Each life saved gives our patients another chance to overcome addiction.
In the summer of 2017, I (Dr. Greenwell) had just graduated college and was excitedly thinking about applying to medical school. Like many young adults, I felt invincible and could see my future laid out in front of me. But my excitement turned to shock when a childhood friend, who had just committed to getting sober, suddenly overdosed and died. That moment helped shape my future in medicine by showing me the value of harm reduction in a very personal and powerful way.
HARM-REDUCTION METHODS AND CHALLENGES
Harm reduction focuses on providing nonjudgmental, patient-centered care for people with substance use disorder who persist with high-risk behaviors.1,2 It aims to reduce the negative consequences of substance use, rather than setting abstinence as the only goal. This requires meeting patients where they are in their recovery and using harm-reduction techniques such as the following:
- Reducing the stigma associated with substance use disorder by using nonjudgmental language (e.g., “person with substance use disorder” rather than “addict” or “testing positive” rather than “dirty”),3,4
- Maintaining open communication with patients during difficult periods (e.g., a positive drug test),5
- Prescribing maintenance medications such as buprenorphine-naloxone and naltrexone,
- Testing for and treating the associated infectious comorbidities of substance use, including HIV and hepatitis C,
- Offering fentanyl test strips and teaching patients how to use them to ensure deadly non-pharmaceutical fentanyl is not hidden in their illicit drugs,
- Prescribing and dispensing a naloxone nasal spray kit to all patients who are receiving opioids, as well as any other patient who requests it, regardless of visit type (naloxone administration by bystanders is usually successful at reversing overdose and faster than waiting for first responders6).
Because some patients are not ready to stop using substances altogether or may relapse on the road to sobriety, these methods can reduce the high risk of overdose and death associated with substance use disorder, especially for fentanyl. Every death prevented gives that patient another opportunity to get and stay off drugs.
Some of these approaches can present challenges. For example, some patients may interpret being given a naloxone kit as a lack of faith in their ability to maintain sobriety or an assumption that they are lying when they deny any current drug use. It can be helpful to reframe the purpose of the kit like this: Many people keep a fire extinguisher in the house even if they have never had to use it.
REDUCING HARM AND CHANGING LIVES
I often contemplate whether harm reduction would have kept my friend alive. What if he, or someone he was with, had a naloxone kit? What if he had felt comfortable seeking help from his doctor's office? What if he had been given a prescription for buprenorphine-naloxone?
While we can't change the past, we can focus on changing the future for thousands of patients like my friend.
