Journal of Addictive Diseases

ISSN: 1055-0887 (Print) 1545-0848 (Online) Journal homepage: http://www.tandfonline.com/loi/wjad20

Harm Reduction: Front Line Public Health Sharon Stancliff MD, Benjamin W. Phillips MIPH, Nazlee Maghsoudi MGA & Herman Joseph PhD To cite this article: Sharon Stancliff MD, Benjamin W. Phillips MIPH, Nazlee Maghsoudi MGA & Herman Joseph PhD (2015) Harm Reduction: Front Line Public Health, Journal of Addictive Diseases, 34:2-3, 206-219, DOI: 10.1080/10550887.2015.1059651 To link to this article: http://dx.doi.org/10.1080/10550887.2015.1059651

Accepted author version posted online: 16 Jun 2015. Published online: 16 Jun 2015. Submit your article to this journal

Article views: 738

View related articles

View Crossmark data

Citing articles: 2 View citing articles

Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=wjad20 Download by: [The UC San Diego Library]

Date: 18 April 2017, At: 01:44

Journal of Addictive Diseases, 34:206–219, 2015 Copyright Ó Taylor & Francis Group, LLC ISSN: 1055-0887 print / 1545-0848 online DOI: 10.1080/10550887.2015.1059651

HARM REDUCTION: FRONT LINE PUBLIC HEALTH Sharon Stancliff, MD1, Benjamin W. Phillips, MIPH1, Nazlee Maghsoudi, MGA1,2, Herman Joseph, PhD3 1

Harm Reduction Coalition, New York, New York, USA Munk School of Global Affairs, University of Toronto, Toronto, Ontario, Canada 3 National Development and Research Institutes Inc., New York, New York, USA 2

Drug use is a public health problem associated with high mortality and morbidity, and is often accompanied by suboptimal engagement in health care. Harm reduction is a pragmatic public health approach encompassing all goals of public health: improving health, social well-being, and quality of life. Harm reduction prioritizes improving the lives of people who use drugs in partnership with those served without a narrow focus on abstinence from drugs. Evidence has shown that harm reduction oriented practice can reduce transmission of blood-borne illnesses, and other injection related infections, as well as preventing fatal overdose. KEYWORDS. Harm reduction, public health, injection drug use, needle and syringe programs, syringe access, opioid overdose, naloxone, safe injection facilities, drug treatment, methadone, buprenorphine

INTRODUCTION

variety of ways including, but not limited to, medically oriented interventions. Drug use is associated with high mortality and morbidity, and is often accompanied by suboptimal engagement in health care.4–5 In 2010, there were 38,329 fatal drug overdoses in the United States, of which 22,134 (57.7%) involved pharmaceuticals. Of these, 16,651 (75.2%) were opioids (alone or in combination with other drugs).6 In addition to mortality, many PWUD have high morbidity, leading to a need for frequent health care intervention and treatment. High morbidity in the PWUD communities is most notable among people who inject drugs (PWID), as injection drug use puts them at higher risk for human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), soft tissue infection, and endocarditis. While transmission of HIV among PWID in the United States has dropped dramatically, the country is witnessing alarming increases in hepatitis C. For example, in Massachusetts from 2007 to 2009, rates of HCV

In 2012, an estimated 23.9 million Americans aged 12 and older self-reported as being active users of illicit drugs, having used an illicit drug, or having used a prescription medication extramedically in the month prior to the survey interview. This estimate represents 9.2% of the total U.S. population of individuals aged 12 and older. Approximately 20% (4.9 million) reported the extra-medical use of prescription opioids, whereas about 1% used non-prescription opioids.1 Given the prevalence of drug use in the United States, strategies to address the unique needs and vulnerabilities of people who use drugs (PWUD) are essential. The World Health Organization (WHO) describes public health “as all organized measures (whether public or private) to prevent disease, promote health, and prolong life among the population as a whole.”2 “Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.”3 Harm reduction strives to fulfill these ideals in a

Address correspondence to Sharon Stancliff, MD, Medical, Harm Reduction Coalition, 22 West 27th Street, 5th Floor, New York, NY 10001. E-mail: [email protected]

206

HARM REDUCTION: FRONT LINE PUBLIC HEALTH

incidence (both confirmed and probable) increased from 65 to 113 cases per 100,000 people aged 15 to 24 years.7 The predominant risk factor was identified as injection drug use. Similarly, it was found that over 55% of PWID in rural Kentucky were HCV positive.8 Given the higher rates of morbidity and mortality among PWUD, and especially PWID, it is troubling that these communities often have substandard access to health care.9,10 Harm reduction strategies and interventions can be effective at increasing the engagement of PWUD with health care services, and thereby lowering the excess mortality and morbidity experienced by these communities. The goal of this article is to provide readers with an understanding of harm reduction and how its interventions and strategies can improve the lives of PWUD and communities as a whole. In this article, harm reduction will be discussed in the context of socioeconomically marginalized PWUD, focusing specifically on those who inject drugs, particularly opioids. This population is often alienated from social and medical institutions because of the stigma associated with their lives and circumstances. Negotiating the available, publically funded health care is challenging and many are not successful in doing so. UNDERSTANDING HARM REDUCTION Harm reduction is a pragmatic public health approach with the explicit aim of reducing the negative harms associated with drug use. Harm reduction is driven by the public health goals of preventing disease, promoting health and wellbeing, and prolonging life. The practical strategies and ideas employed by harm reduction to achieve these public health goals place the overall health, safety, and well-being of PWUD and society above the narrow—and frequently elusive—goal of abstinence. Harm reduction accepts that a continuing level of drug use (both licit and illicit) in society is inevitable and defines objectives as reducing adverse consequences. It emphasizes the measurement of health, social, and economic outcomes, as opposed to the measurement of drug

207

consumption. While harm reduction recognizes abstinence as a valuable outcome, it acknowledges that abstinence may not be a realistic— or desirable—goal. By perceiving drug use along a continuum, harm reduction places emphasis on strategies and interventions that reduce the harms associated with drug use, and thereby improves the health and well-being of PWUD, without necessarily reducing drug use itself. It is important to understand that not all use of alcohol and other drugs is reflective of a substance use disorder amenable to treatment. There is a broad continuum of substance use ranging from abstinence, to occasional or experimental (low risk), to regular/heavy (hazardous/problematic use), and to dependence and/or addiction. Regardless of the level or pattern of use, there are benefits to harmreduction interventions. Someone who has consumed a few drinks of alcohol at a party, for example, is advised to have transportation provided by a designated driver. Note the message here is not a categorical prohibition against alcohol consumption, but rather to reduce harm by focusing on not drinking and driving. Harm reduction is a reallocation of the care provided in medical institutions to the community setting without a reduction in medical standards. Some services are provided in the community such as syringe access, overdose prevention, and screening for blood-borne infections. In other cases, harm reduction agencies may assist in negotiating the larger institutions for example, establishing a relationship in primary care clinics. The Tenets of Harm Reduction While there is no universally accepted definition of harm reduction, its proponents generally accept these tenets:11  psychoactive substance use is ubiquitous in human society, and sanctions against the use of particular drugs are driven more by cultural values than science;  PWUD can be engaged in actively protecting their health and that of their communities by

208

S. STANCLIFF ET AL.

accessing services such as syringe access and medical care; and  many of the harms associated with drug use are not due directly to the drug itself, but rather to other factors that are possible to ameliorate—such as the transmission of blood-borne infections. In addition, harm reduction is not antithetical to drug treatment and it seeks to reduce the harms associated with drug use that may occur before, after, and even during treatment. The Benefits of Harm Reduction There is compelling evidence that harm-reduction interventions avert HIV infections, improve quality of life, decrease mortality, including fatal overdose, and reduce drug dependency.12–13 Moreover, there is also evidence that harm reduction strategies are cost-effective, reduce crime and public disorder, improve social functioning, and provide a bridge to drug treatment.14–15 HARM-REDUCTION INTERVENTIONS AND STRATEGIES Although there are many harm-reduction interventions and strategies for PWUD, four are discussed below, specifically (1) syringe access, (2) opioid overdose prevention, (3) supervised injection facilities (SIFs), and (4) opioid maintenance treatment. Syringe Access Access to sterile needles and syringes, or “syringe access,” is a key component of harm reduction for PWID, including those who use opioids, cocaine, methamphetamine, performance, and image enhancing drugs, such as steroids, and any other drugs which may be injected. The use of sterile injection equipment is central to the prevention of blood-borne infections including HIV and HCV. Numerous studies16–17 have confirmed that access to sterile syringes reduces the number of injections

that occur with previously used syringes. The effectiveness of this harm-reduction strategy can be illustrated by the dramatically declining rate of HIV infection among PWID in New York City (NYC). In 1990, 54% of PWID in NYC were HIV-positive. By 2001, nine years after the first legal syringe exchange program began operations, the HIV prevalence among was reduced to 13%.18 HIV incidence declined from 3.55/100 person-years at risk (PYAR) from 1990–1992, to 0.77/100 PYAR from 1999–2002.19 A reduction in blood-borne infections among PWID as a result of access to sterile syringes is also reflected in rates of HCV infection, as the prevalence among recent PWID (less than five years of injection history) also declined from 71% to 38%.20 Recent research has also found decreases in other serious infections including endocarditis, cellulitis/abscesses, and osteomyelitis associated with increased access to sterile syringes.21 A preponderance of evidence finds that increased access to syringes does not increase drug use among PWID or encourage injection among non-injectors,22,23 and may in fact promote entry into drug treatment.24 A large number of professional medical societies and health care organizations have recognized the value of sterile syringe access and have called for the elimination of barriers, including those listed in Table 1. The options for obtaining legal access to sterile syringes vary considerably across the United States.a,b Some states allow over-thecounter (OTC) access, via pharmacy sales, with variable degrees of regulation. As of 2014, 48 states allowed the purchase of sterile syringes without a prescription at pharmacies, although

TABLE 1. Health-Related Organizations That Have Called for the Elimination of Barriers to Syringe Access American Academy of Family Practice American Academy of Pediatrics American Bar Association American Medical Association

American Public Health Association American Pharmaceutical Association Association of State and Territorial AIDS Officials National Association of Boards of Pharmacy

HARM REDUCTION: FRONT LINE PUBLIC HEALTH

there are a variety of regulations in different states.25,26 There is at least one syringe exchange program in 33 states, although only 16 states and the District of Columbia explicitly authorize it.

Syringe Access Programs (SAPs) SAPs are an additional avenue to provide PWID with access to sterile injecting equipment. In addition to syringe availability, SAPs provide a wide variety of services, such as education on safer injecting practices and safe syringe disposal (for a list of additional services see Table 2).27 According to North American Syringe Exchange Network (NASEN), in 2013, there were 166 cities operating one or more SAPs or sites, for a total of 194 syringe access services in 33 states, the District of Columbia, the Commonwealth of Puerto Rico, and the Indian Nations.28,29 SAPs have been evaluated extensively and have been found to be an effective means of infectious disease prevention.30,31 Harm reduction oriented agencies, including SAPs, may also serve as a safe place where PWUDs feel welcome, regardless of their drug use, gender, sexual orientation, sociocultural or socioeconomic status.

TABLE 2. Services Provided to PWUD by SAPs  

Education about safer injection practices Provision of other clean injecting equipment, such as alcohol swabs, tourniquet, sterile water, vessel to dissolve drug (“cooker”), and filters (“cottons”)  Access to safe syringe disposal  Non-coercive referrals to drug treatment  Onsite medical care and referrals to outside medical care  Mental health services  Public health prevention intervention, such as hepatitis screening and vaccination  Acupuncture  Nutrition services  Condoms  Education about safer sex practices  On-site HIV counseling and testing or referrals to these services  Education about overdose and training in reversing overdoses with naloxone

209

OTC Syringe Access OTC syringe access also reduces the number of injections that occur with used syringes. Pharmacies and other health facilities are appropriate venues to access syringes, as staff are trained health care professionals that can offer targeted information and health education.32 While state laws vary considerably regarding the dispensing of syringes for purposes other than medical use, pharmacies are an accessible outlet for obtaining syringes given their extensive locations and hours of operation. Pharmacies are part of a low-threshold intervention in that syringes may be available anonymously on a walk-in basis and at almost any time. OTC syringe access via pharmacies has been evaluated33 and found to be effective in reducing injection risk behaviors without negatively impacting the communities in which these programs operate. While both SAPs and OTC access is essential to reducing the number of injections that occur with used syringes, publically funded SAPs have been shown to be the more effective intervention for preventing HIV transmission among PWID.34,35

Vending Machines Another low-threshold intervention for increasing access to sterile syringes (or clean smoking pipes) is vending machines. These machines dispense sterile syringes and related injecting paraphernalia and serve to complement existing SAPs and OTC access. The anonymous nature and 24-hour availability make these machines attractive, accessible, and acceptable.36 While syringe vending machines do not exist currently in the United States, reviews of existing evidence from Australia and five European countries suggests that they are a cost efficient, low-threshold intervention for people who are less likely to attend a staffed location such as a SAP or pharmacy.37

Syringe Disposal There are limited options available for the safe disposal of used syringes in the United States,

210

S. STANCLIFF ET AL.

and this affects PWID, as well as people with diabetes and others who inject medications. Disposal may also be inhibited by concerns of having negative interactions with law enforcement or being charged with possession of paraphernalia.38 This is problematic as there are public health risks created by improperly disposing used syringes; including needle stick injury and possible infectious disease transmission.c Opioid Overdose Prevention Opioid overdose is a major public health problem that has recently gained unprecedented attention in the United States. In 2011, there were 18,777 deaths involving prescription opioids, a 440% increase over the 4,263 opioid involved deaths in 1999.39 In 28 selected states, representing 56% of the U.S. population, the overall rate for drug overdose deaths rose 4.3% between 2010 and 2012. The heroin overdose death rates doubled from 2010 to 2012, while prescription opioid overdose death rates declined 6.6%.40 Evidence-based interventions to reduce opioid overdose deaths include increasing access to naloxone, and expanding opioid maintenance treatment (OMT) and SIFs, all of which are addressed in this article. In addition, legislative changes have introduced or broadened Prescription Monitoring Programs, medication take-back events, and Good Samaritan laws.d These interventions are being evaluated. Opioid overdose leads to death by respiratory depression, usually taking one to three hours. Studies report that many heroin overdose incidents are witnessed by a bystander, indicating that an opportunity exists to reduce mortality rates through overdose prevention training. Risk Factors for Opioid Overdose Opioid overdose fatalities often occur after periods of abstinence. Hence, PWUD that have recently left drug treatment, detoxification, or recently released from incarceration are particularly vulnerable. In fact, drug overdose has been found to be the leading cause of death among people recently released from incarceration, and opioids are the most common substance

involved. The majority of overdose fatalities also occur when users combine opioids with depressants such as alcohol, or stimulants such as cocaine.41 People with a history of chronic opioid use are at a high risk and people who have a recent history of overdose are also at an increased risk of future overdoses.42 Naloxone Naloxone, an opioid antagonist, used for decades by professional medical emergency responders (emergency medical technicians and paramedics) is a safe and effective medication that reverses the effects of opioids.43 Naloxone may be administered by injection (intramuscular, subcutaneous, or intravenous) or intranasally. For 30 to 90 minutes after administration, naloxone displaces opioids from receptors in the brain, thus reversing their effects, including the respiratory depression that places an individual at risk for death or brain injury. Naloxone rarely has negative effects other than inducing opioid withdrawal symptoms in individuals who are dependent.44 Withdrawal symptoms include agitation, vomiting, and diarrhea. Access to Naloxone It is legal to prescribe naloxone to those at risk of opioid overdose in all states including patients prescribed opioids and people who use illicit opioids, such as heroin. Regulation of prescribing is done at the state rather than the federal level. At the time of this writing, it is also legal to prescribe naloxone to those at risk of witnessing someone experiencing an overdose in 23 states.45 These include PWUD, their friends and family members, social service providers, and uniformed first responders such as police officers and firefighters. Innovative ways to increase access to naloxone are being developed across the country.e Provision of Naloxone to Persons at Risk of Witnessing An Overdose Since the late 1990s, SAPs have distributed naloxone to participants. As state laws change,

HARM REDUCTION: FRONT LINE PUBLIC HEALTH

this practice has been extended to a wide variety of agencies including, but not limited to, drug treatment programs, community based social service providers, county health departments and at community events. As of 2010, over 50,000 kits had been distributed and over 10,000 people had reported use of kits.46 Data from Massachusetts, which was an early adopter of naloxone distribution, provide evidence that this intervention can have a powerful impact in reducing overdose mortality.47 The same group interviewed participants (primarily PWUD) at receipt of a naloxone kit followed by a second interview when returning for a refill and found that provision of naloxone is not associated with increases in opioid use.48 The 2013 National Drug Control Strategy suggests that uniformed first responders, including police officers, firefighters and Basic Emergency Medical Technicians be trained and equipped with naloxone. The Substance Abuse and Mental Health Services Administration (SAMHSA) has created a corresponding “toolkit.”49 At least 20 states have law enforcement officers carrying naloxone.50 New York State has over 210 police departments carrying naloxone.51

Prescription of Naloxone to Those Receiving Opioid Prescriptions Prescription of naloxone to those at high risk of overdose because of opioid-based pain management was initiated in Wilkes County, North Carolina, as part of a response to high opioidrelated mortality in 2010.52 The Veterans Administration is now recommending prescription of naloxone to patients receiving opioids for pain management and to those misusing opioids.53 This practice has also been endorsed by SAMHSA, which has published a “toolkit” recommending the prescription of naloxone to those receiving opioid prescriptions.54,f Washington State and Rhode Island are allowing the provision of naloxone in pharmacies by the development of a collaborative agreement with a prescriber.55–56

211

SIFs By providing a safe and hygienic environment to consume pre-obtained drugs, SIFs improve the health and social welfare of participants. This harm reduction intervention is an essential, although underused, component of a comprehensive public health approach to the problems associated with injection drug use.57 As of October 2014, there were approximately 90 SIFs operating in nine countries worldwide. Although most SIFs are located in Europe, there are two in Vancouver, Canada, and one in Sydney, Australia.58 Evidence has indicated that SIFs have beneficial outcomes for both PWID and the wider community. SIFs play a crucial role in managing overdoses, as evidence indicates that although overdoses still occur within SIFs, trained supervision within the facility ensures they do not become fatal.59 Most importantly for containing the spread of blood-borne infections, specifically HIV, consistent use of SIFs is associated with decreased needle sharing and increased use of other safer injection practices, which may be taught by staff, and safe syringe disposal. Additionally, although often of concern to communities considering opening SIFs, studies have found no apparent increase in drug dealing or crime, and no observed increase in new initiates into drug use.60 By acting as a point of referral for medical care, drug treatment, mental health care, and social services SIFs can lead to an increased uptake of services to improve the overall health and well-being of PWID.

OMT Opioid maintenance with methadone or buprenorphine is the most effective treatment for opioid-dependent people and a vitally important tool both in the prevention of blood-borne infections and in overdose prevention. The effectiveness of both methadone and buprenorphine has resulted in their inclusion in WHO’s Model List of Essential Medicines. OMT reduces risk behaviors for blood-borne infections, as was indicated by a recent meta-analysis which

212

reported that methadone maintenance patients’ risk of acquiring HIV was reduced by as much as 54%.61 OMT has also been shown to protect against hepatitis C acquisition. In a cohort of young injectors, OMT was associated with a 60% reduction in HCV incidence.62,63 Patients taking methadone or buprenorphine have been found to have a fourfold reduction in fatal overdose and reductions in non-fatal overdoses.64 The risk of fatal overdose, as well as injecting and sharing syringes, are reduced even among OMT patients who continue to use drugs.65 Access to methadone and buprenorphine are significantly limited by regulation. Methadone is available only in specialized clinics within the United States, buprenorphine can be prescribed only by physicians who have undergone eight hours of training and panels are limited to 100 patients. Opioid maintenance is routinely barred from most prisons in the United States (although available in 41 countries worldwide)66 and for the majority of participants in drug court mandated treatment.67 Furthermore, there is a widespread perception that patients may be dismissed from treatment for illicit drug use or refusal of counseling services. In a pilot in which patients were inducted onto buprenorphine in jail, it was found that although many intended to follow up in the community68 a significant portion did not do so as they were not willing to attend counseling.69 Yet studies have found that counseling is not vital to successful treatment with buprenorphine70 and that interim methadone with minimal services also has good outcomes.71 In France, where all physicians may prescribe buprenorphine, overdose deaths dropped dramatically with the rapid rise in access to buprenorphine. In another example, a physician who induces hospitalized patients and patients undergoing intensive outpatient care onto buprenorphine finds it is difficult to find placement with community physicians if they persist in using marijuana.72 Yet patients on OMT who continue to use drugs also have been shown to reduce risk behaviors including frequency of injection, heroin use, and criminal behavior.73 A pilot in which heroin using people

S. STANCLIFF ET AL.

were recruited in harm reduction settings and maintained with minimal requirements found good retention and high patient satisfaction.74 Heroin maintenance is currently available in seven western European countries; generally as a second line of treatment for patients that are refractory to other treatments.75,76 Patients must visit the clinic for each dose of heroin, thus usually require a daily dose of methadone to reduce withdrawal symptoms overnight and the number of visits each day. A randomized clinical trial comparing oral methadone to injectable diacetylmorphine found that the latter showed significantly greater reductions in illicit drug use and criminal activity. An unexpected finding was that patients appeared unable to differentiate hydromorphone (used in a small control group) from heroin. This was corroborated by a second randomized trial comparing the two. Hydromorphone is a legal medication in the United States and many countries. Given the success of heroin maintenance for a population of refractory patients, further studies of hydromorphone maintenance are indicated.77,78

NATIONAL AND INTERNATIONAL SUPPORT FOR HARM REDUCTION Comprehensive Programming The WHO, along with the United Nations Office on Drugs and Crime (UNODC), and the Joint United Nations Program on HIV/AIDS (UNAIDS) have published a technical guide for all countries to set targets for universal access to HIV prevention, treatment, and care for PWID. They explicitly endorse multiple harm-reduction interventions, specifically syringe access and OMT. Harm-reduction interventions have maximum effect when delivered in combination.79 The technical guide explicitly acknowledges the effectiveness of a combination approach and refers to it as a “comprehensive package” of interventions that are needed to address different transmission and illness factors.80 In the most recent guidelines, issued in 2014, the WHO explicitly recommends that PWID have access to naloxone.81 According to

HARM REDUCTION: FRONT LINE PUBLIC HEALTH

the WHO, “people likely to witness an opioid overdose should have access to naloxone and be instructed in its use for emergency management of suspected opioid overdose.”82

National and International Support Seventy-nine countries worldwide have an explicit supportive reference to harm reduction in their national policies.83 Nevertheless, current global coverage of harm reduction remains too low to have an impact on the spread of new HIV and HCV infections, and there is a very urgent need to scale-up services.84 Numerous transnational, international, and national organizations and agencies have endorsed a comprehensive package of harmreduction interventions for PWID. These include the WHO, UNAIDS, UNODC, the UN General Assembly (UNGA), the UN Economic and Social Council (ECOSOC), the UN Commission on Narcotic Drugs (CND), the Global Fund to Fight AIDS, Tuberculosis, and Malaria, the United States’s President’s Emergency Plan For AIDS Relief (PEPFAR) and the International Federation of Red Cross and Red Crescent Societies (IFRC). Additionally, the Office of the High Commissioner for Human Rights has supported harm-reduction interventions, specifically access to sterile needles and syringes, to reduce the risk of HIV transmission among PWID.85

DISCUSSION Harm reduction is an approach to drug use that not only benefits PWUDs but also the community at large, thus placing it firmly in the domain of public health as defined by the WHO. Harm reduction extends evidence-based medical practices from medical institutions to the community, with a focus on street-based populations of PWUD. In medical settings, it is normal practice to use sterile syringes to prevent the transmission of blood-borne infections, and naloxone is the gold standard for reversing an opioid overdose. Harm reduction successfully translates these basic medical practices to the community setting. Medical practice and public

213

health can be provided outside the confines of medical institutions, and must do so to respond to crises.g Harm reduction strategies are effective at preventing infectious diseases, as illustrated by the dramatic drop in HIV seroincidence and prevalence in NYC associated with the development of syringe exchange programs and other services. However, harm reduction is much more than the provision of direct services to a vulnerable population. Rather, it is working with these populations to provide the tools and education needed to promote, maintain, and improve health. In harm reduction, the target population becomes a partner both in designing and implementing the interventions. Indeed the first SAP was founded by the “Junkiebond,” a group of PWID in Amsterdam in response to the spread of hepatitis B in 1984.86 The positive benefits of harm reduction can only be fully realized if PWUD are involved as partners, and they are able to make informed choices to reduce risk behaviors, such as changing injection practices and administering naloxone when needed. Harm reduction prevents disease, promotes health, and prolongs life in accordance with the WHO’s definition. Harm reduction is a frontline public health approach with the explicit goals of improving the physical, mental, and social well-being of PWUD. Drug treatment has traditionally been based on complete abstinence from drugs. In fact, many drug treatment programs terminate services to people who continue to use drugs, whether it be a relapse to the primary drug or use of other drugs for which the patient has not sought treatment. Drug treatment programs that require complete abstinence do not prevent disease, promote health, or prolong life for those people who continue to use drugs. Discontinuing care can dramatically increase patients’ risk of fatal opioid overdose or acquiring a blood-borne infection. The primary goal of drug treatment must be a healthier life both medically and psychosocially, regardless of drug use. Complete abstinence is simply not a longterm option for many PWUD. Drug treatment, whether provided by specialized programs or in primary care, can adapt to the goals of public

214

S. STANCLIFF ET AL.

health by employing the principles of harm reduction. Promoting the health and well-being of PWUD requires a continuum and combination of services ranging from intervention in a lifethreatening overdose to provision of accessible and acceptable treatment options. In conclusion, harm reduction is an essential public health approach which provides service to PWUD all of whom face stigma in accessing medical and social services and particularly those who are socio-economically marginalized or challenged by racism and other social stigmas.

b.

c.

d.

ADDITIONAL RESOURCES Harm Reduction Coalition: www.harmreduction.org Care of Substance Users with HIV Infection: http://www.hivguidelines.org/clinical-guidelines/hiv-and-substance-use/ Centers for Disease Control & Prevention, Health Care Settings Serving IDU’s: http:// www.cdc.gov/ncidod/diseases/hepatitis/recs/ idu.htm SAMHSA Drug & Alcohol Treatment Finder: http://dasis3.samhsa.gov Manual for Primary Care Providers: Effectively Caring for Active Substance Users. Prepared for the HIV Health and Human Services Planning Council of New York. Ed. by Ruth Finkelstein, ScD, and Sandra E. Ramos, PhD: http://www.nyhiv.com/pdfs/NYAMmanual.pdf

NOTES a. This refers to drugs that are manufactured by pharmaceutical companies and are intended for medical use but are either (1) used without a doctor’s prescription (diverted) or (2) used not as prescribed (i.e., stockpiled or administered via non-prescribed routes, such as injection). Extramedical use does not exclude the possibility

e.

f.

g.

that the person may be motivated by medical reasons to use the drug. Readers can find information about syringe access laws in each U.S. state at the following website: http://www.lawatlas.org/pre view?datasetDsyringe-policies-laws-regulat ing-non-retail-distribution-of-drug-parapher nalia Readers can find additional information on syringe disposal at the following website: http://www.safeneedledisposal.org/index. cfm?loadDpage&pageD57 Good Samaritan laws offer some immunity from prosecution for drug possession when calling for medical help at the scene of an overdose. Readers can find additional information on Good Samaritan laws at the following website: http://lawatlas.org/query? datasetDgood-samaritan-overdose-laws Readers can find additional information on increased access to naloxone at the following website: https://www.networkforphl. org/_asset/qz5pvn/network-naloxone.pdf% 20–%202013-11-12 Readers can find additional information on the prescription of naloxone to those receiving opioid prescriptions at the following website: http://www.prescribetoprevent.org In the early 1990s, there were thousands of HIV-positive patients dying of AIDS acquired from unsafe injection practices, as there was no effective treatment. The lead author of this article found as much professional satisfaction in working with a syringe exchange program as a volunteer in order to prevent HIV as in her primary care practice. As overdose deaths eclipsed AIDS deaths, work to distribute naloxone in the community became as meaningful as provision of care in a methadone program

REFERENCES 1. Substance Abuse and Mental Health Services Administration (SAMHSA). Results from the 2012 national survey on drug use and health: summary of national findings.

HARM REDUCTION: FRONT LINE PUBLIC HEALTH

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

Rockville, MD: NSDUH Series H-46, HHS Publication No. (SMA), 2013; 13–4795. Public Health. Geneva (Switzerland): World Health Organization. http://www. who.int/trade/glossary/story076/en/. (accessed November 19, 2014). Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, June 19–22, 1946; signed on July 22, 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on April 7, 1948. Hulse GK, English DR, Milne E, Holman CDJ. The quantification of mortality resulting from the regular use of illicit opiates. Addiction 1999; 94(2):221–9. Randall D, Degenhardt L, Vajdic CM, et al. Increasing cancer mortality among opioid dependent persons in Australia: a new public health challenge for a disadvantaged population. Australian and New Zealand J Public Health 2011; 35(3):220–5. Jones CM, Mack KA, Paulozzi LJ. Pharmaceutical overdose deaths, United States, 2010. JAMA 2013; 309(7):657–9. Onofrey S, Church D, Kludt P, et al. Hepatitis C virus infection among adolescents and young adults: Massachusetts, 2002–2009. MMWR Morbidity and Mortality Weekly Report 2011; 60:537–41. Havens JR, Lofwall MR, Frost SD, Oser CB, Leukefeld CG, Crosby RA. Individual and network factors associated with prevalent hepatitis C infection among rural Appalachian injection drug users. Amer J Public Health 2013; 103(1):e44–52. Vlahov D, Wang C-l, Galai N, et al. Mortality risk among new onset injection drug users. Addiction 2004; 99(8):946–54. Randall D, Degenhardt L, Vajdic CM, et al. Increasing cancer mortality among opioid dependent persons in Australia: a new public health challenge for a disadvantaged population. Australian and New Zealand J Public Health 2011; 35(3):220–5. Principles of Harm Reduction. New York City, NY: Harm Reduction Coalition. http://

215

12.

13.

14.

15.

16.

17.

18.

19.

20.

harmreduction.org/about-us/principles-ofharm-reduction/ (accessed September 26, 2014). Palmateer N, Kimber J, Hickman M, Hutchinson S, Rhodes T, Goldberg D. Evidence for the effectiveness of sterile injecting equipment provision in preventing hepatitis C and human immunodeficiency virus transmission among injecting drug users: a review of reviews. Addiction 2010; 105 (5):844–59. White B, Dore G, Lloyd A, Rawlinson W, Maher L. Opioid substitution therapy protects against hepatitis C virus acquisition in people who inject drugs: the HITS-c study. The Med J Australia 2014; 201(6):326–9. Science addressing drugs and HIV: state of the art. Vienna, AU: United Nations Office on Drugs and Crime, Scientific Consultation, 2014. Andresen MA, Boyd N. A cost-benefit and cost-effectiveness analysis of Vancouver’s supervised injection facility. Internat J Drug Policy 2010; 21(1):70–6. World Health Organization. Effectiveness of sterile needle and syringe programming in reducing HIV/AIDS among injecting drug users (Evidence for action technical papers), 2004. World Health Organization, United Nations Office on Drugs and Crime, Joint United Nations Programme on HIV/AIDS. Policy brief: reduction of HIV transmission in prisons (evidence for action on HIV/ AIDS and injecting drug use), 2004. Des Jarlais DC, Perlis T, Arasteh K, et al. Reductions in hepatitis C virus and HIV infections among injecting drug users in New York City, 1990–2001. AIDS 2005; 19:S20–S5. Des Jarlais DC, Perlis T, Arasteh K, et al. HIV incidence among injection drug users in New York City, 1990 to 2002: use of serologic test algorithm to assess expansion of HIV prevention services. Amer J Public Health 2005; 95(8):1439–44. Des Jarlais DC, Perlis T, Arasteh K, et al. Reductions in hepatitis C virus and HIV infections among injecting drug users in

216

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

S. STANCLIFF ET AL.

New York City, 1990–2001. AIDS 2005; 19:S20–S25. Gonzalez C, Tsui D, Candelas A, et al. A five year trend analysis of emergency department and inpatient diagnoses of endovascular, soft tissue, bone, and pneumonia for intravenous drug users between 2008 and 2012. Poster exhibition presented at: 20th International AIDS Conference, July 20–25, 2014; Melbourne, Australia. Des Jarlais DC, Arasteh K, McKnight C, Ringer M, Friedman SR. Syringe exchange, injecting, and intranasal drug use. Addiction 2010; 105(1):155–8. Frank B. An overview of heroin trends in New York City: past, present, and future. The Mount Sinai J Med, New York 1999; 67(5–6):340–6. Strathdee SA, Celentano DD, Shah MN, et al. Needle-exchange attendance and health care utilization promote entry into detoxification. J Urban Health 1999; 76 (4):448–60. LawAtlas: The policy surveillance portal. Princeton, NJ: Robert Wood Johnson Foundation. http://lawatlas.org/topics#.U17l8fldW3p (accessed September 26, 2014). Bramson H, Des Jarlais DC, Arasteh K, Nugent A, Guardino V, Feelemyer J, Hodel D. A review of state laws, syringe exchange and HIV among persons who inject drugs in the United States: history and effectiveness. Robert Wood Johnson Foundation. In press. Centers for Disease Control and Prevention (CDC). Syringe exchange programs: United States, 2008. MMWR Morbidity and Mortality Weekly Report 2010; 59(45):1488–91. Syringe exchange coverage in the United States—July 2013. Tacoma, WA: North American Syringe Exchange Network (NASEN), 2013. Delivering harm reduction services including syringe exchange. New York, NY: amFAR. http://www.amfar.org/endtheban. (accessed November 16, 2014). Birkhead GS, Klein SJ, Candelas AR, et al. Integrating multiple programme and policy

31.

32.

33.

34.

35.

36.

37.

38.

approaches to hepatitis C prevention and care for injection drug users: a comprehensive approach. Internat J Drug Policy 2007; 18(5):417–25. Adimora AA, Auerbach JD. Structural interventions for HIV prevention in the United States. J Acquired Immune Deficiency Syndromes (JAIDS) 2010; 55:S132–S5. Zaller N, Jeronimo A, Bratberg J, Case P, Rich JD. Pharmacist and pharmacy staff experiences with non-prescription (NP) sale of syringes and attitudes toward providing HIV prevention services for injection drug users (IDUs) in Providence, RI. J Urban Health 2010; 87(6):942–53. Zaller N, Jeronimo A, Bratberg J, Case P, Rich JD. Pharmacist and pharmacy staff experiences with non-prescription (NP) sale of syringes and attitudes toward providing HIV prevention services for injection drug users (IDUs) in Providence, RI. J Urban Health 2010; 87(6):942–53. Degenhardt L, Mathers B, Vickerman P, Rhodes T, Latkin C, Hickman M. Prevention of HIV infection for people who inject drugs: why individual, structural, and combination approaches are needed. The Lancet 2010; 376(9737):285–301. Des Jarlais D, Arasteh K, Mcknight C, et al. Combined HIV prevention, the New York City condom distribution program, and the evolution of safer sex behavior among persons who inject drugs in New York City. AIDS and Behavior 2014; 18(3):443–51. Islam MM, Conigrave KM. Assessing the role of syringe dispensing machines and mobile van outlets in reaching hard-toreach and high-risk groups of injecting drug users (IDUs): a review. Harm Reduction J 2007; 4(1):14. Islam MM, Wodak A, Conigrave KM. The effectiveness and safety of syringe vending machines as a component of needle syringe programmes in community settings. Internat J Drug Policy 2008; 19(6):436–41. Wagner KD, Simon-Freeman R, Bluthenthal RN. The association between law enforcement encounters and syringe sharing among IDUs on skid row: a mixed

HARM REDUCTION: FRONT LINE PUBLIC HEALTH

39.

40.

41.

42.

43.

44.

45.

46.

47.

48.

methods analysis. AIDS and Behav 2013; 17(8):2637–43. Chen LH, Hedegaard H, Warner M. Drugpoisoning deaths involving opioid analgesics: United States, 1999–2011. NCHS Data Brief 2014; (166):1–8. Rudd RA, Paulozzi LJ, Bauer MJ, et al. Increases in heroin overdose deaths—28 States, 2010 to 2012. MMWR Morbidity and Mortality Weekly Report 2014; 63:849–54. Sporer KA, Kral AH. Prescription naloxone: a novel approach to heroin overdose prevention. Annals of Emer Med 2007; 49 (2):172–7. Wines Jr JD, Saitz R, Horton NJ, Lloyd-Travaglini C, Samet JH. Overdose after detoxification: a prospective study. Drug Alcohol Depend 2007; 89(2):161–9. Boyer EW. Management of opioid analgesic overdose. New England J Med 2012; 367(2):146–55. Van Dorp EL, Yassen A, Dahan A. Naloxone treatment in opioid addiction: the risks and benefits. Expert Opinion on Drug Safety 2007; 6(2):125–32. LawAtlas: The policy surveillance portal. Princeton, NJ: Robert Wood Johnson Foundation. http://lawatlas.org/topics#.U17l8fldW3p. (accessed on September 26, 2014). Centers for Disease Control and Prevention (CDC). Community-based opioid overdose prevention programs providing naloxone: United States, 2010. MMWR Morbidity and Mortality Weekly Report 2012; 61 (6):101–5. Walley AY, Xuan Z, Hackman HH, et al. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis. British Med J 2013; f174. Doe-Simkins M, Quinn E, Xuan Z, et al. Overdose rescues by trained and untrained participants and change in opioid use among substance-using participants in overdose education and naloxone distribution programs: a retrospective cohort study. BMC Public Health 2014; 14(1):297.

217

49. Opioid overdose prevention toolkit— updated 2014. Rockville, MD: Substance Abuse and Mental Health Services Administration (SAMHSA); HHS Publication No. (SMA) 2014; 14–4742. 50. US law enforcement who carry naloxone. Durham, NC: North Carolina Harm Reduction Coalition. http://www.nchrc. org/law-enforcement/us-law-enforcementwho-carry-naloxone. (accessed November 9, 2014). 51. White V. New York State Department of Health, New York City, NY. (Personal communication, November 12, 2014). 52. Albert S, Brason I, Fred W, et al. Project Lazarus: community based overdose prevention in rural North Carolina. Pain Med 2011; 12(s2):S77–S85. 53. Oliva EM. Spotlight on pain management—opioid overdose education and naloxone distribution (OEND): preventing and responding to an opioid overdose [cyberseminar]. September 1, 2014. 54. Overdose prevention toolkit: information for prescribers. Rockville, MD: Substance Abuse and Mental Health Services Administration (SAMHSA); HHS Publication No. (SMA) 2013; 13–4742. 55. Green TC, Bratberg J, Dauria E, Rich J. Responding to opioid overdose in Rhode Island: where the medical community has gone and where we need to go. Rhode Island Med J (RIMJ) 2014; 97 (10):29–33. 56. Bowman S, Engelman A, Koziol J, Mahoney L, Maxwell C, McKenzie, M. The Rhode Island community responds to opioid overdose deaths. Rhode Island Medical Journal 2014; 97(10):34. 57. Broadhead RS, Kerr TH, Grund J-PC, Altice FL. Safer injection facilities in North America: their place in public policy and health initiatives. J Drug Issues 2002; 32(1):329–55. 58. Background and evaluation. Sydney, AU: Sydney Medically Supervised Injecting Centre; c2010. http://www.sydneymsic. com/background-and-evaluation#Interna tional-context. (accessed September 26, 2014).

218

59. Kerr T, Tyndall MW, Lai C, Montaner JS, Wood E. Drug-related overdoses within a medically supervised safer injection facility. Internat J Drug Policy 2006; 17(5):436–41. 60. Stoltz J-A, Wood E, Small W, et al. Changes in injecting practices associated with the use of a medically supervised safer injection facility. J Public Health 2007; 29 (1):35–9. 61. MacArthur GJ, Minozzi S, Martin N, et al. Opiate substitution treatment and HIV transmission in people who inject drugs: systematic review and meta-analysis. British Med J 2012; 345. 62. White B, Dore G, Lloyd A, Rawlinson W, Maher L. Opioid substitution therapy protects against hepatitis C virus acquisition in people who inject drugs: the HITS-c study. The Med J Australia 2014; 201(6):326–9. 63. Tsui JI, Evans JL, Lum PJ, Hahn JA, Page K. Association of opioid agonist therapy with lower incidence of hepatitis C virus infection in young adult injection drug users. JAMA Intern Med 2014; 12:1974–1981. 64. Clausen T, Anchersen K, Waal H. Mortality prior to, during and after opioid maintenance treatment (OMT): a national prospective cross-registry study. Drug Alcohol Depend 2008; 94(1):151–7. 65. Gjersing L, Bretteville-Jensen AL. Is opioid substitution treatment beneficial if injecting behaviour continues? Drug Alcohol Depend 2013; 133(1):121–6. 66. Claudia, S. The global state of harm reduction 2012: towards an integrated response. London, UK: Harm Reduction International, 2012. 67. Csete J, Catania H. Methadone treatment providers’ views of drug court policy and practice: a case study of New York State. Harm Reduction J 2013; 10(1):35. 68. Lee JD, Grossman E, Truncali A, et al. Buprenorphine-naloxone maintenance following release from jail. Subst Abuse 2012; 33(1):40–7. 69. Joseph H. National Development and Research Institutes Inc., New York City, NY (personal communication November 17, 2014).

S. STANCLIFF ET AL.

70. Fiellin DA, Barry DT, Sullivan LE, et al. A randomized trial of cognitive behavioral therapy in primary care-based buprenorphine. The Amer J Med 2013; 126(1):74, e11–74. 71. Schwartz RP, Kelly SM, O’Grady KE, Gandhi D, Jaffe JH. Randomized trial of standard methadone treatment compared to initiating methadone without counseling: 12 month findings. Addiction 2012; 107 (5):943–52. 72. Wiegand T. University of Rochester Medical Center, University of Rochester, New York City, NY (personal communication November 17, 2014). 73. Gjersing L, Bretteville-Jensen AL. Is opioid substitution treatment beneficial if injecting behaviour continues? Drug Alcohol Depend 2013; 133(1):121–6. 74. Stancliff S, Joseph H, Fong C, Furst T, Comer SD, Roux P. Opioid maintenance treatment as a harm reduction tool for opioid-dependent individuals in New York City: the need to expand access to buprenorphine/naloxone in marginalized populations. J Addict Dis 2012; 31(3):278–87. 75. Claudia, S. The global state of harm reduction 2012: towards an integrated response. London: Harm Reduction International, 2012. 76. Strang J, Groshkova T, Metrebian N, European Monitoring Centre for Drugs and Drug Addiction. New heroin-assisted treatment: recent evidence and current practices of supervised injectable heroin treatment in Europe and beyond. Publications Office of the European Union, 2012. 77. Oviedo-Joekes E, Brissette S, Marsh DC, et al. Diacetylmorphine versus methadone for the treatment of opioid addiction. New England J Med 2009; 361(8): 777–86. 78. Oviedo-Joekes E, Guh D, Brissette S, et al. Double-blind injectable hydromorphone versus diacetylmorphine for the treatment of opioid dependence: a pilot study. J Subst Abuse Treat 2010; 38(4): 408–11.

HARM REDUCTION: FRONT LINE PUBLIC HEALTH

79. Van Den Berg C, Smit C, Van Brussel G, Coutinho R, Prins M. Full participation in harm reduction programmes is associated with decreased risk for human immunodeficiency virus and hepatitis C virus: evidence from the Amsterdam Cohort Studies among drug users. Addiction 2007; 102 (9):1454–62. 80. Nations Office on Drugs and Crime, Joint United Nations Programme on HIV/AIDS. Technical guide for countries to set targets for universal access to HIV prevention, treatment, and care for injecting drug users, 2012 revision. 81. World Health Organization. Consolidated guidelines on HIV prevention, diagnosis, treatment, and care for key populations, 2014 World Health Organization (WHO): Geneva. 82. World Health Organization. Community management of opioid overdose, 2014

219

83.

84.

85.

86.

World Health Organization (WHO): Geneva. Claudia S. The global state of harm reduction 2012: towards an integrated response. London: Harm Reduction International, 2012. HIV prevention, treatment, and care services for people who inject drugs: a systematic review of global, regional, and national coverage. The Lancet 2010; 375 (9719):1014–28. World Health Organization, United Nations Office on Drugs and Crime, Joint United Nations Programme on HIV/AIDS. Technical guide for countries to set targets for universal access to HIV prevention, treatment, and care for injecting drug users, 2012 revision. Burring, EC. Effects of Amsterdam needle and syringe exchange. Int J Addict. 1991 Dec; 26(12):1303–11.