What is Harm Reduction?
Harm reduction is the understanding that people who use drugs (PWUD) deserve to be treated with respect, dignity, and kindness. It is the understanding that one cannot recover from their drug addiction if they do not survive it. Thus, Harm reduction is a set of strategies aimed at making drug use as safe as possible, while making those services that help make recovery possible more accessible. For those whom harm reduction is a new idea, the best way of thinking about it is comparing it to Sex Education classes. “Abstinence Only” sex education is associated with higher teen-pregnancy rates, higher STD incidences, etc. The only way sex education is effective is to understand axiomatically that teenagers will have sex, and that by giving them tools to do so safely, we can decrease the negative side effects. When society can understand that addiction is a profoundly complex disease, we are then capable of meeting PWUD where they are. This enables us to help them use drugs safely because the critical issue is that people will use drugs, and when healthcare professionals pretend otherwise, greater harm is done to those living with addiction.
Why is Harm Reduction important?
Harm reduction has many benefits for our patients as well as public health. To start, showing a patient that you are non-judgmental of their drug use, and that you want to help them use drugs safely helps improve often difficult to navigate patient-provider relationships. This is because it shows a recognition of their humanity, something often lost in healthcare, particularly amongst PWUD.
Utilizing harm reduction tactics can also help your patient’s short and long-term health. Using services like needle exchanges, teaching best practices for injecting and using drugs reduces the risk of infections like Hepatitis, HIV, along with the long-term risk of endocarditis. In the short term, teaching the use of Naloxone (Narcan) in overdoses, and helping to ensure your patients have access to Naloxone, helps to avoid overdose deaths; while other information and critical teachings, such as instructing patients how to sample, can help avoid the overdose in the first place.
Finally, by reducing individual risk of infectious diseases through Harm Reduction methods, there is overall decreased community risk of these diseases. This helps to “inoculate” the people you can’t reach with harm reduction by reducing the overall disease burden of the population. This also helps first responders who are at-risk for needle sticks. If less of the population has blood-borne illnesses, then the risk of a needle-stick causing an infection decreases simultaneously.
Harm reduction is important, and it works. People who used needle exchange programs had a three-fold increase in their likelihood to stop injecting drugs according to the CDC. While people who disagree with harm reduction may argue that it is encouraging drug use, and thereby makes problems worse, studies have shown time and time again that harm reduction works, and that it decreases drug use.
Paramedics Unique Role
Bored during transport? You’re missing an opportunity!
Being able to have uninterrupted, one-on-one time with a patient is a luxury that we have in Emergency Medical Services (EMS) that we often forget about. How many other healthcare providers, especially in emergency medicine, get time where they don’t have to think about anyone but one patient and their needs alone? We not only get this one-on-one time, but we are “at the bedside” for the entire trip to the hospital. Sure, on some sick patients that require intensive care, we are busy “doing things”. However, on many of our transports, we end up with time to sit and talk with our patients. This puts us in the unique position to have unrushed, meaningful conversations with them, learning more about who they are as people and understanding their needs overall--medically and socially. Using this unstructured time to have free-flowing discussions on Harm Reduction is a way that we can absolutely help our patients, as well as show them that, despite their often very legitimate fears, we as a healthcare team are here to treat them as people, not like the “junkies” that they fear they will be treated as. We as first responders are the only ones with the gift of time one-on-one with patients. Let’s use it for everything we can.
Discussion points
Due to the constraints of working on an ambulance, our ability in EMS to affect Harm Reduction is going to be limited to our ability to have a conversation with our patients, influenced heavily by knowledge of our local resources and the tools available to PWUD.
If you have a local Harm Reduction Center, reach out to them and find out what services are available. Find out when it’s available and how it's accessed. Are there any barriers to access that you can help your patients navigate? Harm Reduction Centers often offer services such as needle exchanges, clean cotton, HIV and Hepatitis testing. They are also a place for resources on recovery programs. Knowing what is available for your at-risk patients is sometimes the most helpful thing you can do--as well as connecting them with advocates in hospital who can continue the conversation.
I tend to have a conversation with my patients about how to most safely inject drugs, if they do. Some things to talk about are using alcohol prep pads, and how to use them appropriately. When drawing up heroin into a syringe, many People Who Inject Drugs (PWID) use cotton as a filter. Sterile cotton is often offered by needle exchanges, and its use should be encouraged to help prevent Cotton Fever, as well as reducing the overall risk of infection. Cigarette filters should be avoided as well.
PWID know that dirty needles should not be used, but often don’t know where or how to obtain clean ones. Do pharmacies in your area sell insulin syringes without a prescription? If so, how much do they cost? What are their hours? These are questions you can help your patients answer. One semi-common practice among heroin users in particular is to lick their needles before injecting. Discouraging this practice is a really easy way to help reduce infection risk, as many do it as part of the “ritual”, unaware of the additional risk posed by the practice.
While one of the tenants of Harm Reduction is to prevent overdose, preventing overdose death is equally important. Helping to ensure access to Naloxone is key. Where can your patients get it? If they do carry it, make sure they are comfortable using it. You are a medical professional, it is second nature for you to give an intranasal dose of a medication. That is not that case for everyone. Also encourage them to make sure their friends know that they carry it, in case your patient needs theirs used on themselves.
When using a new batch of drugs, or drugs from a new supplier, it is best to not use alone (best to not use IV drugs alone ever, if possible), but if “sampling” is not an option (it’s often not, addiction is not that simple), then staggering their use with whoever they are using with is the next-best option.
Beyond the above, having a conversation about Suboxone can be incredibly valuable. Suboxone is an addiction treatment medication, which is seen as a safer and more effective treatment than Methadone. Unfortunately, it is currently regulated, and providers who prescribe it are required to hold the “x-waiver”, making access far from universal. Knowing which of the Emergency Departments (ED) you transport to offer suboxone induction in the ED can help give patients the best chance of recovery. Due to the waiver, not all EDs offer Suboxone inductions 24/7, and not all are able to begin treatment in the ED. Knowing this, and being judicious about transport decisions, can be an excellent way to help your patient and perform actual Harm Reduction.
First responders, namely paramedics, are in the unique position of having extended one-on-one time with patients beyond a clinical assessment. We get to spend time talking with them and this time can be effectively spent by having conversations around Harm Reduction. These conversations can also help to reduce the stigma these patients feel accessing healthcare, and enable providers to meet PWUD where they are without a feeling of paternalism and judgment. Additionally, our understanding of their disease process can help to reduce the short and long-term effects of their addiction. I don’t expect a conversation covering all of the above topics, but I offer various things to think about and to have in your “toolbox” for the patients who will benefit from them. Harm Reduction works, and street paramedics are well suited to have these initial conversations.
-Jace Mullen