The physician’s role in harm reduction

Issue: BCMJ, vol. 60 , No. 8 , October 2018 , Pages 404-405 BCCDC

As respected leaders, physicians are well positioned to address community concerns with evidence and to advocate for harm reduction to reduce health inequities and improve the health of marginalized populations across British Columbia.

What is harm reduction?

Broadly speaking, harm reduction aims to reduce the morbidity and mortality associated with activities that may cause harm. Harm reduction applied to substance use is a comprehensive, nonjudgmental approach that focuses on preventing harm rather than preventing drug use. Harm reduction includes abstinence-based programs; it is one pillar in a four-pillar strategy, working together with prevention, treatment, and enforcement. Evidence shows harm reduction is a pragmatic, safe,[1] cost-effective,[2] and lifesaving[3] response to address adverse health and social outcomes associated with substance use. The Canadian Medical Association fully supports harm reduction strategies to address the adverse outcomes associated with the use of both legal and illegal psychoactive drugs, and recognizes that it is a clinically mandated and ethical method of care.[4]

While harm reduction is often thought of as the provision of sterile injection supplies to people who use drugs or supervised consumption sites, harm reduction approaches are broad-reaching and inform the design and delivery of policy, programs, and services to benefit people who use substances, their families, and the community at large.

Needle distribution and exchange

Policies that restrict the distribution of needles, such as one-for-one needle exchange, increase the likelihood that supplies will be shared, and thus limit the effectiveness of harm-reduction programs in preventing hepatitis C virus and HIV transmission.[5] Therefore, in 2003, consistent with best practice, needle distribution and safe disposal replaced the policy of needle exchange in BC. From 2007 to 2016, HIV diagnoses in people who inject drugs declined from 118 to 16 cases, representing 30% and 6.6% of total cases of HIV identified, respectively.[6] To enable safe disposal of used injection supplies, the BC harm reduction program provides personal sharps containers and safe-disposal education, while health authorities collaborate with municipalities to provide locally appropriate disposal options, including facilitating peer needle-recovery programs (needle sweeps), and needle-disposal containers in public spaces, health centres, and agencies.[7]

Client (or patient)–centred care and addressing stigma

Successful harm reduction programs focus on the needs of clients and embrace client-centred care. Harm reduction best practices in programing involves ongoing, meaningful engagement with organizations led by people who use drugs, and individuals with past or present experience who can provide expert and valuable perspectives.[8] Stigma experienced by people who use drugs creates a barrier to disclosing substance use and a reluctance to seek help. This is particularly salient given the context of the current overdose public health emergency and people dying while using substances alone.[9]

What can physicians do?

Physicians can respect people’s rights to access care by treating the immediate health needs of people who use drugs while acknowledging patients’ experiences—meeting people where they are at. The careful use of nonstigmatizing language by physicians and their staff can signal respect to clients. Guidelines on the use of respectful language have been developed (Figure), with key recommendations encouraging the use of people-first language, language reflecting the medical nature of substance-use disorders, language promoting recovery, and avoiding slang.[10] Addressing the needs of people who use drugs with compassion can build trust between them and health providers. This trust enables physicians to advocate for their patients and to connect them with treatment and harm-reduction services.

Physicians can help address the issue of marginalization by examining their own assumptions and values, and recognizing the role of social determinants of health and health inequities that predispose people to use substances. Physicians can also advocate for harm-reduction services in their communities and respond to public concerns with evidence.
—Brandon Yau, BSc
UBC Faculty of Medicine student, on placement with BCCDC
—Emily Sollows, BN, RNc, MN
Nurse Educator, Harm Reduction, BCCDC
—Sara Young, MA, MHA(C)
Manager, Harm Reduction and Hepatitis Services, BCCDC
—Jane A. Buxton, MBBS, MHSc, FRCPC
Physician Epidemiologist and Harm Reduction Lead, BCCDC

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This article is the opinion of the BC Centre for Disease Control and has not been peer reviewed by the BCMJ Editorial Board.


References

1.    Kappel N, Toth E, Tegner J, Lauridsen S. A qualitative study of how Danish drug consumption rooms influence health and well-being among people who use drugs. Harm Reduct J 2016;13:20.

2.    Laufer FN. Cost-effectiveness of syringe exchange as an HIV prevention strategy. J Acquir Immune Defic Syndr 2001;28:273-278.

3.    Kimber J, Copeland L, Hickman M, et al. Survival and cessation in injecting drug users: Prospective observational study of outcomes and effect of opiate substitution treatment. BMJ 2010;341:c3172.

4.    Canadian Medical Association submission to the House of Commons Standing Committee on Public Safety and National Security. Bill C-2 An Act to amend the Controlled Drugs and Substances Act. Accessed 30 August 2018. www.cma.ca/Assets/assets-library/document/en/advocacy/submissions/CMA_Brief_C-2_Respect%C3%A9-for_Communities_Act-English.pdf.

5.    Bluthenthal RN, Ridgeway G, Schell T, et al. Examination of the association between syringe exchange program (SEP) dispensation policy and SEP client-level syringe coverage among injection drug users. Addiction 2007;102:638-646.

6.    BC Centre for Disease Control. HIV in British Columbia: Annual Surveillance Report 2016. Accessed 30 August 2018. www.bccdc.ca/resource-gallery/Documents/Statistics%20and%20Research/Statistics%20and%20Reports/STI/HIV_Annual_Report_2016.pdf.

7.    BCCDC and Provincial Health Officer Position Statement. Retrieval of used needles. Accessed 24 August 2018. www.bccdc.ca/resource-gallery/Documents/Guidelines%20and%20Forms/Guidelines%20and%20Manuals/Epid/Other/Position%20Statement_Needle%20Buy-Back_FINAL.pdf.

8.    Greer AM, Luchenski SA, Amlani AA, et al. Peer engagement in harm reduction strategies and services: A critical case study and evaluation framework from British Columbia, Canada. BMC Public Health 2016;16:452.

9.    BC Coroners Service. Illicit drug overdose deaths in BC (January 1, 2008 – July 31, 2018). Accessed 24 August 2018. www2.gov.bc.ca/assets/gov/public-safety-and-emergency-services/death-investigation/statistical/illicit-drug.pdf.

10.    Toward the Heart. Respectful language and stigma regarding people who use substances (March 2017) Accessed 24 August 2018. www.towardtheheart.com/resource/new-respectful-language-and-stigma-regarding-people-who-use-substances/open.

Brandon Yau, BSc, Emily Sollows, BN, RNc, MN, Sara Young, MA, MHA(C), Jane A. Buxton, MBBS, MHSc, FRCPC. The physician’s role in harm reduction. BCMJ, Vol. 60, No. 8, October, 2018, Page(s) 404-405 - BCCDC.



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