Read any article about the continuing drug addiction and overdose public health crisis, and you may see a term that you’re not familiar with – “harm reduction”. And if substance abuse has touched your life or the life of someone you care about, you will want to become familiar with this controversial concept.
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First Things First – What Is “Harm Reduction”?
“Harm reduction” is a catchall phrase used to describe any public health strategy or policy aimed at limiting or minimizing the individual and societal damage caused by the potential problems typically associated with drug abuse – crime, disease, death, etc. – without necessarily focusing on completely eliminating drug use among those people who are unwilling or unable to stop. In other words, the strategy is to prevent harm, rather than prevent drug use.
Why Are Harm Reduction Strategies Necessary?
One only has to look around at the epidemic of drug overdose deaths in the United States to understand the necessity of effective harm reduction strategies:
- 2013: 43,982
- 2014: 47,055 (+7%)
- 2015: 52,404 (+11.4%)
- 2016: 64,070 (+22.3%)
- 2017: 71,600 (est.) (+11.8%)
Every year, the number of drug deaths has increased, usually by double digits. According to the Centers for Disease Control and Prevention’s latest Vital Signs report, every part of America saw an increase in opioid overdoses between 2016 and 2017. And this is despite prevention efforts, public awareness campaigns, drug takeback locations, expanded insurance coverage, and even new prescribing guidelines. In fact, the latest numbers revealed that even though the number of painkiller prescriptions has decreased, the number of opioid deaths has INCREASED. These statistics highlight one critically-important consideration – what we have done to this point isn’t working. And considering that there are nearly29 million Americans who report using an illicit drug within the past 30 days, there is an overwhelming need to expand public health options for people struggling with substance abuse. To that end, let’s look at some of the harm minimization programs that are available.
Good Samaritan Laws
In general, so-called “Good Samaritan” laws offer a degree of legal protection to bystanders who volunteer to help someone suffering a medical emergency – keeping them from being sued for unintentional injury or wrongful death, for example. Currently, 40 states and the District of Colombia have some kind of Good Samaritan drug law in place. In general, these measures provide immunity from arrest, charge or prosecution for certain drug possession/paraphernalia crimes for anyone either experiencing or rendering aid for a drug overdose. Many state laws also provide immunity from violations of pretrial, parole, probation, or protective order conditions.
Clean Needle Exchanges
Intravenous drug use significantly contributes to the spread of infectious blood-borne diseases.
- 2010-2015: The number of confirmed new Hepatitis C infections nearly tripled, rising from 85 to 2436.
- The CDC estimates the real number may be much higher – up to 34,000 Americans.
- IV drug users have a prevalence of HIV that is 28 times higher than the general population.
- According to the National Institute on Drug Abuse, IV drug users make up approximately 6% of HIV diagnoses.
- But because many people with HIV are unaware of their condition, up to 14% of IV drug users worldwide may be HIV-positive.
Syringe Services Programs, also known as needle exchange programs, are a means of reducing the spread of these diseases. People who inject drugs can obtain sterile needles free of charge and safely dispose of their used ones. These programs have other benefits, including:
- Preventing accidental needlestick injuries – 1 in 3 law enforcement officers are stuck with a needle during their career.
- Reducing the number of overdose deaths – Participants are taught how to recognize and respond to a drug overdose.
- Increases entries into substance abuse treatment – SSP participants who are interested in reducing or stopping drug use are put in touch with treatment programs and are 5 times more likely to enter drug rehab than non-participants.
But critics are correct when they point out that needle exchange programs do relatively little to remedy the underlying problem of drug addiction. Despite the benefits, there are still serious harms that exist while that issue is under-addressed. Some of the issues include:
- Heroin abuse and overdose deaths are skyrocketing.
- Even “occasional” heroin use worsens HIV.
- In recent years, the number of babies who are born opioid-dependent has increased nearly 5-fold.
- There is the perception among some addicts that SSPs makes heroin use “safe”.
Supervised Injection Sites
Supervised Injection Sites (SISs), also known as “fix rooms”, are medically-supervised facilities where addicts can go to safely consume their illegal drugs. Although the idea is extremely controversial here in the United States, there are already close to 100 SIS facilities in Europe and Canada. It is hard to argue with successful results. One facility in Vancouver has been open since 2003 and has monitored almost 3 million injections. There have been ZERO fatalities. As with SSPs, interested participants are connected to rehab resources. But there are critics who argue that fix rooms send the wrong message and imply government-sponsored approval of an illegal behavior that kills tens of thousands of Americans every year. No less of an authority than Tony Clement, who formerly served as Canada’s Health Minister, said, SISs are like “…a doctor holding a cigarette to make sure a smoker doesn’t burn his lips, or watching a woman with cardiac problems eat fatty french fries to ensure she swallows them properly.” Currently, there are no fix rooms in the United States, although both San Francisco and New York City have introduced bills to authorize their use.
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Opioid Replacement Therapy
Opioid Replacement Therapy (ORT) is when people who are dependent on or addicted to opioids such as heroin or prescription painkiller are given a safer, longer-lasting, and less-euphoric opioid medication as a substitute. The top ORT medications are:
The immediate goal of ORT is not cessation of drug use, but rather to “manage” the opioid addiction and allow patients to live safer, more stable lives. The evidence shows that ORT does just that:
- Two-thirds of patients receiving ORT eventually stop abusing opioids.
- Up to 95% significantly reduce their use.
- IV drug use is reduced, limiting the spread of hepatitis and HIV/AIDS.
- The requirement of daily attendance at a methadone clinic provides many addicts with the structure that they otherwise lack.
- ORT patients can enjoy stable and productive lives – living at home with their families, working, going to school, etc.
The biggest controversy surrounding ORT is the fact that some of the medications used are themselves powerful, dangerous, and addicted potential substances of abuse. Methadone, in particular, is associated with thousands of overdose deaths per year.
Naloxone—commonly-recognized under the brand-name Narcan – is an emergency medication that can reverse an opioid overdose in a matter of minutes. Quite literally, this easy-to-use medication has saved tens of thousands of lives. Because of that, there is a huge push going on right now to expand access to Narcan and make it available everywhere. Even the US Surgeon General is on board, and in early April 2018, issued an advisory recommending urging all Americans to carry naloxone and learn how to administer it. Many addiction experts are of the opinion that addicts are especially open to the idea of treatment immediately following a survived overdose. Upon request, victims are referred to appropriate recovery services. However, there are still concerns. As Dr. Sanjay Gupta, the Chief Medical Correspondent for CNN, says, “You’re basically saying, as a doctor, ‘I’m giving you this opioid for your pain, and by the way, you might kill yourself, so here’s this as well.” In fact, a controversial new study published in March 2018 concluded that increased naloxone access may be unintentionally increasing opioid abuse rates. The biggest supporting argument for this conclusion is the fact that even as availability is expanding, and the number of painkiller prescriptions issued is decreasing, the number of opioid deaths is still going up. Dr. Jennifer Doleac, one of the study’s authors, says, “While naloxone can be a good harm-reduction strategy, it’s clear that naloxone access alone is not a solution to the opioid epidemic. As currently implemented, these policies may be making things worse.”
Moderation Management is a harm reduction strategy for alcoholics who agree there is a problem but still don’t want to give up drinking. The philosophy of is that with the proper help and support, it is possible to “control” one’s drinking and live a productive life. MM is at odds with the currently-accepted view that addiction is a disease. Instead, MM practitioners propose that drinking is a bad habit that can be controlled. As evidence of this, members of MM fellowship groups placed strict limits on their drinking:
- Women – 9 drinks per week/Men – 14 drinks per week
- No driving after drinking
- No drinking during risky situations
- Abstaining from alcohol during the initial 30 days of the program
Unfortunately, both science and anecdotal evidence contradicts the idea of alcoholics being able to successfully control their drinking. Firstly, addiction in all its forms – including alcoholism – is a disease of the brain, and as that disease progresses, it impairs the person’s ability to make rational choices concerning their substance use. In fact, attempting to “bargain” with one’s drinking is one of the primary telltale signs of alcoholism. Secondly, to see how Moderation Management works in practice, we need only look at the tragic story of the movement’s founder, Audrey Kishline. In 2000, just six years after she founded the Moderation Management movement, Kishline drove her vehicle the wrong way down the highway, crashing and killing a father and his daughter. At the time, her blood alcohol content was triple the legal limit. Kishline served time in prison for the accident, and after she was released, she relapsed numerous times, battling not only her alcoholism, but also severe remorse for the deaths she had caused. In 2015, she took her own life.
A “wet shelter” is a homeless shelter that gives residents alcoholic drinks – typically, one drink every 60-90 minutes. Supporters argue that wet shelters reduce the harm associated with alcoholism in several ways:
- Reduces exposure deaths by attracting residents that would otherwise not seek shelter in abstinence-only lodgings.
- Prevents severely alcohol-dependent residents from going into dangerous, possibly-fatal alcohol withdrawal.
- 85% reduction in the time residents spend in the hospital and/or in jail.
- A reduction in drinking – 40% less daily alcohol consumed.
- Cost-effectiveness – In one study, it was determined that the taxpayer burden imposed by homelessness – medical bills, law enforcement, detox, incarceration, etc. – had reached $4066 per person per month. But among wet shelter residents, the cost was drastically reduced, to $958 per person per month.
Dr. Susan Collins, an Assistant Professor of Psychiatry at the University of Washington, says “Participants in the study told us that they’re happy to have a home, and happy that they no longer have to drink to stay warm or put themselves to sleep or to forget that they’re on the streets.” But there are valid criticisms with this method of reducing harm, as well. FIRST, there are no requirements mandating that wet housing residents receive any kind of treatment or even counseling about their drinking. SECOND, although there is a limit on the frequency of drinking, there is no limit on the amount. Residents can have their hourly drink EVERY hour, all day long. For comparison purposes, modern guidelines classify more than one daily drink for women or more than two for men as “heavy drinking”. THIRD, the long-term cost-effectiveness of wet housing is questionable, because lengthy alcohol abuse is associated with over 200 diseases and chronic conditions. This means that healthcare costs among residents with access to that much alcohol are only going to increase exponentially.
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What Supporters Say
A basic philosophy shared by many harm reduction supporters is that there never has been and never will be a society that is completely drug-free. And since that is the sad-but-true reality, public health efforts should focus on reducing the harms and negative consequences associated with drug abuse, without judgement or condemnation.
- Supporters say that they are neither for nor against drug use, likening the matter to other personal health choices such as dieting or smoking.
- According to advocates of harm reduction, drug prevention and control efforts inflict more damage than less-restrictive measures.
- The decision to seek or reject treatment is a personal decision that should not be coerced.
What Critics Say
The biggest criticism about most harm reduction methods is that in some ways, it can be compared to enabling addiction. Many substance abusers are fully aware that they have certain safety nets that are provided by harm minimization programs. When they are protected from some of the consequences of their alcohol-and-drug-driven behaviors – and see that their fellow addicts will are likewise protected – they know that they can continue to use with relative impunity. Looked at another way, these programs can appear to grant tacit approval of substance abuse, because in many cases, they make it easier for active addicts to feed their disease. Clean needles…a safe place to shoot up…overdose reversal medications…free room and board – too much of the “rock bottom” motivation necessary for change is lost, all in the name of reducing harm. And therein lies the true rub – addiction can be prolonged by misguided notions of so-called “harm reduction”. For example, the goal of methadone maintenance – in theory – is to slowly wean a person off drugs by gradually reducing the dosage. But ORT in practice can mean YEARS of daily clinic visits, where the physical urges are addressed, but nothing may ever be done about the psychosocial factors that play a role in addiction.
What’s the Bottom Line?
“The controversy, is, does it encourage people to keep using if we make their lives less dangerous and less miserable, or can we scare people into care?” ~ Dr. Barbara Herbert, M.D., President of the Massachusetts chapter of the American Society of Addiction Medicine There are two key considerations in this debate. On the one hand, there is no denying the fact that certain strategies aimed at reducing harm have had dramatic and positive effects – thousands of lives have been saved. An even greater number of people have gone from a hellish existence ruled by active, out-of-control addiction to a more manageable—if not quite completely abstinent – daily life. However… The harm reduction statistics only tell part of the story. As long as an addiction continues, the risks and the harms continue to add up—deepened dependence, physical and mental decline, broken families, generational substance abuse, and the unfulfilled promise of a life. The best thing a person struggling with an addictive disorder can do for their health, their family, and their future is to participate in an evidence-based rehab program. And here’s the thing—if their addiction is so severe that they aren’t willing to make that decision on their own, then there are other things that can be done in their best interest–interventions by family and friends or compulsory attendance as directed by the Court, for instance. In fact, multiple studies have determined that among individuals who entered treatment because of legal pressure have recovery outcomes that are as good as or better than those who went without being legal pressure. The problem isn’t that most of these strategies are totally without merit. Rather, it’s the fact that they could do so much more. To TRULY “reduce harm”, treatment should always be a required offering.