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

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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:

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

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

• 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

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