The Harm Reduction Coalition defines harm reduction as “…a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use. Harm Reduction is also a movement for social justice built on a belief in, and respect for, the rights of people who use drugs.”
In clinical settings, harm reduction helps to inform our care philosophy, policies, and the resources we promote to our patients. This means we should anticipate that patients may continue to use opioids, other substances, and/or experience relapse episodes during the course of treatment. Our role as providers is to provide compassionate care and work with the patient to help mitigate the risks of use and/or relapse episodes.
▪ Harm reduction respects the autonomy of patients to make decisions that providers may not agree with, which may be difficult for clinicians. Through supporting patients’ autonomy and their ability to make their own decisions, we can establish trust, reduce negative consequences, and retain them in care, which all lead to safer long-term outcomes.
▪ In order to support a harm reduction approach to your services, you may need to overcome stigma barriers that exist within your clinic culture.
▪ While it may sound like something new or controversial, we already practice harm reduction every day. Below are some common examples:
▪ Example 1: Despite the risk of accidents, we do not tell most patients not to drive; we do, however, acknowledge the risk and encourage them to wear seat belts.
▪ Example 2: If a diabetic patient is eating large amounts of sugar/carbs, we do not withhold treatment or insulin. We may counsel them on the risks associated with dietary choices, but also adjust their insulin, talk with them about any concerns they have, and focus on practical ways to make small shifts towards healthier intake, even if they continue to engage in risky consumption habits. Going from 64 oz to 20 oz. of soda is already a win we would celebrate!
▪ Like many chronic diseases, addiction recovery is not a linear path. In many ways, we expect episodic use or relapse from patients even as they engage in treatment. The opportunity lies in learning from those episodes, maintaining relationships, and supporting and keeping the patient safe as they move through phases of change.
Harm Reduction informed clinical policies and procedures:
MAT itself is part of a harm reduction strategy. For decades, harm reduction coalitions and organizations have been pushing for increased access to MAT in order to reduce the negative consequences of drug use. While MAT access has in creased dramatically, there are still a number of situations where patients maybe denied access to MAT despite guidelines recommending continued use.
▪ Benzodiazepines: Many prescribers may be uncomfortable prescribing MAT for a patient who is also taking or using benzodiazepines. While there are serious risks when combining MAT and benzodiazepines, the FDA has issued safety guidance that they do not recommend with holding MAT from patients using benzodiazepines due to the greater risk of overdose from withholding treatment. This statement reviews these guidelines as well as recommendations for managing MAT patients who are on benzodiazepines.
▪ Urine drug screening: According to the American Society of Addiction Medicine (ASAM), “drug testing should be used as a tool for supporting recovery rather than exacting punishment.” A positive drug screen is not a reason to kick a patient out of treatment, but rather an opportunity to have a conversation with a patient about harm reduction. Helping patients feel comfortable talking about their use and explaining to them that they will not be discharged from your program for using opioids will help with treatment retention, eliminate some stigmatizing barriers, and improve patient outcomes. Frame your urine drug screening as a conversation point with your patients. If they are using, but aren’t sure if they are using fentanyl you can offer to have the UDS tested for fentanyl so that the patient is aware, and then refer to them additional resources such as fentanyl testing strips (see below). For additional information you can watch this webinar produced by the NJ Centers of Excellence.
▪ Desire to taper: While patients may desire to taper off MAT for their own reasons, providers should educate patients that there is not are commended duration for MAT treatment according to the FDA, and that in their updated 2020 OUD Treatment guidelines ASAM summarizes (on page 32) that longer treatment periods, including indefinite treatment, is associated with better outcomes.
▪ Intake: Taking a use history from a harm reduction approach - focus on what was used, how it was used, and the circumstances around use. If the patient is continuing to use, focus conversation on safer-use strategies.
▪ Co-prescribe naloxone for every patient receiving MAT: Whether or not they are continuing to use, relapses are part of the journey. Patients may be able to use naloxone to help someone else in their community/circle who is using or by a family member or friend in the event of overdose for the patient themselves.