Since the start of the COVID-19 pandemic over a year ago, alcohol and substance use has surged in the United States, along with overdoses from opioids. To save lives, using practical strategies to reduce the negative effects of substance use, or harm reduction strategies should become federal health policy now, urges experts Kimberly Sue, MD, PhD, and David Fiellin, MD, from the Yale Program in Addiction Medicine.
In a new commentary, “Bringing Harm Reduction into Health Policy — Combating the Overdose Crisis,” published in The New England Journal of Medicine, they urge the Biden administration to name, embrace, and implement harm reduction programs to save American lives. In addition to expanding treatment, they argue, there is a need for additional measures to abate the tidal wave of death from overdoses. Additionally, they say funds should be allocated to combat the health inequities and racial injustice for Black Americans who are suffering from a disproportionate rise in deaths from substance use disorders, along with COVID-19.
Sue is an instructor (general medicine) at Yale and medical director of the National Harm Reduction Coalition. Fiellin is a professor of medicine (general medicine), emergency medicine, and public health at Yale, and director of the Yale Program in Addiction Medicine.
In a conversation they discuss how COVID-19 has worsened what was already a dire national crisis, strategies that help reduce harm in vulnerable populations, and how federal policies can reduce overdose deaths. The below conversation was condensed and edited.
Q: How has COVID-19 affected people with alcohol or substance use disorders?
David Fiellin: Substance use disorders and the overdose crisis were the country’s “pre-existing condition” coming into the COVID-19 pandemic. The COVID-19 pandemic has essentially collided with the opioid epidemic. We know that during the pandemic, there's been increased use of substances, and increased isolation due to physical and social distancing. Unfortunately, there have been restrictions on access to treatment and the entire treatment paradigm has changed to a more virtual approach from a direct in-person approach. As well, we've seen a rise in fentanyl and deadly fentanyl analogs and rapid changes in drug supplies. These are all on top of the increased economic and family stressors that all individuals are experiencing during this time. So the collision of these two epidemics has been a real challenge for individuals who use substances.
Q: What are harm reduction strategies and how might they help this population?
Kimberly Sue: Harm reduction strategies are simply a variety of tips and techniques that we can use where we don't ask that people have or require abstinence, but really rather that people can use more safely and avoid harmful outcomes. Harm reduction strategies range from a variety of programs, including syringe service programs where people can exchange used syringes for sterile syringes. We have overdose education and naloxone distribution (OEND), which are community-based programs that distribute naloxone, a medication used to reverse opioid overdose, as well as trains people who use drugs and their family and friends to recognize opioid overdoses and use the medication. Drug-checking, which is a strategy that people use around the world, examining substances for purity and for the presence of contaminants or impure aspects of the supply, like fentanyl, as David mentioned. And overdose prevention sites or centers, safer consumption spaces, which are places where people can use substances and trained people will respond and take care of them in case they overdose or have another untoward outcome.
Q: You both recently co-authored a commentary in New England Journal of Medicine, where you talk about harm reduction strategies or policies in the United States. So can you explain the history or lack thereof of harm reduction strategies or policies in the U.S.?
Fiellin: The United States has had a fluctuating history of recognizing and endorsing harm reduction strategies, especially as they relate to people who use substances and have substance use disorders. We use harm reduction strategies all the time in other parts of medicine and public health. Unfortunately, we tend to think of substance use disorders in non-medical terms. As a primary care physician and somebody who treats patients who have depression, schizophrenia, diabetes, asthma, I recognize that in addition to providing treatment, I also provide what could be considered harm reduction strategies, often in the way of education, diet, exercise, and other things that people can do to reduce the harm of their primary condition, and their medical outcomes. I do this assuming that they may not meet our target goals for their treatment. I also don’t withdraw or prevent them from receiving these services if they don't achieve that target goal. I think most of the world assumes in substance use disorders that the only appropriate outcome is abstinence, for everybody. from the beginning of treatment. We know from most of medicine that complete control of a condition from day one is unrealistic and so, a lot of what we do, quite frankly, is harm reduction through behavioral and educational, and sometimes medication-based interventions.
What we've seen in the U.S. is that policies and attitudes around harm reduction for substance use have evolved. We now see widespread endorsement for services such as syringe service programs and naloxone education and distribution. That endorsement really reflects the science that demonstrates the effectiveness of these strategies. What we need from a federal level is to have a more uniform acceptance and endorsement of evidence-based practices that are harm reduction-focused. We also need more science. This means we have to remove barriers from conducting the science and allow for adequate evaluation of new harm reduction strategies that are used in other countries.
Q: What medications can be used to reduce the use of illegal substances and improve the health of those people with use disorders?
Sue: There are so many important and life-saving medications that we have access to, and part of the work that we do here at Yale, and that I do at the APT Foundation, doing primary care for patients on methadone, and also at the Yale Addiction Medicine Consult Service at Yale New Haven Hospital, is to start these medications that we use for very specific use disorders. Methadone and buprenorphine are two examples of life-saving medications. They decrease overdose mortality by 50%, but only 25% of people are able to access them. And many places that are residential programs for people with opioid use disorder do not offer them or permit people to take them. With alcohol and tobacco, we have FDA-approved medications. With stimulants, we have emerging research, including a recent trial in the New England Journal of Medicine that showed promise of combining two FDA-approved medications. So we really have a lot to offer, and we want people to know that there is hope and that people get better, and treatment works.
Q: How can clinicians assist their patients who may have a substance use disorder?
Sue: Clinicians can assist their patients who may have a substance use disorder in many ways. The first is just being compassionate and non-judgmental, really meeting people where they're at, being consistently there and taking into consideration the neurobiology of addiction and treating people with evidence-based medications, like I mentioned previously. The Yale Program in Addiction Medicine has over 30 years of showing that treatment can be initiated in a variety of settings, like primary care, emergency rooms, hospitals, and OBGYN clinics. Really what we can do is educate others in starting these medications, letting them know that you can start them immediately, and even getting out of the clinic and providing them in novel spaces like syringe service programs.
Part of what I do in New York City and have done is provide buprenorphine for patients in the syringe service programs and meeting people literally where they're at. They are still using and desperate to seek treatment but can't figure out how to access it. So really we should, also on top of that, provide people with what they can do to use more safely. So for example, today I saw a patient coming in to start methadone treatment, and this person is still using cocaine, and I was able to get him a safer crack pipe. Really this is what he needed to use more safely and to protect himself against infectious diseases and other harmful outcomes.
Q: Kimberly, you had mentioned that you provided a crack pipe to a patient who was using cocaine. And you mentioned that that was less harmful. Can you explain how that would be less harmful for the patient?
Sue: Most people who use drugs in this country are using many substances at once. And poly-substance use is the norm in this country, not the exception. We have a rise in stimulant-related deaths, including cocaine and methamphetamine in this country, according to the Centers for Disease Control. So while this patient is initiating and starting treatment for his opioid use disorder with methadone, which is a life-saving medication for patients with opioid use disorder, he has been continuing to use substances on top of that, including stimulants. He tells me that he is still smoking crack, and he is trying to cut down, but he does have a crack pipe that is torn, that it is ripped, it is really decayed, and that can cause a lot of complications, including risk for infectious disease transmission. We worry about transmission of Hepatitis C and HIV. And so I was able to provide him with sterile equipment, so that we can prevent the harms of ongoing cocaine use while I treat his opioid use disorder and work with him to address his cocaine use.
Q: Can you provide examples of communities or other countries that have implemented harm reduction strategies and the outcomes of such programs?
Sue: There are many ways in which we are thinking about and taking the lead from people who have done this before, and cities and countries that have provided us the evidence. We also know that there are overdose prevention centers and sites. There are over a hundred of them operating around the world, and there have been zero overdose deaths in these facilities. That is really effective. In this country, we have 80,000 overdose deaths a year, and we really have not yet implemented all the strategies that are life-saving. We're hoping that our piece in the New England Journal of Medicine can encourage people to fund the research for and implement these programs.
Q: Why should the Biden administration consider implementing harm reduction programs as federal health policy?
Fiellin: It is important for the Biden administration to consider implementing harm reduction programs, because year after year, even before the COVID epidemic, we've been seeing an increase in the overdose deaths related to drugs. And now it's both opioids and stimulants. The tragic deaths are just the tip of the iceberg. For every overdose death there are hundreds of individuals and families that are being impacted. There are specific things that the Biden administration can do through its Office of National Drug Control Policy, and through other federal agencies, including Health and Human Services, the Substance Abuse Mental Health Service Administration, the CDC, and the NIH. For example, they could remove bans for the use of federal funds to purchase sterile needles, or syringes for the injection drugs. There are also opportunities through the Department of Justice that would allow for the overdose prevention sites and allow for research to take place to determine the impact of those on the overdose epidemic. There are very specific barriers that could be removed by the Biden administration. Now is the time to do that because it's clear that despite our efforts to make more treatment available, we're seeing an increase in overdose deaths, and we need to bring additional support and strategies to help save lives.
The Yale Program in Addiction Medicine seeks to expand access to and improve the effectiveness of prevention and treatment services for substance use. For more on their work, visit Yale Program in Addiction Medicine.