Harm Reduction Strategies for the Opiod Crisis

Only a decade ago the words “harm reduction” would send many public health officials, law enforcement, and elected representatives scrambling for political cover. Harm reduction had often been controversial because it doesn't subscribe to the abstinence-only curriculum that has long been the main source of teaching about sex and drugs in the United States. Many people now support the idea that condoms are an effective way to prevent pregnancy and disease transmission. They recognize that merely trying to scare or shame people doesn't usually work. Yet with drugs, we continue to fall back to “just say no” messaging. Harm reduction programs that teach practical methods such as clean syringe distribution to lessen mortality or disease transmission associated with drugs are often accused of “sending the wrong message” or “enabling drug use.” But in recent years, the severity of the opioid crisis has led policymakers and the public to be more willing to embrace alternative methods to resolve the problem. Several of these methods have recently been implemented in North Carolina.

In 2013, in response to the wave of opioid-related overdose deaths, the North Carolina General Assembly passed a law expanding the availability of naloxone for lay people. Naloxone is a safe, non-addictive medication that reverses opioid overdose. From August 1, 2013 to February 11, 2018, community based distribution programs across the state handed out over 60,000 overdose prevention kits containing naloxone to people at risk for overdose and their loved ones [1]. During the same time period, people across the state reported using 10,240 of these kits to reverse an overdose [1]. Each kit is accompanied by a short training on how to avoid an overdose, and how to recognize and respond to an overdose should one occur. Additionally, 210 law enforcement departments across the state—about half the total departments—now carry naloxone so that officers and deputies have a tool to use to respond to an overdose [2]. Law enforcement officers had conducted over 800 rescues with naloxone as of February 11, 2018 [2].

In 2016, 3 years after the passage of the original overdose prevention law, North Carolina's state medical director signed a standing order enabling pharmacists to dispense naloxone to anyone at risk for an overdose or anyone who knows someone at risk. As of February 11, 2018, 1,409 pharmacies across the state were active participants in this program [3]. This program allows North Carolinians in need of an overdose prevention kit to walk into any pharmacy and ask for naloxone without a prescription, which greatly expands the medicine's accessibility. Many governmental and non-governmental organizations across North Carolina are also working to encourage pharmacists to be proactive about talking to all patients who fill opioid prescriptions about naloxone, instead of waiting for the patient to ask.

In 2016, North Carolina also legalized another harm reduction program: syringe exchange. Syringe exchange programs distribute sterile syringes to injection drug users, collect used syringes, and offer wraparound services such as HIV testing and linkage to drug treatment programs. Back in the 1980s when the nation was grappling with the AIDS epidemic, many people lost their lives as HIV spread through injection drug use. The very first harm reduction programs began by introducing the concept of syringe exchange. Initially, these programs were met with storms of protests and accusations of enabling. But over 30 years of research, the effectiveness of syringe exchange programs is pretty clear: they significantly reduce the spread of HIV, Hepatitis C, and other bloodborne illnesses among injecting drug users [4, 5]. They remove used syringes from the streets [6], reduce syringe-stick injury to first responders [7], and have even been shown to reduce crime by connecting people with social services such as food banks, employment programs, and health care [8]. Additionally, some studies have demonstrated that people who participate in syringe exchange programs are more likely to seek treatment for drug use than people who do not [9]. As of February 2018, 26 syringe exchange programs exist throughout North Carolina in such diverse locations as bookstores, pawn shops, churches, fire departments, health departments, AIDS services organizations, and drug user unions [10]. During the first year after legalization, the programs distributed over 1 million syringes, administered over 2,600 HIV tests, and referred over 3,500 people to drug treatment programs [11].

North Carolina has adopted many other harm reduction techniques and programming, including medication-assisted treatment, overdose prevention training for people impacted by drug use and first responders, pre-arrest diversion programs that divert low-level drug users from jail to social services, HIV and Hepatitis C testing and linkage-to-care programs, laws that protect people who call 911 to report an overdose from being prosecuted if police find small amounts of drugs on the scene, expansion of substance use treatment programs, and much more. But the latest debate across the country, and to an extent in North Carolina as well, is over safe injection facilities. Safe injection facilities are sites where people can legally consume drugs under staff or medical supervision. They are designed to reduce the incidences of people injecting drugs in public parks, bathrooms, cars, or other public areas, and also to reduce other public harms such as overdose, intoxicated driving, and improper disposal of syringes. Though no sites are currently in operation in the United States, several cities are currently advocating for them and safe injection facilities have been operating in Australia, Canada, and some European countries for many years. As with all new harm reduction initiatives, the sites initially met a wall of criticism about enabling drug use, but today enjoy significant public support [12]. In the United States, San Francisco plans to open its first safe injection facility in the summer of 2018, while other cities such as Philadelphia, Baltimore, and Seattle are debating whether to implement safe injection facilities as well.

Decades of research support the efficacy of harm reduction techniques in reducing disease transmission, saving lives, and even helping people lessen or stop their drug use. In the same sense that taking small, practical steps to improve diet and exercise habits is often more effective than attempting to lose massive amounts of weight very quickly, for many people, taking small steps to reduce the harms of drug use can be more achievable than total abstinence from all drugs. Even in the context of the current opioid crisis, where pharmaceutical-grade drugs may be laced with unknown substances that increase the risk of overdose, there are harm reduction techiques to reduce these risks. Examples include using test strips to detect the presence of high-risk opioids like fentanyl, doing small “test shots” to check the potency of a drug before using it, keeping naloxone on hand, never using alone, and being knowledgeable about local laws that may protect people who call 911 to report an overdose. The goal of harm reduction with regard to drug use is to encourage positive steps toward improving a person's health and wellness, however that person may choose to define it. For some people, that means abstinence from drugs. For others, it means lessening their drug use, managing their drug use, or in some cases improving other areas of their lives while mindfully seeking help to manage the risks of drug use (eg, needle exchange, naloxone, MAT, etc.), even as they continue their drug use. Harm reduction recognizes the harm that chaotic drug use coupled with ineffective drug policy can cause.

The opioid crisis and the willingness of the public and policymakers to consider new ideas to combat mortality and the spread of disease have propelled harm reduction toward an increasingly visible role in the public health debate. Moving forward, it will be critical for harm reduction to help move the conversation from an opioid-centric focus to one around drug policy as a whole. Though it is encouraging to see diverse groups come together to help resolve the issue of opioid-related disease and death, opioids will not always be the drug of choice. When that changes, public health professionals, policymakers, and communities need to be prepared to confront the next wave of drug-related harms, whether they be from the drugs themselves or from policies that make it harder for people to live healthy lives due to stigma, the effects of a criminal record, or difficulty accessing treatment and health care. How we handle the opioid epidemic will shape the debate on whether substance use is treated as a medical problem or a criminal one for decades to come. We need to all come together to advocate for evidence-based solutions to improve health and save lives across the state.

• ©2018 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.