CATR: What does harm reduction mean?

Eliza Wheeler: Harm reduction is a model for practicing public health that seeks to provide services in a nonjudgmental way. It seeks behavior change while acknowledging the need to meet a person where they are—especially in their particular journey through substance use. Abstinence is not a prerequisite for treatment or a condition that someone must meet to receive services.

CATR: Is this a fairly new model?

Eliza Wheeler: Not really. It was developed in Europe and started to take root in the U.S. in the mid- to late ‘80s. This was during the early days of hepatitis and HIV transmission when it was identified that those diseases were transmitted through the sharing of injection equipment. You had the old model, which was, “Everyone stop using injection drugs. You’re going to get HIV.” That was ineffective, because people don’t just stop using drugs because they are told to.

CATR: Right. So what happened?

Eliza Wheeler: Early harm reduction activists, who were primarily drug users, public health workers, and people affected by HIV/AIDS, realized that there had to be a different way to approach the issue. That’s how the early interventions like syringe exchange were created, out of that idea that people are going to inject drugs, so what can we do that’s more common sense and health focused. Providing an environment that at least provides safe injection equipment, along with education, support, and access to treatment makes sense. Since then, harm reduction has been integrated into many different public health programs. Methadone and Suboxone programs are examples. 

CATR: You mention harm reduction as a less judgmental approach. How does it improve upon the traditional doctor/patient, client/provider relationship roles?

Eliza Wheeler: At its core, harm reduction deconstructs the power dynamics: this idea that doctors and case managers and clinicians know better about what other people are supposed to do, and that they have the power to get people to “stop doing” something that’s bad for them. Harm reduction is a different orientation in which the people who are accessing services are the experts of their own lives and the providers are more like a conduit—people that can provide information and access to services for that person to engage at their own pace.

CATR: Let’s talk more specifically about syringe exchange programs. How do they work? 

Eliza Wheeler: We provide people a place to dispose of their dirty syringes and pick up clean ones. While it is legal in most places for people to purchase clean syringes over the counter at pharmacies, many people don’t have enough money, or they fear the stigma they’ll face in approaching a pharmacy. Also, some pharmacies refuse to participate despite the legality. Even if they do, they’re not going to provide any harm reduction information or treatment services. 

CATR: And most of these places provide other services in addition to syringe exchange?

Eliza Wheeler: Absolutely. They do HIV and hepatitis testing; some programs provide case management, therapists, wound care doctors—it depends on the program and the funding and how established they are. Some of the oldest studies of syringe exchange show that drug users who engaged in syringe exchanges were significantly more likely to actually access treatment than people who weren’t engaged in syringe exchange. Because of the ongoing contact they had with a person and with a program that worked with them, users were able to progress through the stages of behavior that led directly to recovery in some cases.

CATR: How successful are syringe exchange programs?

Eliza Wheeler: Syringe exchange programs reduce the spread of communicable disease among users and the community. They are the only evidence-based intervention that reduces the spread of HIV and hepatitis among injection drug users [Ed. Note: An excellent summary of this evidence is available here].

CATR: I understand that syringe exchange programs also provide naloxone, an opiate antagonist used to reverse opiate overdoses. I think many physicians, myself included, originally thought of naloxone as being something that only ER doctors or first responders would use. Tell us a little bit about the evolution of distributing naloxone directly to lay people. 

Eliza Wheeler: For as long as there has been drug use, drug users have been developing methods of trying to save whoever it is that they’re with when they’re using. There are street methods that are passed along from person to person throughout drug-using communities. They are well intentioned but not always the most effective ways, like throwing people in showers and injecting them with stimulants or putting ice on them. But naloxone actually works, so it makes sense to provide it to drug users themselves, who are most likely to be the very first responders to an overdose. They are the people who are with each other when they’re using drugs.

CATR: And people have been able to use naloxone successfully?

Eliza Wheeler: Yes. We have almost 20 years of experience distributing naloxone to lay people—mostly drug users—in various programs throughout the country. In an MMWR study I participated in, we reported that these programs have trained over 150,000 people and received about 26,000 reports of overdose reversals (Wheeler EJ et al, MMWR Morb Mortal Wkly Rep 2015;64(23);631–635).

CATR: In your study, did you determine who was most likely to administer the naloxone?

Eliza Wheeler: Yes, we found that 83% of reversals were administered by people who used drugs, and about 9% were from non-drug using friends and family.

CATR: So the bottom line is that naloxone should definitely be given to drug users. Were these primarily injectable versions of naloxone?

Eliza Wheeler: Yes, and currently the majority of programs nationally are still distributing the low-cost injectable naloxone.

CATR: But I assume the landscape is changing now, with the introduction of easier-to-use versions of Narcan.

Eliza Wheeler: Yes, it’s all shifting. The Evzio product is an auto-injector that makes it very easy for lay people to inject, and it has been out now for about two years. We distribute that as well as the regular vial and syringe injectable naloxone. We used to distribute the off-label, adapted device but had to phase it out when the manufacturer doubled the price, and we probably won’t be able to give out the recently approved Narcan nasal spray either because of cost. Most distribution programs are operating on fixed amounts of money from grants or private donations, so we are pretty bound by wholesale distribution costs of naloxone. 

CATR: So if I have a patient who I believe would benefit from naloxone, cost-wise am I better off writing a prescription or sending them to a program?

Eliza Wheeler: If the patient has insurance, you can write a prescription and have them go fill it at the pharmacy, and their insurance will cover the cost. Also, with third party prescribing, which is legal in most states, a person can get naloxone for a family member or friend if that person is at risk for opioid overdose. Legal info can be found on your specific state at the Public Health Law Research website. In addition, there are many states that now don’t require a prescription in order to dispense naloxone at a pharmacy. You can check the most recent legislation for your state on the same Website mentioned above. Alternatively, you can check your city or state’s Department of Public Health website. You’ll find information about syringe exchanges and drop-in centers, places like that. The North American Syringe Exchange Network also provides a directory of syringe exchange programs that can be searched by state. Then there’s the distribution programs, the HIV prevention programs; they’re the full-service harm reduction programs.

CATR: Is the process easy? 

Eliza Wheeler: Yes. The patient fills out a little bit of paperwork and then sits with somebody to learn how to use the drug; the training takes about 5–10 minutes. 

CATR: One of the interesting questions for prescribers is how often we should be prescribing naloxone. Clearly, opiate overdoses are a growing threat, and some unknown percentage of our patients are using or abusing opiates in one form or another. How wide of a net should we be casting on our patients in terms of prescriptions for naloxone?

Eliza Wheeler: It is a tricky issue. According to the National Center for Health Statistics for the Center for Disease Control and Prevention, in 2014, the most recent year for which we have figures, there were over 47,000 deaths from drug overdoses in the U.S., over 29,000 of which were opioid related. This includes heroin, but the majority were due to prescription opioids of various types. There are millions of people taking prescription opioids; in 2012, 259 million prescriptions for opioid painkillers were written, more than enough for each American adult to have their own bottle of pills. So a relatively small proportion of those people who take prescription opioids die from overdose, whereas a relatively large proportion of heroin users die from overdose. This means that prescribing naloxone to heroin users is important, but it’s not as clear that providing every prescription opioid user with naloxone will make a significant impact or be cost-effective. However, there are problems with trying to determine who should or should not receive naloxone. We are learning as we go with this intervention in terms of offering it to prescription drug users.

CATR: And often, we see patients who are substance abusers and may deny opioid use, yet we don’t know if we can believe them. We might be tempted to prescribe all of them naloxone, just in case. 

Eliza Wheeler: Right, and there are risk matrices available to help prescribers decide which patients are most at risk for overdose. They include factors like whether patients are on benzodiazepines and/or alcohol, whether they have chronic pain, chronic obstructive pulmonary disease, liver issues, and so on (See our table “Risk Factors for Opioid Overdose."). Depending on these variables, the matrices estimate the probability that the patient might overdose. Here in San Francisco, all of our Department of Public Health medical clinics prescribe naloxone to anyone who’s on chronic pain management with opioids. So if you are on an ongoing prescription of opioids, for any reason, you get a naloxone prescription. 

Eliza Wheeler: Yes, because they’ve found that that was the best way to go about it—focus on risky drugs rather than risky people, which removes the hyper focus on patients who are “badly behaved” in terms of their opiate use. So the clinicians here started offering a discussion on opiate safety to all chronic opioid users and stopped calling it overdose prevention. 

CATR: How did this change in language improve matters?

Eliza Wheeler: It changed the conversation, because you’d have these chronic pain patients on prescription opioids, some of whom were using their meds in risky ways, taking benzodiazepines and/or drinking. But generally they did not consider themselves to be drug addicts. So when their providers said to them, “We’re going to talk to you about overdose prevention and prescribe you Narcan,” these people would get angry and say, “What are you accusing me of?” So clinicians shifted the conversation to opioid safety and started saying, “We’ve started this new initiative where we talk to all our patients that take opioids about safety, and one of the safety things that we do is that we provide you the antidote if you stop breathing or have trouble breathing from your medications. You can pick it up at the pharmacy along with your prescription for your opioid medication.” And instead of being resistant, people were more likely to respond, “Great. Thanks for the information.” They felt taken care of vs. judged. 

CATR: So how would we apply this approach in our psychiatric practices? Let’s say I have a patient to whom I’m prescribing a benzodiazepine and I know that in the past this person has used prescription opiates. 

Eliza Wheeler: Just say, “You might be prescribed opiate drugs like Vicodin or Percocet, and I’m wondering if you know about some of the risks of mixing these types of drugs. I’m concerned about that interaction, and there’s a medication I want to show you how to use; it’s really easy. I’d like to have you keep it on hand or have a friend keep it on hand or know how to use it in case you ever have trouble breathing from the mixture of medications.” Something like that. Keep it focused on the medications.

CATR: That non-judgmental, harm reduction approach is certainly something most psychiatrists are used to, so I think it’s an easy strategy to adopt. 

Eliza Wheeler: It’s interesting to see how much more positively people react when you de-emphasize the term “overdose.” People associate overdose with people who inject heroin, and they don’t associate it with the more common scenario, which is the person who drinks and takes a bunch of Vicodin. In these cases, the respiration slows, the heart rate slows, respiratory failure occurs, and the heart stops. That’s a much more common kind of overdose death than the proverbial heroin user who is found with a needle sticking in the arm.

CATR: And I could imagine that this information might be surprising to some of my patients. They might be thinking that they have a small but manageable problem. They take a couple of Vicodin a day and they have a few drinks. They may not realize that on a given day they might drink a little too much and they take a couple of extra Vicodin, and that might be enough to tip them over the edge into an overdose.

Eliza Wheeler: Absolutely. These less threatening conversations can also open up a larger discussion about the use of opiates in general, and can keep people more engaged in treatment.

CATR: Are there any good training resources for readers who might want to learn more about this approach?

Eliza Wheeler: Yes, there is the Prescribe to Prevent website (www.prescribetoprevent.org), which has some training videos and links to webinars to help providers learn about these discussions, and there is practical information on exactly how to write the prescriptions for naloxone, and scripts to help you tell the patients how to use the drug if needed.

CATR: Thank you for all of this helpful information, Ms. Wheeler.