Step up harm reduction strategies in your clinical practice! We discuss partnering with patients who use substances and methods to keep patients safe and healthy. Dr. Kim Sue (@DrKimSue, Yale University), the National Harm Reduction Coalition Medical Director, joins us. We discuss safer injection practices, stimulants, alcohol, nicotine use, and more!
Claim free CME for this episode at curbsiders.vcuhealth.org!
Episodes | Subscribe | Spotify | | iTunes | Swag! | Top Picks | Mailing List | CurbsidersAddictionMed@gmail.com | Free CME!
Harm reduction (HR) can be viewed from a micro and macro lens. On a micro level, HR offers practical strategies that we can use in clinical practice to reduce the negative consequences associated with drug use. On a macro level, HR is a social movement that promotes the health and dignity of people who use drugs.
Harm Reduction 101:
For individuals who inject substances, remember that your patient is an expert! Ask open-ended questions, such as: “Can you tell me how you inject substances?” and “Can you walk me through a typical day of how you use substances?” Dr. Sue recommends getting granular with a patient’s substance use history.
Check out this guide for more information.
More on Setting
Encourage patients to use substances in environments where they feel safe. The need to rush can lead to unsafe practices. Encourage individuals to use with others, identify someone who can check on them, or use the Never Use Alone hotline.
Harm Reduction Supplies:
As a prescriber, you may be able to prescribe sterile injection supplies such as alcohol pads, cotton balls, or sterile needles/syringes (consider a 27g or 28gauge needle, Manual Getting Off Safely). Check your state regulations for clarification on your local syringe prescription laws.
Refer patients to local syringe exchanges and/or harm reduction agencies. You can locate syringe exchanges through The North American Syringe Exchange Network.
Some individuals will continue to use substances while engaged in addiction treatment. Dr. Sue recommends exploring an individual’s goals surrounding their substance use on an ongoing basis. The clinician’s ultimate goals may include keeping people safe, alive, and healthy, and meeting these goals requires meeting patients where they are at. Dr. Sue recommends approaching the conversation with curiosity and humility. Recognize that abstinence is not a realistic or coveted goal for everyone, and try to understand on a granular level what the individual hopes to achieve.
For individuals taking medication for opioid use disorder, consider asking if the individual is having cravings or withdrawal, reassessing the dose of the medicine, and exploring what circumstances contribute to ongoing substance use when relevant. Work in collaboration with your patient to keep them safe. For patients on buprenorphine or methadone, do NOT stop these medications because the individual has ongoing drug use.
Different routes of administration have various associated risks. Generally, experts believe that injection confers the highest risk of overdose or infectious complications. The following routes of use may confer a lower risk of complications: rectal (commonly known as “booty bumping”), insufflation, inhalation, or oral ingestion. Counseling patients on HR may include a discussion of safer routes of administration.
Stimulant (e.g., cocaine, methamphetamine) use and associated mortality are rising (Mbabazi, 2021). It is essential to counsel individuals on the signs and symptoms of stimulant overdose, also called overamping (Mansoor, 2022). Individuals may have increased energy, intrusive thoughts, and psychosis. Educate patients on which symptoms constitute a medical emergency and when to go to the emergency room. Overamping complications such as stroke, seizure, chest pain, and hyperthermia should be managed in a hospital setting.
Counsel patients to avoid mixing substances if possible. Give fentanyl test strips and naloxone to all patients who use stimulants (as well as those who use non-prescribed substances) since the cross-contamination of stimulants is on the rise (Park, 2021).
Safer smoking kits may include pyrex pipes (do not chip as easily as glass), copper filters, push sticks, condoms, lubrication, gum, and a mouthpiece to prevent burns. Emphasize mouth and nose care since burns and cuts can be entry points for the hepatitis C virus.
It is important to count drinks, space drinks, eat meals even when drinking, take vitamins when appropriate (Defries, 2021), identify an accountability partner, and set financial limits on alcohol purchases.
Ask patients whether they have ever experienced an overdose and if so, ask them to walk you through the circumstances of their last overdose. Always discuss strategies that could have prevented it and assess for ongoing risky use. Train individuals to use naloxone and have it on hand. If using alone, encourage the use of the Never Use Alone hotline. This organization keeps someone on the phone with you confidentially while you use and can call for help if needed. Suggest starting with a test dose of any new substance, then advancing the quantity slowly. Avoid mixing substances, and if using with other individuals, suggest that they stagger their use.
Other Harm Reduction
Offer PREP (Choopanya, 2013), treat hepatitis C aggressively even if someone is actively using drugs (Palmateer, 2021), and encourage appropriate vaccinations and low-dose lung cancer screening when indicated. PREP can be offered to individuals who inject drugs. Check out these guidelines to learn more.
Listeners will apply harm reduction principles to their clinical practice when caring for individuals who use substances or have substance use disorders.
After listening to this episode listeners will…
Dr. Kim Sue reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.
Stahl N, Sue, K, Mullins K, Williams PN, Chan CA“#3 Harm Reduction: Partnering with Patients with Dr. Kim Sue”. The Curbsiders Addiction Medicine Podcast. http://thecurbsiders.com/episode-list July 21st, 2022
The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit.
Got feedback? Suggest an Addiction Medicine topic. Recommend a guest. Tell us what you think.
We love hearing from you.
You'll soon be able to join our exclusive community of core faculty at Kashlak Memorial Hospital along with all the perks:
Close this notice to consent.