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Harm Reduction, Safe-Injection Sites, and Naloxone

Fifth Annual Addiction Leadership Conference

Safe-injection sites, also known as supervised injection facilities, fix rooms, safer-injection facilities, drug-consumption facilities, or medically supervised centers were first developed in Australia and then in Vancouver, British Columbia (Dolan et al., 2000). The idea is to create a place where addicts can go and administer drugs with health professionals standing by with naloxone/Narcan if an overdose or bad reaction occurs.

This is a harm-reduction approach for substance use treatment that involves a set of practical techniques that are openly negotiated with clients around what is most likely to be achieved. The focus is on reducing the negative consequences and risky behaviors of substance use; it neither condones nor condemns any behavior. By incorporating strategies on a continuum from safer drug use to managed substance use and up to abstinence, this harm-reduction practice helps clients affect positive changes in their lives. To counter injection-related consequences, switching from injecting to snorting heroin, needle-exchange programs, and safe-injection practices are standard harm-reduction approaches (HRC, n.d.).

The following are examples of services available to prevent harm from substance use (HealthLinkBC, 2015):

  • “Needle distribution/recovery programs that distribute sterile needles and other harm-reduction supplies, recover used needles and other supplies, and provide information and containers for their safe disposal”
  • “Substitution therapies that substitute illegal heroin with legal, noninjection methadone or other prescribed opioids”
  • “Take-home naloxone programs that provide an antidote to opioids to reverse an overdose thereby preventing brain injury (due to depressed breathing) and death”
  • “Supervised consumption facilities that help prevent overdose deaths and other harms by providing a safer, supervised environment for people using substances”
  • “Outreach and education services that make contact with people who use substances to encourage safer behavior”
  • “Peer-support programs that are group run and attended by people who use substances to improve their quality of life and to address gaps in services”
  • “Impaired driving prevention campaigns that create awareness of the risks of driving under the influence of alcohol and other legal or illegal substances”

Myths and facts about harm reduction include the following (NHCHC, 2010):

  • Myth: “harm reduction is opposed to abstinence and therefore conflicts with traditional substance abuse treatment”
  • Myth: “Harm reduction encourages drug use”
  • Myth: “harm reduction permits harmful behavior and maintains an ‘anything goes’ attitude”
  • Fact: “harm reduction is not at odds with abstinence; instead, it includes it as one possible goal across a continuum of possibilities which includes abstinence”
  • Fact: “harm reduction is neither for nor against drug use. It does not seek to stop drug use, unless individuals make that their goal—harm reduction focuses on supporting people’s efforts to reduce the harms created by drug use or other risky behaviors”
  • Fact: “harm reduction neither condones nor condemns any behavior. Instead, it evaluates the consequences of behaviors and tries to reduce the harms that those behaviors pose for individuals, families, and communities”

There was a great deal of opposition to the concept of harm reduction by the federal government, characterized by its opposition to needle-exchange programs. The Health Omnibus Programs Extension Act of 1988 established support for investment in HIV prevention, testing, and education through the CDC, but contained a significant clause:

None of the funds provided under this Act or an amendment made by this Act shall be used to provide individuals with hypodermic needles or syringes so that such individuals may use illegal drugs, unless the Surgeon General of the Public Health Service determines that a demonstration syringe exchange program would be effective in reducing drug abuse and the risk that the public will become infected with the etiologic agent for acquired immune deficiency syndrome (Health Omnibus Programs Extension Act of 1988).

This restriction and its concomitant political and social implications ushered in the harm-reduction era in the United States. Since 1988 the federal ban on the funding of syringe exchange has been the lightning rod for both advocates and opponents of harm reduction. The ban in the US lasted twenty-one years and would serve to structure the political and practical agenda of harm-reduction advocates for the coming two decades in spite of the fact that harm reduction was embraced by the other English-speaking countries (Clear, 2011).

According to a news release by Rice University,

The United States’ law-and-order approach to reducing the supply of drugs and punishing sellers and users has impeded the development of a public health model that views drug addiction as a disease that is preventable and treatable. A new policy paper . . . advocates that a harm-reduction approach would more effectively reduce the negative individual and societal consequences of drug use (Falk, 2015).

The opposition to a harm-reduction approach has made itself felt in other harm-reduction approaches. In addiction it was characterized by opposition to clean needle-exchange programs in which opponents claimed that these programs would seduce young people into IV drug use, disregarding that the average age of such programs was increasing over time. The use of agonist drugs, particularly methadone, to treat opioid dependence was opposed by many because of the erroneous belief that an opioid-dependent person using methadone was “still addicted,” whereas the reality was that they remained physically dependent, not addicted.

Remember the outcry over sex education in schools, with parents claiming that such education would induce their children into sexual activity? A new poll by NPR, the Kaiser Family Foundation, and Harvard’s Kennedy School of Government finds the vast majority of Americans agree that sex education should be taught in schools (“Sex education,” 2004). According to NPR’s article on the study,

However, this does not mean that all Americans agree on what kind of sex education is best. There are major differences over the issue of abstinence. Fifteen percent of Americans believe that schools should teach only about abstinence from sexual intercourse and should not provide information on how to obtain and use condoms and other contraception. A plurality (46 percent) believes that the most appropriate approach is one that might be called “abstinence-plus”—that while abstinence is best, some teens do not abstain, so schools also should teach about condoms and contraception (“Sex education,” 2004).

This mirrors the controversy about harm reduction for IV drug users.

There has even been some opposition to naloxone. One common objection to distributing naloxone to opiate users is that doing so might encourage increased drug use. Existing data on naloxone distribution in community settings do not support this claim (Maxwell, Bigg, Stanczykiewicz, & Carlberg-Racich, 2006).

For those people who are opposed to harm reduction in general and needle-exchange programs specifically, the question I would like answered is this: Since needle-exchange programs can save people from appalling medical consequences (including hepatitis B and C and infective endocarditis) and naloxone can save people from dying from an opioid overdose and potentially function as the vehicle for some people to enter treatment and recover, what objections can you have?

 

References

Clear, A. (2011). Harm reduction in the United States: Whose history? Part I. Retrieved from https://www.huffingtonpost.com/allan-clear/harm-reduction-in-the-uni_b_525390.html

Dolan, K., Kimber, J., Fry, C., Fitzgerald, J., Mcdonald, D., & Trautmann, F. (2000). Drug consumption facilities in Europe and the establishment of supervised injecting centres in Australia. Drug and Alcohol Review, 19(3), 337–46.

Falk, J. (2015). US needs harm-reduction approach to drug use, Baker Institute researcher says. Retrieved from http://news.rice.edu/2015/01/14/us-needs-harm-reduction-approach-to-drug-use-baker-institute-researcher-says/

Harm Reduction Coalition (HRC). (n.d.). Principles of harm reduction. Retrieved from https://harmreduction.org/about-us/principles-of-harm-reduction/

HealthLinkBC. (2015). Understanding harm reduction: Substance use. Retrieved from https://www.healthlinkbc.ca/healthlinkbc-files/substance-use-harm-reduction

Health Omnibus Programs Extension Act of 1988, 42 U.S.C. §300ee–5

Maxwell, S., Bigg, D., Stanczykiewicz, K., & Carlberg-Racich, S. (2006). Prescribing naloxone to actively injecting heroin users: A program to reduce heroin overdose deaths. Journal of Addictive Diseases, 25(3), 89–96.

National Health Care for the Homeless Council (NHCHC). (2010). Harm reduction: Preparing people for change. Retrieved from https://www.nhchc.org/wp-content/uploads/2011/09/harmreductionFS_Apr10.pdf

“Sex Education in America: An NPR/Kaiser/Kennedy School Poll.” (2004). Retrieved from https://www.npr.org/templates/story/story.php?storyId=1622610

Gerald Shulman, MA, MAC, FACATA, is a clinical psychologist and fellow of the American College of Addiction Treatment Administrators. He has been providing treatment or clinically or administratively supervising the delivery of care to alcoholics and drug addicts since 1962.