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Harm Reduction In Opiate And Opioid Users


ARTICLE SUMMARY: Harm reduction refers to a variety of approaches that aim to prevent or reduce a person’s overall level of drug consumption. It is based on the belief that many people will continue to use drugs, despite their best efforts to quit. As an alternative to total abstinence, it focuses on solutions like medication and behavioral therapies to help people remain functional.


TABLE OF CONTENTS

Definition
Core Principles
Main Harms
Top 10 Approaches
Maintenance Medications
Buprenorphine
LAAM
Methadone
Psychotherapy
Criticism


Definition

There are many opinions about what harm reduction is and is not. Most broadly, harm reduction can be described as a strategy directed toward individuals or groups that aims to reduce the harms associated with certain behaviors. When applied to drug use, the non-profit advocacy group, Harm Reduction International, defines “harm reduction” as:

‘Harm Reduction’ refers to policies, programmes and practices that aim primarily to reduce the adverse health, social and economic consequences of the use of legal and illegal psychoactive drugs without necessarily reducing drug consumption. Harm reduction benefits people who use drugs, their families and the community.

In other words, harm reduction encompasses treatment alternatives for people diagnosed with substance use disorders whom abstinence is not feasible. The approach accepts the fact that some folks are simply unable or unwilling to stop using drugs. How does this definition translate into practice? According to David Purchase, a formative leader of the North American Syringe Exchange Network, harm reduction is more of an attitude than a fixed set of rules or regulations. The approaches of harm reduction are oriented towards teaching people health related behaviors.

Another important element of harm reduction is understanding what constitutes “harm”. The term harm has been elaborated on in many different ways. Harm can be defined on:

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  1. An individual level (HIV from shared needles, skin infections).
  2. The community level (unsafe drug use).
  3. A societal level (increasing infection rates, economic loss from publicly funded health service).

Core Principles

Harm reduction has yet to reach mainstream medical acceptance. Many services are provided by non-rofit, advocacy groups, including the Harm Reduction Coalition.  The Model of Harm Reduction is based on the following 7 core principles.
  1. Professionals should treat each person in recovery as an individual.
  2. The addictions counselor should start where its patient is.
  3. People in recovery are viewed as more than their problems.
  4. Accepting change involves small steps before a person can heal completely.
  5. Abstinence is not a necessary precaution of therapy before getting to know the person.
  6. The doctor and the person in recovery should develop a collaborative and empowering relationship.
  7. Destigmatizing addiction as a disease and separating it from the person in recovery is essential.

Main Harms

The main harms of drug use include:
  • Criminal activity
  • DUI or DWI fatal car accidents
  • Fetal withdrawal snydrome
  • Overdose and death
  • Spread of disease

Historically, certain drug use patterns have been a consistent focus of harm reduction interventions. For example, needle exchange programs are perhaps one of the most well-known and controversial harm reduction techniques that address disease that is spread by opiate injection. Additionally, the success of methadone maintenance programs has also come under scrutiny; these programs aims to reduce heroin or hard opiate use by substituting less potent opioids in a controlled environment.

Harm reduction techniques aim to address public health and order problems caused by drug users. However, there are additional harms that you may not have heard of that can come from opiate or opioid use. These include:

  • Addiction
  • Drug interactions
  • Increased emergency department visits
  • Progression to more potent opiate use, especially heroin
  • Public order problems (crime, theft, public intoxication, etc.)
  • Transmission of blood borne diseases (HIV, hepatitis B, hepatitis C)

Millions of Americans misuse illicit and prescription drugs.  In fact, the CDC reports on a recognized Opioid Epidemic in the U.S. Access to opioid pain killers is fairly easy, while availability of prescription pills is high in the U.S. market. But what do people who use opiates risk? And how can harms of opiate or opiate use be minimized?

Further, opioid use disorders continue to affect Americans. Use of prescription pain killers is truly a national problem. The 2016 National Survey on Drug Use and Health reported that an estimated 3.3 million people aged 12 or older were pain killer users in the past month, or about 1.2 percent of the population aged 12 or older.

Top 10 Approaches

Opiate harm reduction techniques aim to reduce or eliminate illicit opiate and opioid use. Although this goal is the basis for abstinence based programs, as well, elimination of all drug use often not possible. In fact, sometimes just keeping people “medically maintained” keeps them in treatment, reducing illicit drug activity and associated harms. Some of the most recent approaches to reducing opiate and opioid harm include:

  1. Drug substitution (opiate substitution therapies for less potent or less harmful substance; ie. LAAM, methadone).
  2. Drug consumption rooms.
  3. Health care provider interviews including drug screening, drug testing, and drug contracts.
  4. Ibogaine treatment for opiate cravings and depression.
  5. Increasing access to to addiction treatment services.
  6. Informational campaigns for prescription drug interactions and disposal.
  7. Needle exchange programs.
  8. Prescribing inject-able heroin (diamorphine) or oral heroin (diacetylmorphine).
  9. Prescription drug labeling and warnings.
  10. Supervised drug injection sites.
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Medication Maintenance Treatment

 1. Buprenorphine: Buprenorphine is a semisynthetic opioid agonist formulated for oral administration with duration of action similar to methadone (24-36 hours). The recommended therapeutic dose ranges from 8 to 16 mg. Unlike methadone and LAAM, buprenorphine creates less respiratory depression, even at higher doses. According to a study on Harm Reduction Agencies as a Potential Site for Buprenorphine Treatment, published on NCBI in 2015 buprenorphine has been proven effective.

2. L-Alpha- Acetylmethadol: Similar to methadone, LAAM belongs in the category of synthetic opioid agonists designed for oral administration that is less harmful than heroin. This drug is different than methadone in its duration of action and its side effects. For example, the effects of a 50-20mg LAAM dose last 48-72 hours following administration, compared to the 24 hours of methadone and 6 hours of heroin. As a result, people take the medication every other day as opposed to regular daily consumption. According to a study about Methadone vs. L-alpha-acetylmethadol (LAAM) in the treatment of opiate addiction, LAAM is as effective almost as effective as methadone in reducing heroin use.

3. Methadone Maintenance: Methadone is a synthetic opioid agonist formulated for oral administration. In comparison to heroin, a therapeutic dose of methadone (60-120 mg) produces less intense euphoria and cravings for a longer period of time. The end result is less frequent need for use. According to the results of a deacde-long study, “Trends in methadone maintenance treatment participation, retention, and compliance to dosing guidelines in British Columbia, Canada: 1996–2006,” methadone maintenance programs have shown better treatment retention rates than abstinence-oriented interventions.

Psychotherapy in Harm Reduction

Therapeutic alliance is essential when using talk therapy in harm reduction cases.The essence of harm reduction is the recognition that treatment must start from a person’s own needs and personal goals. So, when applied to a therapeutic, counseling setting, the psychotherapist must first believe in the effectiveness and the acceptability of harm reduction. In this way, all change that reduces the harms associated with substance use can be regarded as valuable.

Psychotherapy modalities focus on strategic skills-building while looking at multiple meanings of “substance use”. According to this 2010 review of research regarding the use of talk therapy in harm reduction, best practices require a deep understanding of moving people to change. When people are ambivalent or resistant to change, harm reduction gives therapists an opportunity to build rapport and help clients make little steps in the right direction. Ideally, a person chooses to stop using substances completely. However, in the absence of a commitment to abstinence, a clinical success is any client improvement and reduction in harm.

Criticism

Over time, it has become increasingly clear to clinicians that the majority of people diagnosed with stronger addiction problems were not being helped by traditional approaches.  100% abstinence simply did not interest every person dealing with a drug problem. This motivated medical professionals to search for alternative ways of understanding substance use problems and for treatment approaches that offered more hope. This is how harm reduction model was discovered and carried a single goal: fostering positive change in people with addiction problems.

The practice of harm reduction continues to undergo research and evolution. As tools are available to drug treatment providers to help target opiate use and abuse, we as a society set the stage for harm reduction. So what needs to be in place for harm reduction techniques to work for opiate addicted individuals? Your feedback, comments, opinions and questions about harm reduction for opiate and opioid use are welcomed below.

Reference sources: Harm Reduction: Pragmatic Strategies for Managing High Risk Behaviors (2012) pp. 170-200.
NCBI: Harm Reduction Agencies as a Potential Site for Buprenorphine Treatment
NCBI: Harm Reduction Agencies as a Potential Site for Buprenorphine Treatment
NCBI: Reducing Fatal Opioid Overdose: Prevention, Treatment and Harm Reduction Strategies
NCBI: Methadone vs. L-alpha-acetylmethadol (LAAM) in the treatment of opiate addiction

Photo credit: Todd Huffman

Leave a Reply

6 Responses to “Harm Reduction In Opiate And Opioid Users
phatpooch
11:25 pm March 30th, 2012
4:51 am March 31st, 2012

Thanks for sharing that link, phatpooch. The interviews with methadone and heroin users were for me an eye opener, and I could really see the difference that methadone can make for people. I know that many people criticize methadone maintenance, but I think that the first two women interviewed are doing much better than the last woman.

phatpooch
4:42 pm March 31st, 2012

Thanks. You can check out my other vids i made. One I created with three of my friends we all were hard core addicts here in Vancouver. I am doing the interview

Luke
11:33 pm April 1st, 2012

Although I agree methadone is safer to use than heroin and can be extremely helpful for individuals who are trying to fight their drug addiction, I remain very torn about it’s use. Even though it is not as powerful of heroin, it is often much more difficult to withdrawal from because it has such a long half-life. While heroin users may face withdrawals for about a week, methadone withdrawal tends to last for about a month because it stays in your body for so long. I have even heard of withdrawals lasting beyond six weeks. With methadone withdrawals last so long, people tend to trade one highly addictive substance for another. However, I agree most individuals are able to function better in society on methadone, and it is given by a professional who limits the use so it is definitely safer. I just would like to see some type of program implemented that helped individuals get clean from methadone after a few months of use in order to help them get completely clean. In the end, I wonder if those who become addicted to methadone wish they were able to go through a substance abuse program from the beginning so they did not have to go through a month of withdrawal to quit.

3:29 am April 2nd, 2012

Hi Luke. Thanks for sharing your opinion about methadone. There has been research which shows that 6 months is about the minimum amount of time that people should take methadone, But as doctor prescriptions are based on individual doctor decisions as well as patient outcomes,methadone maintenance programs CAN last for years for some people.

Have you heard of any programs that also have detox / withdrawal from methadone as part of clinical services?

Heath Hart
2:29 am June 13th, 2016

I agree with Luke. I have been on methadone for eight years and the withdrawal can be much more severe as compared to short acting opioids. I have seen people sick for months and have experienced much the same when trying to quit methadone cold turkey. I believe that we need more options for this epidemic of opiate use. I think that Ibogaine should be being heavily researched as a true detox medication in order to get completely clean.

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