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Jessica L. Mulhollan, PharmD, BCPP, Clinical Pharmacy Specialist, Substance Use Disorders
Veterans Affairs Northeast Ohio Healthcare System

Over 70% of the nearly 70,000 drug overdose deaths in the United States in 2019 involved an opioid.1 So how do we address this public health crisis?

Dr. Michelle Geier walked us through how harm reduction strategies are key to addressing the opioid overdose epidemic. Harm reduction is a public health approach aimed at reducing negative consequences associated with drug use. One of the key principles of harm reduction is acceptance that illicit drug use is a part of our world and the choice to work to minimize its harmful effects rather than simply ignoring or condemning them. Harm reduction also recognizes that persons who use drugs (PWUD) are entitled to basic human rights and access to programs to reduce the harmful effects of drugs. Quality of both individual and community life and well-being are used as criteria for successful interventions and policies.2 Harm reduction efforts are not only for PWUD. Condoms to prevent pregnancy and decrease the risk of sexually transmitted infections, sunscreen to prevent sunburns and skin cancer, helmets to prevent head injuries in motorsports, seat belts to prevent death in the event of a vehicle accident, and police wearing bullet-proof vests to decrease their risk of death if shot are all examples of harm reduction.

Harm reduction programs for PWUD vary from state to state, and even from city to city, based on state and local laws. Person-first language and education are examples of harm reduction that are not governed by laws. Person-first language is intended to reduce stigma, the perpetuation of stereotypes, and the reinforcement of negative attitudes. Person-first language identifies a person with a condition versus someone as a condition and extends beyond PWUD.3 Some examples of person-first language include “person with a substance use disorder” instead of “substance user,” “urine drug screen positive for fentanyl” instead of “dirty urine,” and “person with diabetes” instead of “diabetic.” Education related to safer injection practices can lead to decreased risk of bacterial and viral infection from injections, which otherwise can lead to increased healthcare costs including hospital admission.4

Evidence for harm reduction programs and their positive effects is not lacking. Opioid overdose prevention and response with naloxone has led to decreased opioid overdose death rates5, reduced opioid-related emergency department visits, beneficial behaviors with opioid use6, and no increase in drug use7. States with Good Samaritan protections have a 15% lower incidence rate of opioid overdose deaths compared to states without these protections. These protections are not associated with increased non-medical opioid use.8 Syringe and clean works access programs are intended to reduce the spread of bloodborne infections through the distribution of safe injection kits. These programs have been associated with decreased risky injection behaviors9, decreased human immunodeficiency virus (HIV) seroconversion10, and decreased abscesses9. Syringe and clean works access programs have not been associated with an increase in the number of new PWUD, increase in frequency of injecting substances, increase in discarded needles in public spaces, or increased crime.11 Safe medication disposal via Drug Enforcement Agency (DEA) National Drug Take Back Days, DEA-authorized collection bins, and pharmacy mail-back programs are all examples of how to decrease unused pharmaceuticals in the home, however the impact on substance use disorders has not been studied. Point-of-care (POC) testing for HIV/hepatitis C is associated with increase in number of people tested12, decrease in loss to follow-up after a positive test13, and successful linkage and engagement in treatment.13,14 Off-label POC testing for fentanyl in drug supplies can be done using fentanyl test strips indicated for urine drug screening.15 Studies have shown that once properly educated on how to dilute drug supply, patients were able to demonstrate proper use of the strips and reported changes in drug use behavior when the sample was positive.16 Lastly, pre-exposure prophylaxis with HIV medications used to prevent HIV from sex or injection drug use has decreased the risk of infection by 99% and 74%, respectively.17

Dr. Geier’s presentation was well-received thanks to her ability to to show real-world application. 

References

  1. Drug Overdose Deaths. https://www.cdc.gov/drugoverdose/data/statedeaths.html. June 15, 2021.
  2. Principles of Harm Reduction, 2020. National Harm Reduction Coalition.
  3. Crocker A, Smith S. Person-first language: are we practicing what we preach? J Multidiscip Healthc. 2019;12:125-9.
  4. Stein M, Sobota M. Injection drug users: hospital care and charges. Drug Alcohol Depend. 2001;64(1):117-20.
  5. Walley A, Xuan Z, Hackman H, et al. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis. BMJ. 2013;346:1-13.
  6. Behar E, Rowe C, Santos G, et al. Primary care patient experience with naloxone prescription. Ann Fam Med. 2016;14(5):431-6.
  7. Doe-Simkins M, Quinn E, Xuan Z, et al. Overdose rescues by trained and untrained participants and change in opioid use among substance-using participants in overdose education and naloxone distribution programs: a retrospective cohort study. BMC Public Health. 2014;14(297):1-11.
  8. McClellan C, Lambdin B, Ali M, et al. Opioid-overdose laws association with opioid use and overdose mortality. Addict Behav. 2018;86:90-95.
  9. Hart G, Carvell A, Woodward N, et al. Evaluation of needle exchange in central London: behaviour change and anti-HIV status over one year. AIDS. 1989;3(5):261-5.
  10. Gibson D, Flynn N, Perales D. Effectiveness of syringe exchange programs in reducing HIV risk behavior and HIV seroconversion among injecting drug users. AIDS. 2001;15(11):1329-41.
  11. Institute of Medicine; Report Brief 2006:1-4.
  12. Kassler W, Dillon B, Jones W, et al. On-site, rapid HIV testing with same-day results and counseling. AIDS. 1997;11(8):1045-51.
  13. Trooskin S, Poceta J, Towey C, et al. Results from a geographically focused, community-based HCV screening, linkage-to-care and patient navigation program. J Gen Intern Med. 2015;30(7):950-7.
  14. Falade-Nwulia O, Mehta S, Lasola J, et al. Public health clinic-based hepatitis C testing and linkage to care in Baltimore. J Viral Hepat. 2016;23(5):366-74.
  15. Amlani A, McKee G, Khamis N, et al. Why the FUSS (fentanyl urine screen study)? A cross-sectional survey to characterize an emerging threat to people who use drugs in British Columbia, Canada. Harm Reduction Journal. 2015;12(54)1-7.
  16. Peiper N, Clarke S, Vincent L, et al. Fentanyl test strips as an opioid overdose prevention strategy: findings from a syringe services program in the Southeastern United States. Int J Drug Policy. 2019;62:122-8.
  17. Center for Disease Control and Prevention. Pre-Exposure Prophylaxis 2020.
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