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.

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 Observational studies have demonstrated that overdose education and take-home naloxone kits decrease overdose-related deaths.⁸ Naloxone distribution is particularly important in communities with rapidly rising overdose rates⁹ or on reentry into the community after incarceration, when overdose rates are particularly high.¹⁰ In addition to decreasing overdose-related deaths, prescribing naloxone to patients with high-risk behaviors is an act of caring. As one physician described it, “I expected the decreases in deaths from overdose—but I hadn't thought about how this simple act of prescribing potentially lifesaving treatment has opened up other important conversations that have allowed me to provide better, safer and more compassionate care to my patients.”¹¹

MEDICATIONS FOR OPIOID USE DISORDER

Many patients with opioid use disorder (OUD) decline a generic offer of treatment. Some patients are not ready to change their use patterns; others have experienced detoxification and abstinence-based counseling that have not been helpful. In a large retrospective analysis of outcomes for patients with OUD, only buprenorphine and methadone decreased opioid overdoses and reduced serious opioid-related acute care use. Conversely, inpatient detoxification, residential services, intensive and nonintensive behavioral health interventions, and naltrexone did not.¹²

All patients with moderate or severe OUD should be offered medications for treatment.¹³ However, in a 2017 study, 60% of residential treatment centers did not offer any FDA-approved medications for OUD.¹⁴ Both buprenorphine and methadone maintenance are harm-reduction strategies that improve treatment retention, suppress illicit opioid use, decrease deaths from overdose, and decrease all-cause mortality.¹⁵ Methadone has superior evidence for retention in treatment, but it can be prescribed only in federally licensed outpatient treatment programs, limiting the scope of this intervention.¹⁶ Buprenorphine, however, can be prescribed by waivered family physicians; an article from American Family Physician provides guidance for buprenorphine use.¹⁷ Recent changes have streamlined the process to obtain a waiver.¹⁸ Extended-release naltrexone is another treatment option, although an opioid-free period is required that can delay and complicate starting the medication.¹⁹