Curbside Consultation

Harm Reduction for Patients With Substance Use Disorders

 

Am Fam Physician. 2022 Jan ;105(1):90-92.

Case Scenario

S.R., a 27-year-old patient with a history of depression, presents to my clinic with a painful outbreak of genital herpes. During the physical examination, I notice what appear to be track marks on the patient's feet. I mention my concern, and S.R. admits to recently resuming daily heroin and methamphetamine injection drug use with their partner. I offer a referral for treatment, but S.R. declines. What additional options are available for me to help this patient?

Commentary

HARM REDUCTION: BACKGROUND AND APPROACH

Patients engaged in high-risk activities are often ambivalent about changing their behavior.1 Harm reduction is an approach that focuses on limiting harm and improving quality of life for patients who persist with high-risk behaviors; the foundations of harm reduction are pragmatism and compassion. The approach encompasses a range of evidence-based practices that decrease risk for patients and the community.2 For health professionals, harm reduction is not only a set of evidence-based interventions, but it also conveys respect for personal autonomy that empowers patients to take responsibility for their behavioral changes.2 Acknowledging the complexity of high-risk behavior and using a supportive, practical approach to address the situation can decrease friction between the patient and physician and build trusting therapeutic relationships that can pay off in often unexpected ways.

Patients engaged in high-risk behaviors, including substance use, are often stigmatized and mistreated in the medical system.3 When patients are treated poorly, they have worse outcomes, making behavioral change even more difficult.4 When physicians measure success in small steps that reduce harm, patients can experience positive emotions that make subsequent behavioral change more likely.5  For patients with substance use disorders, the leading harm-reduction interventions target prevention of overdose and infection and also reproductive issues. By embracing harm reduction, physicians can offer interventions and resources that are not contingent on abstaining from substance use. Table 1 provides resources that physicians can use to implement harm-reduction interventions with their patients.

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TABLE 1.

Resources for Harm Reduction in Patients With Substance Use Disorders

National Harm Reduction Coalition National harm reduction advocacy organization https://harmreduction.org/

North American Syringe Exchange Network Search for syringe exchange programs by location https://nextdistro.org/resources-collection/2020/2/4/north-american-syringe-exchange-network

SAMHSA: Behavioral Health Treatment Services Locator Search for treatment facilities for substance use disorder and/or mental health problems by location https://findtreatment.samhsa.gov/

SAMHSA: Become a Buprenorphine Waivered Practitioner Learn how to obtain a waiver to prescribe buprenorphine for the treatment of opioid use disorder https://www.samhsa.gov/medication-assisted-treatment/become-buprenorphine-waivered-practitioner


SAMHSA = Substance Abuse and Mental Health Services.

TABLE 1.

Resources for Harm Reduction in Patients With Substance Use Disorders

National Harm Reduction Coalition National harm reduction advocacy organization https://harmreduction.org/

North American Syringe Exchange Network Search for syringe exchange programs by location https://nextdistro.org/resources-collection/2020/2/4/north-american-syringe-exchange-network

SAMHSA: Behavioral Health Treatment Services Locator Search for treatment facilities for substance use disorder and/or mental health problems by location https://findtreatment.samhsa.gov/

SAMHSA: Become a Buprenorphine Waivered Practitioner Learn how to obtain a waiver to prescribe buprenorphine for the treatment of opioid use disorder https://www.samhsa.gov/medication-assisted-treatment/become-buprenorphine-waivered-practitioner


SAMHSA = Substance Abuse and Mental Health Services.

OVERDOSE EDUCATION AND NALOXONE DISTRIBUTION

Overdose is the leading cause of death among people who use nonprescribed opioids.6 Naloxone has been approved by the U.S. Food and Drug Administration (FDA) for reversal of opioid overdoses since the early 1970s, but communities have only recently embraced overdose education and naloxone distribution programs. All 50 states and the District of Columbia now have naloxone access laws that expand where and how naloxone can be obtained and used.7 Ob

Address correspondence to Christopher J. Frank, MD, PhD, at cfrank@med.umich.edu. Reprints are not available from the authors.

Author disclosure: No relevant financial relationships.

References

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1. McMahan VM, Kingston S, Newman A, et al. Interest in reducing meth-amphetamine and opioid use among syringe services program participants in Washington State. Drug Alcohol Depend. 2020;216:108243....

2. Marlatt GA, Larimer ME, Witkiewitz K, eds. Harm Reduction: Pragmatic Strategies for Managing High-Risk Behaviors. 2nd ed. Guilford Press; 2012.

3. Nyblade L, Stockton MA, Giger K, et al. Stigma in health facilities: why it matters and how we can change it. BMC Med. 2019;17(1):25.

4. van Boekel LC, Brouwers EPM, van Weeghel J, et al. Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: systematic review. Drug Alcohol Depend. 2013;131(1–2):23–35.

5. Van Cappellen P, Rice EL, Catalino LI, et al. Positive affective processes underlie positive health behaviour change. Psychol Health. 2018;33(1):77–97.

6. Larney S, Tran LT, Leung J, et al. All-cause and cause-specific mortality among people using extramedical opioids: a systematic review and meta-analysis. JAMA Psychiatry. 2020;77(5):493–502.

7. Legislative Analysis and Public Policy Association. Naloxone access: summary of state laws. September 2020. Accessed September 18, 2021. https://legislativeanalysis.org/wp-content/uploads/2020/10/Naloxone-summary-of-state-laws-FINAL-9.25.2020.pdf

8. Walley AY, Xuan Z, Hackman HH, et al. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts. BMJ. 2013;346: f174.

9. Irvine MA, Buxton JA, Otterstatter M, et al. Distribution of take-home opioid antagonist kits during a synthetic opioid epidemic in British Columbia, Canada. Lancet Public Health. 2018;3(5):e218–e225.

10. Bird SM, McAuley A. Scotland's National Naloxone Programme. Lancet. 2019;393(10169):316–318.

11. Behar E, Rowe C, Santos G-M, et al. Acceptability of naloxone co-prescription among primary care providers treating patients on long-term opioid therapy for pain. J Gen Intern Med. 2017;32(3):291–295.

12. Wakeman SE, Larochelle MR, Ameli O, et al. Comparative effectiveness of different treatment pathways for opioid use disorder. JAMA Netw Open. 2020;3(2):e1920622.

13. The ASAM National Practice Guideline for the treatment of opioid use disorder: 2020 focused update [published correction appears in J Addict Med. 2020;14(3):267]. J Addict Med. 2020;14(2S suppl 1):1–91.

14. Huhn AS, Hobelmann JG, Strickland JC, et al. Differences in availability and use of medications for opioid use disorder in residential treatment settings in the United States. JAMA Netw Open. 2020;3(2):e1920843.

15. Sordo L, Barrio G, Bravo MJ, et al. Mortality risk during and after opioid substitution treatment. BMJ. 2017;357:j1550.

16. Mattick RP, Breen C, Kimber J, et al. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev. 2014;(2):CD002207.

17. Zoorob R, Kowalchuk A, de Grubb MM. Buprenorphine therapy for opioid use disorder. Am Fam Physician. 2018;97(5):313–320. Accessed September 15, 2021. https://www.aafp.org/afp/2018/0301/p313.html

18. Federal Register. Practice guidelines for the administration of buprenorphine for treating opioid use disorder. April 28, 2021. Accessed June 15, 2021. https://www.federalregister.gov/documents/2021/04/28/2021-08961/practice-guidelines-for-the-administration-of-buprenorphinefor-treating-opioid-use-disorder

19. Lee JD, Nunes EV Jr, Novo P, et al. Comparative effectiveness of extended-release naltrexone versus buprenorphine-naloxone for opioid relapse prevention (X:BOT). Lancet. 2018;391(10118):309–318.

20. Centers for Disease Control and Prevention. Syringe services programs (SSPs) fact sheet. Updated May 23, 2019. Accessed May 11, 2021. https://www.cdc.gov/ssp/syringe-services-programs-factsheet.html

21. World Health Organization. WHO, UNODC, UNAIDS technical guide for countries to set targets for universal access to HIV prevention, treatment and care for injecting drug users; 2012. Accessed September 18, 2021. https://www.who.int/publications/i/item/978924150437

22. Platt L, Minozzi S, Reed J, et al. Needle syringe programmes and opioid substitution therapy for preventing hepatitis C transmission in people who inject drugs. Cochrane Database Syst Rev. 2017;(9):CD012021.

23. Marx MA, Crape B, Brookmeyer RS, et al. Trends in crime and the introduction of a needle exchange program. Am J Public Health. 2000;90(12):1933–1936.

24. Hagan H, McGough JP, Thiede H, et al. Reduced injection frequency and increased entry and retention in drug treatment associated with needle-exchange participation in Seattle drug injectors. J Subst Abuse Treat. 2000;19(3):247–252.

25. Finer LB, Zolna MR. Declines in unintended pregnancy in the United States, 2008–2011. N Engl J Med. 2016;374(9):843–852.

26. Heil SH, Jones HE, Arria A, et al. Unintended pregnancy in opioid-abusing women. J Subst Abuse Treat. 2011;40(2):199–202.

27. Terplan M, Hand DJ, Hutchinson M, et al. Contraceptive use and method choice among women with opioid and other substance use disorders: a systematic review. Prev Med. 2015;80:23–31.

28. Centers for Disease Control and Prevention. Appendix D. Contraceptive effectiveness. April 25, 2014. Morb Mortal Wkly Rep (MMWR). Accessed April 25, 2021. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6304a5.htm

29. Committee on Gynecologic Practice Long-Acting Reversible Contraception Working Group. Committee opinion no. 642: Increasing access to contraceptive implants and intrauterine devices to reduce unintended pregnancy. Obstet Gynecol. 2015;126(4):e44–e48.

Case scenarios are written to express typical situations that family physicians may encounter; authors remain anonymous. Send scenarios to afpjournal@aafp.org. Materials are edited to retain confidentiality.

This series is coordinated by Caroline Wellbery, MD, associate deputy editor.

A collection of Curbside Consultation published in AFP is available at https://www.aafp.org/afp/curbside.

Please send scenarios to Caroline Wellbery, MD, at afpjournal@aafp.org. Materials are edited to retain confidentiality.

 

 

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