Efficacy of Harm Reduction on Prevention of Fatal Opioid Overdoses
Social Work Practice in Alcohol and Substance Abuse T7302
Professor Jacques Nir
The opioid epidemic that has been exponentially worsening since its onset in the 1990s continues to be one of the most significant public health issues we are facing as a nation today. One study, “Increases in Drug and Opioid Overdose Deaths,” that examines this recent increase in fatal opioid overdose notes that “the rate for drug overdose deaths has increased approximately 140% since 2000,” a statistic that is “driven largely by opioid overdose deaths” (Rudd et al., 2016). Another study, “Distinguishing Signs of Opioid Overdose and Indication for Naloxone” attributes overdose to a common and unfortunate product of persistent heroin and pharmaceutical drug abuse, even stating that “it is the single greatest cause of mortality among injecting drug users (IDU) in the united states,” (Green et al., 2008). This public health crisis is widespread and continuous, indicating the need for a shift in awareness, treatment, and targeted services among the injecting drug user population.
As the risk for fatal overdose is higher for some than others, it is important to acknowledge the disparities among different populations and demographics of injecting drug users. Individuals who are “prescribed more than 100 mg per day of oral morphine equivalents with a personal history of overdose; those recently released from a controlled environment such as jail and inpatient substance abuse treatments; and those who mix opioid use with alcohol, benzodiazepines, or other drugs” (Hawk et al., 2015) are all at increased risk. The establishment of treatment protocols must take greater consideration to these specific and endangered demographics in order to provide equitable and culturally-competent care to opioid users.
Harm reduction, described in “Understanding the Role of Harm Reduction in Preventing Opioid Overdose” as “a set of practical strategies, policies, and programs to reduce the negative consequences associated with the misuse of drugs,” (Understanding the Role of Harm Reduction, 2018), may be an effective solution in ameliorating the lethality of opioid abuse. Rather than targeting blame towards injecting drug users, a harm-reductive approach to substance abuse treatment favors creating a safer environment for users. In “Reducing Fatal Opioid Overdose: Prevention, Treatment and Harm Reduction Strategies”, a study that denotes several specific practices in harm reduction, explains that “it does not endorse drug use, but accepts drug use as a reality” and aims to prevent “death, HIV, Hepatitis C, criminal activity, and incarceration,” (Hawk et al., 2015). Hawk specifies “targeted overdose education, naloxone distribution, and policies to increase bystander assistance in the case of an overdose,” (Hawk et al., 2015) as effective and necessary harm reduction strategies. Another notable practice cited in “Understanding the Role of Harm Reduction” is the implementation of needle exchange programs that provide clean syringes to opioid users. Clinicians, medical practitioners, and those serving populations of injecting drug users that are adherent to harm reductive techniques “are committed to fighting the entrenched belief that drug use is a moral failing and that people who use drugs are less deserving of help and support than those who do not,” (Understanding the Role of Harm Reduction, 2018). Once judgment is set aside, we can begin to support the celebration of life and safety among drug-using populations.
As wider Naloxone distribution, the establishment of needle exchange programs, drug use and overdose education, use of methadone, and awareness of the Good Samaritan Law are effective preventative measures in reducing fatal opioid overdoses, greater awareness and establishment of these harm reductive strategies will ensure higher levels of safety among populations of injecting drug users.
The efficacy of harm-reductive treatments in the prevention of fatal opioid overdose is substantiated by research done in the field of substance abuse treatment. If more programs targeted towards reducing the harm caused by opioid use were implemented among specific populations known to be at risk due to external systemic influences, injecting users would have a higher chance of accessing care while engaging in safer opioid use.
One of the most effective strategies in place to prevent opioid overdose from becoming fatal for injecting drug users is distribution and heightened awareness of Naloxone. Defined by the Substance Abuse and Mental Health Service Administration (SAMSA) website, Naloxone is “a medication approved by the Food and Drug Administration (FDA) designed to rapidly reverse opioid overdose,” (SAMSA). In the previously mentioned study titled “Distinguishing Signs of
Opioid Overdose and Indication for Naloxone,” Green explains that the medication can prevent or reverse the lethality of opioids on the human brain and can aid in the resumption of breathing in someone who has overdosed. In the same study, it was found that Naloxone “training programs improved recognition and response to opioid overdoses significantly so that fewer opioid overdoses would be missed and fewer overdoses would be responded to inappropriately by trained participants,” (Green et al., 2008). As opioid overdoses represent a significant percentage of fatal drug overdoses, more widespread use of medication that directly targets the adverse effects of these drugs would be hugely impactful in the reduction of these statistics. If Naloxone possession and administration were further normalized and widespread, our society would be a safer place for opioid users.
Needle Exchange Programs
Another useful tactic in opioid abuse treatment is the implementation of needle exchange programs in communities with substantial drug injecting user populations. In a 1998 study titled “The Role of Needle Exchange Programs in HIV Prevention,” these programs are described as “provid[ing] sterile needles in exchange for contaminated or used needles to increase access to sterile needles and to remove contaminated syringes from circulation in the community,” (Vlahov et al., 1998). As mentioned previously, harm reduction does not seek to shame, demoralize, or punish injecting drug users for their addiction, but focuses instead on creating safer options and environments for those at the highest risk for fatal overdose. Needle exchange programs not only accept the realities of opioid abuse but aim to “provide participants with information about and/or access to other available services, including overdose prevention education, HIV and hepatitis testing, case management, and referral to treatment,” free of judgment (Understanding the Role of Harm Reduction, 2018). Additionally, in the same 1998 study, “of the eight reports that examined the issue of injection frequency, three showed a reduction in injection frequency,” (Vlahov et al., 1998). Although needle exchange has not been proven to be solely influential in reducing fatal opioid overdoses, when utilized in combination with other harm-reductive strategies these programs may add to the overall safety of injecting drug users and “have been shown to be effective in reducing risky behaviors associated with injection drug use,” (Understanding the Role of Harm Reduction, 2018).
Similar to the manner in which needle exchange programs aid in the reduction of risky behavior associated with opioid abuse, programs that aim to educate individuals in regards to overdose response and risk may impact the choices they make and improve safety conditions if those choices become dangerous. A 2013 study, “Opioid overdose rates and implementation of overdose education and nasal naloxone distribution,” piloted in Massachusetts explains that “overdose education and naloxone distribution (OEND) programs tackle overdose by educating people at risk for overdose and bystanders in how to prevent, recognize, and respond to an overdose,” (Walley, 2013). This study indicates the efficacy of education program initiation in reducing fatal overdoses as “both low and high implementation of OEND were associated with lower rates of opioid-related deaths from overdose,” (Walley, 2013). Although this study took place in a specific location and served a specific population of injecting drug users, it implies overall success for these types of educational resources and programs. Furthermore, if combined with other strategies like needle exchange, injecting drug users and those who support and care for them would benefit greatly due to their ability to access multiple resources at once.
Methadone and Suboxone
An additional medication-based therapy that aims to reduce the harm caused by continuous opioid abuse is Methadone treatment. In “The Impact of Harm-Reduction-Based Methadone Treatment on Mortality Among Heroin Users,” this treatment is described as being “widely used for detoxification, but [also as] a maintenance treatment to prevent withdrawal symptoms” (Langendam, 2001). Again, harm reductive strategies operate under the assumption that it is unrealistic to expect individuals engaged in persistent use to simply terminate their dependency on these substances. Comparable to how “nicotine replacement is used to reduce the urge to smoke, these medications reduce opioid cravings and withdrawal symptoms,” (Understanding the Role of Harm Reduction, 2018). Methadone treatment “has been linked to decreased mortality” and “reductions in illicit opioid use,” (Understanding the Role of Harm Reduction, 2018).
Similar to Methadone, Suboxone, a prescription drug comprised of naloxone and buprenorphine, works to ease withdrawal symptoms of opioids. Noted in “Opioid maintenance treatment as a harm reduction tool for opioid-dependent individuals in NYC: the need to expand access to buprenorphine in marginalized populations,” it lessens the effects of the illicit drug in that “naloxone becomes effective as an opioid antagonist,” (Stancliff et al., 2012). In addition to potentially replacing lethal opioids with a more controlled substance, the use of Suboxone provides people who use drugs with the opportunity to access medical care and treatment without expending the high cost that rehabilitative clinic-based outpatient and inpatient substance abuse programs necessitate. These prescriptive interventions are another harm-reductive strategy that,
when employed alongside other methods of treatment, may aid in the well-being of injecting drug users.
Good Samaritan Law
In the previously cited Vladhov (1998) study that denotes needle exchange as a protective factor in HIV transmission, it is stated that “fear of arrest and incarceration for violation of drug paraphernalia laws” is cited as a contributing factor for “multiperson use of needles and
syringes” (Vladhov et al., 1998). This multiperson use is an example of a risky behavior associated with opioid abuse. More generally, it has been confirmed by multiple sources that “the most common reason people cite for not calling 911 is fear of police involvement,” (Good Samaritan Fatal Overdose Prevention Laws). Due to fear of arrest and police violence, even those who require assistance from medical professionals in the case of an overdose may not call
911 for services. Good Samaritan laws “provide protection from prosecution for low-level drug offenses, like sale or use of a controlled substance or paraphernalia, for the person seeking medical assistance as well as the person who overdosed,” (Good Samaritan Fatal Overdose Prevention Laws). While many “people are unaware of the law[s]” in place to protect them, a study conducted in Washington State “found that 88% of people who use opioids said they would be more likely, and less afraid, to call 911 in the event of a future overdose after learning about the law,” (Good Samaritan Fatal Overdose Prevention Laws). These laws aim to encourage individuals to pursue medical services to protect against overdose in a non-punitive manner. The primary issue that prevents this policy from being effective is a lack of awareness. For example, “two-thirds of the 22 clients interviewed at a needle exchange in Baltimore did not know there was a Good Samaritan law” in place (Good Samaritan Fatal Overdose Prevention Laws). The usefulness of these laws would be greatly improved by enhanced education and awareness efforts that could be employed by not only policymakers but by the same services that offer other harm-reductive tactics like needle exchange and naloxone education.
Fentanyl Test Strips
Another effective harm reduction intervention in fatal opioid overdose prevention is the implementation and use of fentanyl testing strips (FTS) in communities of injecting drug users. As cited in “Perspectives on Rapid Fentanyl Test Strips as a Harm Reduction Practice Among Young Adults Who Use Drugs”, a qualitative study denoting the usefulness of FTS in overdose prevention, “consumption of fentanyl causes more profound respiratory depression than other opioids and produces clinically distinct symptoms (e.g., bradycardia, chest wall rigidity) that precipitate rapid onset of overdose death, narrowing the window of opportunity to administer naloxone,” (Goldman et al., 2019). While naloxone administration is a useful and preventative harm reduction tactic, its effectiveness only increases with greater awareness and use of FTS in conjunction. In the Goldman study, it was found that “persons who use FTS and who receive a positive test result may be more likely to partake in overdose prevention strategies than a person who is not aware that their drug is contaminated with fentanyl,” (Goldman et al., 2019). If more people who use drugs were to test for fentanyl before using, their safety would exponentially increase when doing so. Due to the intense lethality of fentanyl, it is important to consider multiple harm reduction tactics in overdose prevention implementation.
Case Management and Peer Counseling
While not solely employed as a harm-reductive intervention for people who use drugs, case management and peer counseling can contribute to greater education and awareness among communities at risk for fatal opioid overdose. Allison O’Rourke explores the integration of harm reduction idealogy into case management treatment in “Client-Identified needs and agency-provided services at a harm reduction community-based organization in the District of Columbia”. As substance use disorder and opioid abuse may co-occur with other mental illness diagnoses and low-income status, many people who use drugs may already be connected to care that may include case management services. O’Rourke cites case managers’ “willingness to apply the harm reduction framework to service provision as an alternative to more rigid abstinence-only models of care” (O’Rourke et al., 2015). Tenets of case management and harm reduction are harmonious in that they both seek to “understand needs from clients’ perspectives,” (O’Rourke et al., 2015). Case management is a valuable channel for dissemination of harm reductive intervention as it can be incorporated into prior care plans.
Recommendation for Policy Improvement
In the conclusion of this exploration of harm reduction as a viable prevention strategy for fatal opioid overdoses, policies that may contain areas for improvement in New York state will be explored. A 50-state survey of harm reduction laws in the United States created by the Network for Public Health Law examines many of these policies. Presently, the only established categories of policy related to harm reduction include Syringe Possession and Distribution, Naloxone Access Law, Naloxone Standing Order, and the Good Samaritan Law. While there are several laws in place that both provide practitioners and organizations with permission to distribute clean syringes and Naloxone, as well as protect people who use drugs from lawful persecution for possession of drug paraphernalia, there are no policies seeking to regulate the distribution process or any mention of fentanyl testing as of right now. As the increase of fatal opioid overdoses in injecting drug users is a rising public health crisis, it is imperative that more policies surrounding harm reduction are written. For example, although individual pharmacies have the ability to give out naloxone under standing order, New York State does not have a standing order regarding Naloxone distribution. As compared to North Carolina, where pharmacists are sanctioned by the state to allocate naloxone to those in need and provide overdose information to those it is given to, New York State has room for improvement in this area. Furthermore, more documents such as this 50 State Survey that employ digestible language should be created to ensure understanding among drug-using populations of individuals’ rights and policies that may affect and help them. As policy stands right now, there are far more laws in place that seek to protect people who use drugs from legal ramifications than those that aim to take proactive and preventative measures such as standardized FTS and Naloxone distribution. With these policies in place, we may prevent overdose while not taking punitive measures against those who inject drugs.
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