Harm reduction is a strategy to engage with people who use drugs to keep them alive so that they have the opportunity to begin recovery and to help prevent infectious disease transmission in the community. Harm reduction services include [1]:
- Overdose reversal education and training
- Linking people to HIV and viral hepatitis prevention and testing
- Pre- and post-exposure prophylaxis
- Access to hepatitis A and hepatitis B vaccinations
- Access to HCV and HIV antiviral therapy and treatment
- Prevention of mother-to-child and partner-to-partner virus transmission
- Distribution of naloxone kits
- Distribution of substance test kits (e.g., fentanyl test strips)
- Distribution of safer sex kits
- Distribution of sharps and medication disposal kits
- Distribution of medication lock boxes
- Distribution of wound care supplies
- Distribution of sterile injection supplies
- Distribution of safer smoking kits
- Educational material for safer injection practices
|More: Here’s an overview of what naloxone is and how responders are helping curb the opioid epidemic
Opioid abuse misconceptions
One of the great misunderstandings about opioid use and addiction is the belief that it is in all cases a “choice” made by irresponsible people. As healthcare professionals, it is not the purview of EMS providers to judge our patients. It is our job to care for them. Opioids have been used for pain management for acute and chronic medical conditions, for post-oral surgery pain, for chronic non-cancer patients, for post-surgical care, for musculoskeletal pain and for multiple sclerosis. Opioids can have a psychological effect as well as a chemical effect that changes the brain and has an antinociception effect on opioid receptors in the central nervous system. Genetic factors contribute to dependence behavior and relapse after treatment [2].
One of the tenants of harm reduction is that people who inject drugs are not necessarily “powerless” or morally flawed and incapable of self-care. People who use drugs may be experiencing barriers, such as homelessness, financial instability, mental illness, physical illness and engagement in crime which interferes with their ability to employ self-care.
By decriminalizing certain activities and making harm reduction services available to people who use drugs, they may be better able to employ self-care practices [4].
Harm reduction can be contrasted with zero-tolerance policies. Even in countries that espouse zero-tolerance, such as the United States’ “war on drugs,” methadone maintenance programs are considered acceptable, while needle and syringe programs and safe injection sites have typically faced backlash.
One way to overcome this backlash is to focus on the cost benefit of harm reduction on the public’s health, as well as reducing the spread of HIV and AIDS, treating drug users with dignity and as humans, and without including moralistic judgement as part of a program [3].
Harm reduction results
The reported results of harm reduction strategies are mixed. One of the oldest and best established safe injection programs is found in Vancouver, Canada. The Manhattan Institute for Policy Research, a right-wing think tank, alleges that the program increases the problems of addiction, homelessness and public disorder [5]. The Cato Institute, on the other hand, reports that the program has been successful in reducing the overdose death rate through take-home naloxone kits, safe injection sites and opioid agonist therapy, also known as medication-assisted treatment [6]. Research published in the journal “Addiction,” found that these three interventions resulted in an estimated 3,030 death events averted during a study period of April 2016 and December 2017 in British Columbia [7].
|More: Introduction to medication-assisted opioid dependence treatment for EMS
The success of the Vancouver efforts shows that harm reduction strategies do not enable drug use, has reduced HIV infection in the community, reduced needle sharing and increased drug injection cessation [8].
EMS role in harm reduction
The City of Boston has published a toolkit on how harm reduction programs can be implemented in a community. This includes the principles and practices of harm reduction, how community stakeholders can be engaged, how services are designed, and how services are delivered [9]. The roles for community EMS can be varied.
Local EMS likely has a wealth of information from its experience engaging with people who use drugs and can contribute to an assessment of the social determinants of health (SDOH) contributing to drug use in the community. Understanding local SDOH can inform the design and development of local strategies in implementing a harm reduction program.
Another contribution that EMS can make, along with law enforcement, is in the identification of “hot spots” and problem areas where interventions can be geographically targeted. If there is a new program being developed in a community, EMS may want to be represented on its advisory board as it can be expected that EMS will potentially be impacted.
Community EMS likely already has experience engaging patients facing socioeconomic disadvantages, multiple chronic health conditions, and those with a history of crisis-oriented episodic care. If a program include mobile addiction services, community EMS is already experienced in operating in a mobile environment.
In contributing to the development of a harm reduction program, think about what goals you want to achieve. Is it to reduce 911 emergency responses for drug overdoses? Is it to reduce the number of drug overdose deaths in your coverage area? Is it to build relationships with the people living in your community and break down cultural and racial barriers to improve overall service in your community? Then you can consider the strategies to implement in a harm reduction program that can achieve desired outcomes. Periodically evaluate and fine-tune the processes you are implementing.
Here are some typical components found in harm reduction programs:
- Syringe services
- Safer injection education and supplies
- Drug checking (verifying drug ingredients, e.g. fentanyl test strips)
- Harm reduction practices for sex workers
- Overdose prevention (naloxone)
- Wound care
- Referrals to counseling and rehabilitation services
By collaborating with other community organizations with harm reduction goals, and obtaining proper training for staff, community EMS can support harm reduction projects. Activities can include safety education, testing drug ingredients, and naloxone distribution and training.
EMS can also be instrumental in reaching out to people at risk and where to find support. Homelessness, loss of employment, chronic medical problems, and other concerns related to the social determinants of health are all areas where community EMS assessments and referrals to community services are where a difference can be made.
By offering basic care, making referrals and providing information on accessing harm reduction services, people who use drugs can reduce the risks, and potentially enter counseling and rehabilitation programs.
REFERENCES
- SAMHSA, “Harm Reduction,” Substance Abuse and Mental Health Services Administration, 8 June 2022. [Online]. Available: https://www.samhsa.gov/find-help/harm-reduction.
- C. J. Mistry, M. Bawor, D. Desai, D. C. Marsh and Z. Samaan, “Genetics of Opioid Dependence: A Review of the Genetic Contribution to Opioid Dependence,” Current Psychiatry Reviews, vol. 10, no. 2, pp. 156-167, 2014.
- N. Hunt, “A review of the evidence-base for harm reduction,” 2003. [Online]. Available: https://www.hri.global/files/2010/05/31/HIVTop50Documents11.pdf.
- L. M. Boucher, Z. Marshall, A. Martin, K. Larose-Hébert, J. V. Flynn, C. Lalonde, D. Pineau, J. Bigelow, T. Rose, R. Chase, R. Boyd, M. Tyndall and C. Kendall, “Expanding conceptualizations of harm reduction: results from a qualitative community-based participatory research study with people who inject drugs,” Harm Reduction Journal, vol. 14, no. 18, 12 May 2017.
- C. F. Rufo, “The Harm in “Harm Reduction”,” City Journal, vol. Spring, 2020.
- J. A. Singer, “New Evidence From British Columbia Provides a Strong Case for Harm Reduction Strategies,” 8 July 2019. [Online]. Available: https://www.cato.org/blog/new-evidence-british-columbia-provides-strong-case-harm-reduction-strategies.
- M. A. Irvine, M. Kuo, J. A. Buxton, R. Balshaw, M. Otterstatter, L. Macdougall, M. J. Milloy, A. Bharmal, B. Henry, M. Tyndall, D. Coombs and M. Gilber, “Modelling the combined impact of interventions in averting deaths during a synthetic-opioid overdose epidemic,” Addiction, vol. 114, no. 9, pp. 1602-1613, September 2019.
- L. Ti and T. Kerr, “The impact of harm reduction on HIV and illicit drug use,” Harm Reduction Journal, vol. 11, 21 February 2014.
- City of Boston, “Harm Reduction Toolkit,” 2021. [Online]. Available: https://www.rizema.org/wp-content/uploads/2021/09/CoB-Harm-Reduction-Toolkit.pdf.
