Harm Reduction: Theory and Practice

If we want to reduce the harm that derives from psychoactive substances, we need to begin by ending two ineffective, enduring and hugely expensive policies and practices in this country. Then we can get to true harm reduction.

The first are strategies that seek to control access to and distribution of psychoactive substances. The most notorious example is Prohibition. Remember that? Didn’t last long but did put organized crime on the map. More contemporary control strategies include border interdiction and crop destruction; ‘buy and bust’ (where undercover police or FBI agents purchase drugs then arrest the dealer, who is often a youth or person addicted and selling to support their habit); “build a wall” (when the deadliest drugs, like fentanyl, are coming in from China and Russia); and the latest, out of Attorney General Sessions’ ideologically driven office, namely, arrest cannabis (non-violent) users by prosecuting federal laws in states where recreational pot is legal.

We all have seen the photo-ops of a card table laden with plastic bags full of drugs, piles of cash, and usually illegal weapons, which have become deadlier to defend against competitors and “the war on drugs.” These various control strategies have resulted in the USA having the greatest number of incarcerated people in the world – disproportionately people of color and impoverished – costing vast sums of money yet with no increase in the safety of our neighborhoods. Control strategies are ignorant of reality, puritanical and punitive. Money that could be spent on prevention and treatment goes into the pockets of propriety prison and jail companies.

The second strategy continuing to cause harm is scare tactics. Ads or packaging that declare “this drug will kill you” or police in uniform going into school classrooms to “DARE” and scare students are examples that truly waste precious resources. These approaches also can paradoxically promote use because adolescents are neurologically drawn to risk.

What does work? What can reduce the harms of substance misuse? Prevention, diversion from correctional settings, early detection and comprehensive, continuous treatment. As I detail in The Addiction Solution: Treating Our Dependence on Opioids and Other Drugs (Sederer, 2018), the greatest ‘problems’ with psychoactive drugs are that they are powerfully and immediately effective (of course, that effect is eclipsed over time but that is usually when the disease of addiction has set in). People use substances to mitigate physical and psychic pain, to tolerate a hard life with few prospects, and to escape the grind and weariness of our everyday existence.

A first preventative step would focus on the flood of fatal overdoses now occurring. We can reduce deadly overdoses of opioids by scaling up the provision of naloxone. It needs to be ubiquitous. We have learned, as well, that higher doses of naloxone are needed for longer periods of time when opioids laced with fentanyl and carfentanil are taken, often inadvertently. Some cities are piloting safe injection sites. We can also reduce many downstream consequences of IV drug use, such as Hep C and HIV/AIDS, through needle exchange programs.

As Maya Angelou remarked, “…let us try to offer help before we have to offer therapy. That is to say, let’s see if we can’t prevent being ill by trying to offer a love of prevention before illness.”

With prevention, the earlier the better. When provided to youth, as early as in elementary school. And to their families. Skill building is at the core of some of the most successful prevention programs. Youth can learn decision-making, how to better manage feelings and impulses, and ways to improve their self-regard (e.g., Life Skills Training (http://lifeskillstraining.com/). These are skills proven to prevent use and abuse of substances. Another effective approach is Big Brothers/Big Sisters, which demonstrates the protective power of a caring adult (http://www.bbbs.org/).

Whenever possible, families too can learn the skills that make for better parenting and home life. The Strengthening Parents Program is a good example. Positive and supportive communications, time spent together (like at dinner with no TV or texting), and how to help youth engage in activities and after-school programs are important parts of their curriculum (http://www.strengtheningfamiliesprogram.org/). SBIRT (Screening, brief intervention and referral for treatment) for youth (http://pubs.niaaa.nih.gov/publications/Practitioner/YouthGuide/YouthGuide.pdf) and adults illustrates the principle of early detection and intervention.

SBIRT needs to be introduced in all pediatric and primary care practices, schools and selected community programs, and in emergency rooms. SBIRT with teenagers can focus on those youth showing evidence of problem alcohol and drug use (e.g., accidents, missing school or failing in class, risky behaviors, trouble with the law, and medical problems without a clear physical condition). The youth is asked as few as 2 questions: The first asks about friends’ drinking, an early warning sign highly associated with current or future substance use, and often easier to ask. The second question is about the youth him or herself, and asks about frequency of substance youth. With older youth, the questions are reversed. The American Academy of Pediatrics, in 2011, recommended substance screening as a “routine” part of adolescent health care (https://www.aap.org/en-us/about-the-aap/aap-press-room/pages/AAP-Recommends-Substance-Abuse-Screening-as-Part-of-Routine-Adolescent-Care.aspx ). SBIRT for adults follows a similar and feasible game plan (https://www.samhsa.gov/sbirt).

Treatment begins with assessing for a co-occurring mental or physical disorder and delivering simultaneous treatment. The odds of recovery are not good if a person has an active, additional condition that impairs their ability to effectively engage in and sustain substance disorder treatment.

Consumers and families should ask if a program they are considering provides comprehensive treatment. A good treatment plan would offer 12-Step Recovery but ensure that it is complemented by evidence-based practices for SUD. These include: 1) CBT (Cognitive Behavioral Therapy) focused especially on techniques to control responding to triggers. Remember that addiction is in part driven by conditioned responses, as illustrated by Pavlov’s dogs who salivated to the bell, not just the food; so it is, as well, when people with substance problems pass a bar, see a needle, watch a program or listen to music infused with substance triggers. 2) Family education and support. Families represent an early warning system for recognizing problems and when relapse is imminent. They are usually the most important and enduring sources of support for a person in recovery. 3) Relapse Prevention Groups can teach about triggers, soften the shame of falling off the wagon, and provide critical peer support.

A highly effective treatment strategy is medication assisted treatment (MAT). We have abundant evidence that MAT works for opioid and alcohol use disorders. Methadone has been a MAT for opioid dependence for decades, but its demands of attending a program and directly observed medication administration deter many from using it. Since 2002, we have had buprenorphine (e.g., Suboxone and others) to reduce relapse for people dependent on opioids. Far too few doctors and nurse prescribers take the training necessary, and among those many do not prescribe or carry very small caseloads. Patient and family demand is needed to improve access to buprenorphine. Another MAT is naltrexone, especially the monthly injectable form called Vivitrol. This medication has a strong evidence base with alcohol dependence, and some promising studies on its use with opioid dependence. Dated prejudices such as “treating an addiction with an addicting drug” further impede the use of these agents.

Of course, we need alternatives to opioids for pain, with their dependency risks. Non-opioid, non-addicting medications will be welcome, as will effective magnetic and electrical devices that mitigate pain.

Individuals with any chronic condition, including diabetes, hypertension, asthma, cancer and substance use disorders, can learn to better care for their bodies and minds. They can benefit substantively from exercise, a healthy diet, and a variety of mind-body interventions such as yoga, mindfulness, meditation and slow breathing.

Before long, we will have vaccines that prevent an individual from responding to a specific drug, like heroin or cocaine. We already widely use vaccines for infectious diseases like polio, measles, and mumps, examples of harm reduction that need to propagate into the addictions. Some people dependent may want to have this protection as may others at risk.

Harm can also be substantially reduced by diverting people with substance (and often co-occurring mental) disorders from correctional settings. Drug and Mental Health Courts are good examples. Living under the conditions of incarceration is not conducive to recovery.

I like to think of Winston Churchill’s famous words when considering the opioid (and other drugs) epidemic that has seized this country. He remarked during the darkest of days in WWII, just after the Americans entered the war: “We are not at the beginning of the end. We are at the end of the beginning.”

There is so much we can and must do to reduce the harms of substance use and dependence. We have landed on the beach, have a lot of firepower (in terms of prevention and treatment), but are not effectively using the resources we have. When we do, we will change the course of this epidemic.

Dr. Lloyd Sederer is a psychiatrist and public health doctor. The opinions offered here are entirely his own. His next book, The Addiction Solution: Treating Our Dependence on Opioids and Other Drugs, will be published by Scribner (Simon & Schuster) on May 8, 2018 (http://www.simonandschuster.com/books/The-Addiction-Solution/Lloyd-Sederer/9781501179440). You may reach him on Twitter: @askdrlloyd, and on his Website: www.askdrlloyd.com.

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