substance possession and use, and addressing racial, gender, and sexual orientation inequities in SUDs.
Implementing harm reduction into pharmacy practice is imperative as the opioid overdose crisis continues to worsen alongside other concerning substance use trends. Overdose deaths related to opioids have continued to rise steadily despite annual decreases in opioid prescribing, driven primarily by potent synthetic opioid adulterants in the illegal drug supply. 17 Concerningly, polysubstance overdoses are also rising steeply with increased stimulant use, growing adulteration of the illegal benzodiazepine supply, and persistent concomitant use of alcohol. 18-19 The science associating harm reduction efforts with a positive impact on individual and public health is crystal clear. These interventions have been associated with higher uptake of SUD treatment, greater retention in care, fewer overdoses, safer injection practices, and greater viral suppression of transmittable diseases such as HIV and HCV. 20 Additionally, harm reduction is cost-effective, as it is estimated that syringe services programs cost $23 to $71 per person per year which are minimal when compared to the alternative medical costs of treating substance use and injection-related complications in addition to new HIV and HCV cases. 21 Lastly, harm reduction services are not associated with increased substance use, riskier substance use behavior, or increased crime in areas densely populated with harm reduction services. 22-24
Case
You are a pharmacy student on a community pharmacy advanced pharmacy practice experience (APPE) in a state where non-prescription syringe sales are legal.
CC: “I’d like to buy naloxone and a pack of syringes, please.”
Patient: The patient appears to be a non-Hispanic white male in their mid-20s. They use a wheelchair.
Interaction: You overhear a dialogue between the patient and one of the technicians at the pharmacy counter.
- Technician : “Do you have a prescription for those?”
- Patient : “No. I need 28 gauge, ½ inch, ½ mL, please.”
- Technician : “Well, what are the syringes for?”
- Patient : “Um, my grandmother. She has diabetes.”
- Technician : “Well, then she should have a prescription.”
- Patient : “Okay, well I do not have a prescription.”
- Technician : “And why do you need naloxone? That is for junkies.”
- Patient : “The naloxone is for a friend. Can I please just get these items? I can pay for them; they both really need them.”
- Technician : “No, I know what’s going on here. I am not selling you syringes to get high. You need to get clean.”
Case Questions
- What stigmatizing words were used in this interaction and how are these words harmful? What are their preferred alternatives?
- The patient appears distressed and begins to walk away from the pharmacy counter. You want to re-engage them in conversation and see how you can help. You approach them and offer to grab the intranasal naloxone and a pack of the syringes. You direct them to wait in the private consultation area while you grab the items. How would you establish rapport with this patient following their mistreatment by a member of the pharmacy staff?
- How would you counsel this patient on opioid overdose recognition and response, including proper use of intranasal naloxone?
- Now that you have re-engaged this patient and have openly discussed intranasal naloxone, you learn that they have only starting injecting substances within the past three months, but they share that they often reuse syringes which has led to irritation and infection in the past. At this point, how can you incorporate other harm reduction strategies into your conversation?
- What types of harm reduction services might you be able to offer this patient today?
- During your conversation, the patient expresses concern that they shared syringes with someone yesterday who may be HIV positive, but they are not sure and does not have a way of contacting this person. They are nervous, scared, and do not know what to do. How do you navigate this conversation?
Author Commentary
In community settings, pharmacists are rarely aware that they are interacting with a person who is using illegal or illegally-obtained drugs. If they are aware, that is often because they have identified a forged prescription or some other issue that is likely to lead to confrontation. Thus, a non-prescription syringe purchase presents a unique opportunity to engage with a person who may be at risk for harm related to illegal drug use without confrontation. A person who has progressed to injecting illegal drugs is unlikely to be in control of their drug use. The neurological changes associated with SUD are triggering a cycle of addiction that is not going to be interrupted by a pharmacist refusing to sell syringes. In the absence of sterile injection equipment, this patient will almost certainly reuse or share syringes. Additionally, carrying naloxone is encouraged not only for individuals who may be at risk of experiencing overdose, but also for individuals who may be likely to witness an overdose and thus be able to save a life. While a debate about whether pharmacists should sell syringes to someone they suspect of illegal drug use may be interesting in the context of an ethics class, the appropriate response is to sell the syringes. Pharmacists who refuse to do so, and institutions which establish policies that seek to prevent pharmacists from doing so, are acting in a manner that undermines public health. Furthermore, for pharmacists to truly provide a non-judgmental space to offer care for their patients, particularly related to harm reduction, it is very useful to reflect on their own experiences and exposure to narratives about substance use that may hinder their ability to be objective and offer patient care with compassion.
Imagine you are a person who injects heroin. Your family and friends want you to quit, you think about quitting often, and you have even been to inpatient treatment facilities a few times but always started using again eventually. You have been injecting for a few months using syringes given to you by a friend who obtained them from a syringe services program. You do not share, but you have been reusing and it is starting to hurt more when you inject. You decide to purchase some new syringes from the local pharmacy. You are anxious as you approach the counter. What if the pharmacist confronts you and asks why you need the syringes? What if they ask to see your arms to check for track marks? What if they loudly tell you to leave the store and talk about you later with other staff? As a pharmacist, what happens for this patient is up to you. Will you confirm their worst fears and risk discouraging them from ever purchasing sterile syringes from a pharmacy again, or will you embrace a harm reduction approach that protects their health? It is urged to choose the latter.
Patient Approaches and Opportunities
Pharmacists should recognize situations where naloxone should be offered and should utilize such opportunities to offer naloxone in a non-confrontational manner. In clinical practice, pharmacists may encounter less dramatic versions of this scenario where a patient asks for syringes, but does not request naloxone, despite your clinical intuition that they may benefit from it. In these types of scenarios, naloxone can be offered in a non-confrontational manner that does not make it about that person, such as informing them that this is an offering provided to all. This allows the patient to engage without the feeling that they may be implicitly admitting that their syringe purchase puts them at risk for an overdose. If the interaction goes well, and especially if the patient accepts the naloxone, it is helpful to close on a friendly note by inviting them to come back for a refill when needed, or if more questions arise. This will make the patient feel more comfortable returning and gives them some assurance when they can come in without fear of encountering a confrontational pharmacist.
Let the technicians and interns in your work environments know that you are comfortable selling syringes to anyone without a prescription or unnecessary hassle. Surveys indicate these individuals will typically follow the guidance of their supervisors on this topic. However, in the absence of guidance, they are likely to make the more conservative choice not to sell syringes to avoid reprimand. In addition to modeling supportive behaviors toward people who use drugs and enforcing a non-judgmental attitude among all staff, consider going further to educate colleagues by sharing resources designed to decrease stigma. 24
Related chapters of interest:
- Safe opioid use in the community setting: reverse the curse?
- Smoke in mirrors: the continuing problem of tobacco use
- A stigma that undermines care: opioid use disorder and treatment considerations
- PrEPare yourself: let’s talk about sex
- Alcohol use disorder: beyond prohibition
- Expanding the pharmacists’ role: assessing mental health and suicide
- Unintended consequences of e-cigarette use: a public health epidemic
External resources:
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IDU-related harm reduction and social justice action
- National Harm Reduction Coalition. https://harmreduction.org/issues/safer-drug-use/injection-safety-manual/
- Drug Policy Alliance. https://drugpolicy.org
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Naloxone training
- Narcan ® . https://www.narcan.com/patients/how-to-use-narcan
- Evzio ® . https://evzio.com/
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Non-stigmatizing language
- NIDA. https://www.drugabuse.gov/nidamed-medical-health-professionals/health-professions-education/words-matter-terms-to-use-avoid-when-talking-about-addiction
- The University of Texas at Austin Dell Medical School. Reducing Stigma Education Tools (ReSET). https://www.ResetStigma.org
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SUD treatment
- Crotty K, Freedman KI, Kampman KM. Executive summary of the focused update of the ASAM national practice guideline for the treatment of opioid use disorder. J Addict Med 2020;14:99-112.
- American Psychiatric Association. Practice guideline for the pharmacological treatment of patients with alcohol use disorder. 2018. https://psychiatryonline.org/doi/book/10.1176/appi.books.9781615371969
- Substance Abuse and Mental Health Services Administration and National Institute on Alcohol Abuse and Alcoholism. Medication for the treatment of alcohol use disorder: a brief guide. HHS Publication No. (SMA) 15-4907. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2015.
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Finding MOUD providers and programs
- Substance Abuse and Mental Health Services Administration. https://www.samhsa.gov/medication-assisted-treatment/find-treatment
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Finding syringe services laws by state
- The Policy Surveillance Program. http://lawatlas.org/datasets/syringe-services-programs-laws
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Locating the nearest syringe services program
- North American Syringe Exchange Network. https://nasen.org/map/
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Harm reduction for pharmacists
- College of Psychiatric and Neurologic Pharmacists. https://cpnp.org/guideline/harmreduction
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Smokable drug use harm reduction
- Canadian Institute for Substance Use Research. https://www.heretohelp.bc.ca/sites/default/files/safer-smoking-crack-and-crystal-meth-2020.pdf
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Alcohol consumption harm reduction
- University of Washington, Harm Reduction Research and Treatment Center. https://depts.washington.edu/harrtlab/wordpress/wp-content/uploads/2018/11/Safer-Use-Alcohol.pdf
References
- National Harm Reduction Coalition. Principles of harm reduction. https://harmreduction.org/about-us/principles-of-harm-reduction/ . Accessed January 29, 2021.
- National Harm Reduction Coalition. Getting off right: a safety manual for injection drug users. https://harmreduction.org/drugs-and-drug-users/drug-tools/getting-off-right/ . Accessed January 29, 2021.
- Larochelle MR, Bernson D, Land T, et al. Medication for opioid use disorder after nonfatal opioid overdose and association with mortality: a cohort study. Ann Intern Med 2018;169(3):137-45.
- Wakeman SE, Larochelle MR, Ameli O, Chaisson CE, McPheeters JT, Crown WH, Azocar F, Sanghavi DM. Comparative effectiveness of different treatment pathways for opioid use disorder. JAMA Netw Open 2020;3(2):e1920622.
- Cicero TJ, Ellis MS, Chilcoat HD. Understanding the use of diverted buprenorphine. Drug Alcohol Depend 2018;193:117-23.
- Carlson RG, Daniulaityte R, Silverstein SM, Nahhas RW, Martins SS. Unintentional drug overdose: Is more frequent use of non-prescribed buprenorphine associated with lower risk of overdose? Int J Drug Policy 2020;79:102722.
- Sullivan LE, Moore BA, Chawarski MC, et al. Buprenorphine/naloxone treatment in primary care is associated with decreased human immunodeficiency virus risk behaviors. J Subst Abuse Treat 2008;35:87-92.
- Metzger DS, Donnell D, Celentano DD, et al; HPTN 058 Protocol Team. Expanding substance use treatment options for HIV prevention with buprenorphine-naloxone: HIV Prevention Trials Network 058. J Acquir Immune Defic Syndr 2015;68:554–61.
- Edelman EJ, Chantarat T, Caffrey S, et al. The impact of buprenorphine/naloxone treatment on HIV risk behaviors among HIV-infected, opioid-dependent patients. Drug Alcohol Depend 2014;139:79-85.
- MacArthur GJ, Minozzi S, Martin N, et al. Opiate substitution treatment and HIV transmission in people who inject drugs: systematic review and meta-analysis. BMJ 2012;345:e5945.
- Cohen MS, Chen YQ, McCauley M, et al; HPTN 052 Study Team. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med 2011;365:493–505.
- Montaner JSG, Lima VD, Barrios R, et al. Association of highly active antiretroviral therapy coverage, population viral load, and yearly new HIV diagnoses in British Columbia, Canada: a population-based study. Lancet 2010; 376:532-9.
- Wood E, Kerr T, Marshall BD, et al. Longitudinal community plasma HIV-1 RNA concentrations and incidence of HIV-1 among injecting drug users: prospective cohort study. BMJ 2009;338:b1649.
- Springer SA, Di Paola A, Azar MM, et al. Extended-release naltrexone improves viral suppression among incarcerated persons living with HIV with opioid use disorders transitioning to the community: results of a double-blind, placebo-controlled randomized trial. J Acquir Immune Defic Syndr 2018; 78:43-53.
- Springer SA, Qiu J, Saber-Tehrani AS, Altice FL. Retention on buprenorphine is associated with high levels of maximal viral suppression among HIV-infected opioid dependent released prisoners. PLoS One 2012; 7:e38335.
- US Centers for Disease Control and Prevention. Increase in fatal drug overdoses across the United States driven by synthetic opioids before and during the COVID-19 pandemic. https://emergency.cdc.gov/han/2020/han00438.asp . Accessed January 29, 2021.
- US Centers for Disease Control and Prevention. Other drugs. https://www.cdc.gov/drugoverdose/data/otherdrugs.html . Accessed January 29, 2021.
- Esser MB, Sherk A, Liu Y, et al. Deaths and years of potential life lost from excessive alcohol use – United States, 2011-2015. MMWR Morb Mortal Wkly Rep 2020;69(39):1428-33.
- Peckham AM, Young EH. Opportunities to offer harm reduction to people who inject drugs during infectious disease encounters: narrative review. Open Forum Infect Dis 2020;7(11):ofaa503.
- Wilson DP, Donald B, Shattock AJ, Wilson D, Fraser-Hurt N. The cost-effectiveness of harm reduction. Int J Drug Policy 2015;26 Suppl 1:S5-11.
- Kennedy MC, Karamouzian M, Kerr T. Public health and public order outcomes associated with supervised drug consumption facilities: a systematic review. Curr HIV/AIDS Rep 2017;14:161-83.
- Supervised Consumption Services. Drug policy alliance. https://www.drugpolicy.org/resource/supervised-consumption-services . Accessed January 29, 2021.
- Petrar S, Kerr T, Tyndall MW, et al. Injection drug users’ perceptions regarding use of a medically supervised safer injecting facility. Addict Behav 2007;32:1088–93.
- The University of Texas at Austin Dell Medical School. Reducing Stigma Education Tools (ReSET). https://www.ResetStigma.org . Accessed March 31, 2021.