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Overview

As Congress works to find solutions to the nation’s opioid crisis and explores ways to prevent future opioid abuse, experts point to strategies to reduce harm for those already using opioids. Unfortunately, for families and communities ravaged by this crisis, preventative measures are often too little, too late. More than 42,000 Americans died of an overdose involving opioids in 2016, a number five times higher than in the late 1990s. According to the most recent National Survey on Drug Use and Health, 2.1 million Americans had an opioid use disorder in 2016, so the question becomes: How do we protect those already addicted?

In this Basic, we kick off a series on Harm Reduction and the ways in which we can mitigate against negative, potentially deadly consequences of opioid abuse.

Harm Reduction as it Relates to Opioids

For opioids, harm reduction is a set of guiding principles that accepts drug use as a reality and seeks to reduce consequences associated with it, such as death, HIV, hepatitis C, criminal activity, and incarceration. Strategies of harm reduction range from safer and managed use to abstinence and meeting individuals “where they are” to minimize harmful effects on the individual, their family, and their community.
Critics of harm reduction believe policies that fail to recognize the harms of drugs themselves, and instead focus on the possible consequences of use, do nothing to prevent drug-related harm. Furthermore, they argue these strategies increase drug use and prolong addiction by creating the perception that drugs are not inherently dangerous.

There are numerous harm reduction techniques employed around the world that are determined by individuals’ specific situations. Below we explore just a few of the most common harm reduction approaches employed in the U.S.

Harm Reduction Methods for Opioid Disorders

Syringe Service Programs:
One of the most commonly known methods of harm reduction, syringe service programs (SSPs), also referred to as syringe exchange programs (SEPs), needle exchange programs (NEPs), and needle-syringe programs (NSPs), are community-based programs that supply sterile needles and syringes free of cost and provide for the safe disposal of used materials. According to the CDC, injection drug users can substantially reduce their risk of getting and transmitting HIV, viral hepatitis, and other blood borne infections by using sterile needles and syringes. Additionally, most SSPs offer other prevention materials and services, such as education on safer injection practices and wound care, overdose prevention, referral to substance use disorder treatment programs, and counseling for HIV and hepatitis C. A directory of SSPs by state can be found HERE.

Opioid Treatment Programs:
Opioid treatment programs (OTPs) are accredited and certified by the Substance Abuse and Mental Health Services Administration (SAMHSA) and provide medication-assisted treatment (MAT) to individuals diagnosed with opioid use disorder. Federal law requires patients who receive treatment in an OTP to receive a full range of services in addition to prescribed medication, including medical, counseling, vocational, educational, and other assessment and treatment services. Ultimately, these programs aim to reduce, eliminate, or prevent the use of illicit drugs, and the potential harms associated with them by providing a more comprehensive, individually-tailored program for patients. More information on MAT and the medications utilized in treatment can be found HERE.

Naloxone distribution:
Naloxone is an FDA-approved medication to prevent overdose by opioids. Timing is everything when someone is exhibiting signs of an overdose and by blocking opioid receptor sites, naloxone can reverse the toxic effects of overdose and save lives. Following broad acceptance of the drug nationwide, distribution of naloxone has expanded dramatically over the past decade, and 41 states have now legalized its sale without prescription. Furthermore, SAMHSA published the Opioid Overdose Prevention Toolkit in 2014 to serve as a basis for educating and training communities, prescribers, first responders, patients, and family members in distributing the antidote. According to a 2014 report published by the Centers for Disease Control and Prevention (CDC), expanded access to naloxone for patients and families has been highly effective. Since programs first began in 1996, 644 local distribution centers were responsible for 26,453 overdose reversals and lives saved. More information on naloxone and where to find it by state can be found HERE.

Looking Ahead

As a result of the opioid crisis, communities, researchers, and policymakers have come together to establish ways to prevent harm to those already addicted to opioids and to prevent addiction for those at risk. Services for those already addicted, such as syringe exchange programs, opioid treatment programs practicing medication-assisted treatment, and naloxone distribution have dramatically expanded in the past decade to respond to communities’ urgent need. However, for those suffering from chronic pain, there are currently not many non-opioid options available, and due to the opioid crisis, doctors are increasingly concerned about prescribing opioids, even for those patients that use them responsibly and desperately need relief. So how will the U.S. treat chronic pain patients in the future while also decreasing the use of opioids?

Fortunately, research into non-opioid alternatives has taken off and there are currently 17 drugs in late-stage clinical development and 40 more drugs in early-stage development moving their way to market. These alternatives hold promise for the 100 million Americans suffering from chronic pain and could save the U.S. healthcare system billions of dollars a year. According to a 2011 study by Johns Hopkins University and George Washington University, chronic pain costs the U.S. healthcare system between $560 billion and $635 billion every year, taking into account the healthcare costs to treat pain and the lost productivity from Americans missing work.

To address the opioid epidemic, the U.S. House recently passed a bipartisan package of 58 bills ranging from expanding access to treatment, to encouraging non-addictive opioid alternatives to treat pain, to cracking down on the flow of illicit drugs into the U.S. With the White House’s endorsement, the package has moved to the Senate where they are expected to take up their own opioid package before the end of this session.
As Congress continues to push through legislation aimed at eliminating the opioid crisis, be on the lookout for policies that both reduce the risk of overdose for those currently addicted as well as promote innovation in alternative pain management methods. As long as Americans continue to suffer from chronic pain, the U.S. will need to seek long-term solutions. Without them, Americans could be forced to endure this crisis for years to come.

Key Statistics

● On average, 115 Americans die every day from an opioid overdose.
● Opioids were involved in 42,249 deaths in 2016, and opioid overdose deaths were five times higher in 2016 than 1999.
● The highest overdose death rates in 2016 from prescription opioids were in West Virginia, Maryland, Maine, and Utah.
● In 2016, an estimated 2.1 million people aged 12 or older had an opioid use disorder, or 0.8 percent of people aged 12 or older.

Definitions

● Chronic pain – Pain that lasts 3 months or more and can be caused by a disease or condition, injury, medical treatment, inflammation, or even an unknown reason.
● Non-opioid therapy – Methods of managing chronic pain that does not involve opioids. These methods can include, but are not limited to, acetaminophen or ibuprofen, cognitive behavioral therapy, physical therapy and exercise, medications for depression or for seizures, or interventional therapies (injections).
● Opioid – Natural or synthetic chemicals that interact with opioid receptors on nerve cells in the body and brain and reduce the intensity of pain signals and feelings of pain. This class of drugs that include the illegal drug heroin, synthetic opioids such as fentanyl, and pain medications available legally by prescription, such as oxycodone, hydrocodone, codeine, morphine, and many others. Opioid pain medications are generally safe when taken for a short time and as prescribed by a doctor, but because they produce euphoria in addition to pain relief, they can be misused.
● Opioid use disorder – A problematic pattern of opioid use that causes significant impairment or distress. A diagnosis is based on specific criteria such as unsuccessful efforts to cut down or control use, or use resulting in social problems and a failure to fulfill obligations at work, school, or home, among other criteria. Opioid use disorder has also been referred to as “opioid abuse or dependence” or “opioid addiction.”

Links to Other Resources:

Yale Journal of Biology and Medicine:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4553643/

Annual Review of Clinical Psychology:
https://www.annualreviews.org/doi/pdf/10.1146/annurev.clinpsy.121208.131438

CDC Prescription Opioid Overdose Data:
https://www.cdc.gov/drugoverdose/data/overdose.html

CDC Understanding the Epidemic:
https://www.cdc.gov/drugoverdose/epidemic/index.html

CDC Opioid Overdose Commonly Used Terms:
https://www.cdc.gov/drugoverdose/opioids/terms.html

NIH Opioid Overdose Crisis:
https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis

Drug Free America Foundation – Position Statement:
https://dfaf.org/about-us/position-statements/

SAMHSA: 2016 National Survey on Drug Use and Health
https://www.samhsa.gov/data/report/key-substance-use-and-mental-health-indicators-united-states-results-2016-national-survey

Harm Reduction Coalition:
http://harmreduction.org/about-us/principles-of-harm-reduction/

CDC Syringe Service Programs:
https://www.cdc.gov/hiv/risk/ssps.html

SAMHSA Medication-Assisted Treatment:
https://www.samhsa.gov/medication-assisted-treatment/treatment#medications-used-in-mat

Pew Charitable Trusts:
http://www.pewtrusts.org/en/research-and-analysis/fact-sheets/2016/11/medication-assisted-treatment-improves-outcomes-for-patients-with-opioid-use-disorder#0-overview

SAMHSA Naloxone:
https://www.samhsa.gov/medication-assisted-treatment/treatment/naloxone

Harm Reduction Coalition – Naloxone Distribution:
http://harmreduction.org/miscellaneous/dramatic-expansion-of-naloxone-programs-amid-rising-drug-overdose-rates/

USA Today – Naloxone:
https://www.usatoday.com/story/news/nation-now/2018/04/06/opioid-antidote-no-prescription/492254002/

NCBI Economic Costs of Pain in the United States:
https://www.ncbi.nlm.nih.gov/books/NBK92521/

Business Insider:
http://www.businessinsider.com/pharmaceutical-companies-developing-non-opioid-pain-medications-2018-6?r=UK&IR=T

House Energy and Commerce:
https://energycommerce.house.gov/opioids-legislation/