by Don Stader, MD, CMS Liaison, Colorado Consortium for Prescription Drug Abuse Prevention
Featured in the July/August 2018 Colorado Medicine.
Harm reduction is a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use. The approach is predicated on respecting patients and their choices, removing stigma, and discussing with patients ways that they can keep safe and reduce risk if they choose to continue using drugs.
Harm reduction aims to prevent the spread of infection, including HIV/AIDS, hepatitis B and C, sepsis, soft tissue infections and endocarditis; reduce the risk of overdose and other drug-related fatalities; and decrease the negative effects drug use may have on individuals and communities.
Initially developed in response to the US AIDS epidemic, the harm reduction philosophy has been used in recent years for the treatment of people who inject drugs; however, its principles are broadly applicable to most patients who abuse drugs. Injection drug use is intertwined with the growing opioid epidemic; roughly 75 percent of injection heroin addictions originate with prescription opioids. Significant risks are associated with this behavior, as injection drug use accounts for between 12 percent and 26 percent of new HIV diagnoses and the majority of new hepatitis C infections. Rates of Hepatitis C in Colorado have increased by 80 percent from 2011 to 2015, demonstrating the need for medical providers to take a more proactive approach. For many clinicians, that may involve introducing harm reduction techniques into their practice.
Four ways to implement harm reduction in your practice:
1. Judge not: Patients who abuse opioids should be managed without judgment; addiction is a medical condition and not a moral failing. Caregivers should endeavor to meet patients “where they are,” infusing empathy and understanding into the patient/medical provider relationship. A patient who believes that their doctor is judging them is unlikely to be open to counseling.
2. Know how to inject drugs safely: Clinicians should be well-versed in the safe injection of heroin and other intravenous drugs, and understand the practical steps for minimizing the dangers of overdose, infection and other complications. When treating patients with complications of IV drug use, injection habits should be discussed in detail, unsafe practices should be identified and instruction should be given about safe practices.
A good video introduction to safe injection can be found at: www.youtube.com/watch?v=Miv8i-slK2w and more in-depth counseling advice can be found in the Colorado ACEP Opioid Guidelines available online at www.coacep.org.
3. Refer patients who inject drugs to syringe access programs: Local syringe access programs can be life changing. These facilities provide sterile injection materials and support services such as counseling, HIV/hepatitis testing and referrals to recovery centers. They are great public health partners, and medical practices should encourage their use for appropriate patients.
4. Embrace naloxone: High-risk patients such as those who are being treated for an overdose, are on high doses of daily prescription opioids, abuse prescription opioids or inject drugs should be provided naloxone. A best practice is to provide naloxone prior to discharge for high-risk patients. In Colorado, naloxone is available via a standing order at most Colorado pharmacies. However, providing a prescription to a patient or their family member can be a powerful motivator for a patient to follow through and fill their prescription.