#3 Harm Reduction: Partnering with Patients

July 21, 2022 | By Carolyn Chan

with Dr. Kim Sue

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!

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Credits

• Written, Infographics, and Produced by: Natalie Stahl, MD, MPH 
• Show Notes, and Cover Art by: Carolyn Chan, MD
• Hosts: Carolyn Chan, MD,  Natalie Stahl, MD, MPH, Paul Williams MD
• Reviewer: Katherine Mullins, MD
• Showrunner: Carolyn Chan, MD
• Technical Production: Greg Abate
• Guest: Dr. Kim Sue

Production Partner: ACAAM

CME Partner: VCU Health CE

Show Segments

• Intro, disclaimer, guest bio:  1:26
• Guest one-liner, Picks of the Week: 2:44
• Case from Kashlak; Definitions 4:28
• Harm Reduction Definition: 5:20
• Safer Injection use 13:40
• Safer smoking:  26:30
• Alcohol Harm Reduction 34:20
• Tobacco Harm Reduction 36:19
• Overdose Prevention: 38:31
• Primary Care Harm Reduction 43:30
• Take-Home Points 45:37
• Outro 48:19

Harm Reduction Pearls

1. Learn to consider harm reduction (HR)from both 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. 
2. Normalize talking to patients about their substance use in a non-judgemental way, and understand their personal goals. These goals may not necessarily include abstinence.
3. Drug, Set, Setting: Utilize this model to talk to patients about their substance use.
4.  Your patient is an expert! Ask them to walk you through their injection drug use practices. 
5. Familiarize yourself with your local harm reduction organizations and syringe exchanges. Be able to refer your patients to these locations as needed. 
6. Stimulant Harm Reduction: Ask patients about the route of use, counsel on symptoms of overamping, and review safer smoking equipment/practices.
7. Alcohol Harm Reduction: Counsel patients on counting and spacing drinks, eating, setting maximum dollar limits to spend, and having an accountability partner. 
8. Overdose Prevention: Be aware that stimulants, benzodiazepines, and counterfeit pills are increasingly contaminated with fentanyl. All patients who use substances should be counseled about this, and be provided naloxone and fentanyl test strips. 
9. Understand that all overdoses are preventable. If a patient overdoses, review the details of the scenario with the patient to prevent future overdoses. 

Harm Reduction – Notes

What is Harm Reduction?

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:

• Communicate respectfully and compassionately, knowing that your patient has likely experienced stigma in healthcare settings because of their substance use.
• Normalize talking about substance use with your patients: e.g., “These are questions that I ask everybody.”
• Explain why you are asking about substance use: e.g., “I am asking questions about your substance use because I want to help with issue X.” Ensure that the patient’s primary concern is addressed and explore how it relates to their substance use when appropriate.
• Ask what a patient’s goals are regarding their substance use and allow them to direct the conversation.
• Treat pain and withdrawal first, as needed, and obtain a thorough history when your patient is more comfortable. 
• Provide friendly messaging or signs within your workspace to normalize talking about substance use.

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. 

Steps to Safer Injection  

• Hand washing 
• Safe Drug, Set, Setting
• Substance preparation (e.g. sterile water to dissolve a substance)
• Use of clean filter when drawing liquid into the syringe (e.g. part of cotton ball)
• Identification of veins and effective injection location 
• Skin cleaning
• Tourniquet use
• Injection technique: Insert needle bevel up at an angle, ensure flash of blood before injection, inject slowly
• Tourniquet removal
• Aftercare: Dispose of syringe

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. 

Substance Use While in Treatment

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. 

Routes of Administration

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 Use

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).

Stimulant Equipment

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.

Alcohol Use

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. 

Overdose Prevention

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.

Take-Home Points

1. Believe, partner, and learn from people who use drugs.
2. Many evidence-based strategies exist beyond abstinence to keep patients safe and healthy. 
3. Prescribe naloxone to individuals who use ANY street drugs.

Links

1. National Harm Reduction Coalition 
2. Harm Reduction Supplies: Next Distro 
3.  The North American Syringe Exchange Network
4. National Harm Reduction Coaliition Conference – Puerto Rico, October 2022

Goal

Listeners will apply harm reduction principles to their clinical practice when caring for individuals who use substances or have substance use disorders. 

Learning objectives

After listening to this episode listeners will…  

1. Define harm reduction philosophy, and describe how to apply it in clinical settings..
2. Rank safer methods of substance delivery from highest risk to lower risk (e.g. injection, rectal, smoking, insufflation). 
3. Describe the following safer injection drug use practices: site, needle/syringe, water selection, cooker,  skin clearing, tourniquet use, injection process, and supply disposal.
4. Describe safer ways to use cocaine and/or methamphetamine.

Disclosures

Dr. Kim Sue reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

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