On May 20th, 2021, Yale’s Department of Internal Medicine and Program in Addiction Medicine hosted its first event on Clubhouse, a social networking app that allows members to gather in audio chat rooms and discuss issues in a live podcast style. The event focused on the drug overdose crisis in the United States and incorporation of harm reduction into U.S. health policy and practice.
David Fiellin, MD, Professor of Internal Medicine, Emergency Medicine, and Public Health, and Director of the Yale Program in Addiction Medicine, moderated the session. Dr. Fiellin was joined by several expert panelists:
- Gregg Gonsalves, PhD; Associate Professor of Epidemiology (Microbial Diseases), Associate (Adjunct) Professor of Law, Co-Director of the Global Health Justice Partnership, Co-Director of the Collaboration for Research Integrity and Transparency
- Kathryn Hawk, MD, MHS; Assistant Professor of Emergency Medicine and Epidemiology (Chronic Diseases)
- Robert Heimer, PhD; Professor of Epidemiology (Microbial Diseases) and Pharmacology
- Darvé Robinson, MD, MS; PGY3 Resident in the Yale Internal Medicine Primary Care Program
- Kimberly Sue, MD, PhD; Instructor in Internal Medicine, Medical Director, National Harm Reduction Coalition
Highlights from this event have been edited for clarity and brevity.
Q: What is Harm Reduction?
Kimberly Sue: Harm Reduction has both a micro and a macro definition. When we're talking about people who use drugs, we think specifically about practical strategies and ideas that we can utilize to reduce negative consequences from substance use. At the same time, [harm reduction] is part of a broader movement that is grounded in social justice, racial equity and human rights.
Gregg Gonsalves: It's really been a movement driven by people who use drugs themselves. And the term gets loosely thrown around in many different settings, but it's really about people taking care of themselves and people taking care of their communities and taking care of their friends and family and the people they love.
Robert Heimer: [Harm reduction] really is, in many ways, considering the War on Drugs, one of the most important civil rights struggles in our country right now.
Kimberly Sue: So the things that you can offer people [include] sterile syringes, supplies, and prescriptions [i.e. medications for addiction treatment, naloxone]. I think through not only opioids, but safer stimulant use, how people are using cocaine or methamphetamines, making sure that people have their own supplies and that they are not sharing, thinking about ways [people are using], the context in which they're using, and how to make those interactions safer. We are [also] talking about safe supply, and that's a really important conversation that we need to have in the setting of so many deaths from people using opioids that they find on the street or even pressed pills. I've been seeing a lot of people in Connecticut, and we know this is going on around the country, who think they're taking oxycodone but they're actually taking fentanyl. We have really forced people to play Russian roulette with what is available on the street. Until we can talk about ways that we can pilot [safe supply] and scale that up here in the US, we’ll see more and more fentanyl-related deaths.
Q: Can we talk a little bit about this idea of overdose prevention sites or supervised injection facilities? What do we know about those?
Robert Heimer: Like in many other areas, the United States lags behind the civilized world in implementation of such things. We've begun to see some evidence from underground sites in the US that they have the same kind of effectiveness as the ones that operate legally above ground [in other countries]. But we're not going to see them expand in the US until there's a group of people who are willing to take the risk of prosecution the same way people were 30 years ago as illegal needle exchange programs sprang up.
Kimberly Sue: There's over one hundred sites that operate around the world in a variety of different models. They can either be [run by] healthcare staff, like nurses, or by peers, and both have been shown to be effective models. People use drugs that have been pre-obtained outside the facility, and they use them in these sites. There's places for them to hang out after they've used and they can be monitored for safety in case they need oxygen or an opioid overdose response. People can get naloxone and sterile supplies. Wouldn’t you rather someone that you love be in a place where they can get necessary medical attention and care, a place that's clean, that's well lit, that's dry, that, if they can't find a vein, they don't have to rush? Substance use is going on whether you think it is or not, and it can go on in a sterile, supervised and compassionate manner to help treat people who use drugs with dignity and respect, or it can happen in a Starbucks or Dunkin bathroom.
Robert Heimer: In so many places where it might be possible to [implement these interventions] drug users themselves have been disenfranchised. They can't vote because they've been convicted of felonies This makes it much easier for them to be ignored or pushed into the corner. One of the things we need to do is […] make greater efforts to restore the voting and political rights of people who have been convicted on a whole range of drug-related problems associated with the failed War on Drugs.
Q: Over the years, what has the receptivity been to harm reduction by presidential administrations and federal administrations?
Robert Heimer: In our earliest applications to get the study of the New Haven Syringe Exchange Program funded, we didn't even call it needle exchange. We had to remove that term. It was too provocative in the early 1990s because it was illegal under federal guidelines, because in 1986, even before there was a single legal program in the United States, a Senator, Jesse Helms, from North Carolina had inserted language into the Health and Human Services Appropriations Bill, banning all funds for it. So it's been an uphill battle.
Gregg Gonsalves: What we're facing right now in West Virginia where the State Legislature put into place laws that will shut down all the needle exchanges in the state in the midst of an opioid and HIV crisis […] shows you how far we still have to go. It's unbelievable to me that with the rise in overdoses over the past year, in places in which HIV and HCV are pretty rife, politicians are still playing politics with people's lives.
David Fiellin: It seems like there's, perhaps, limitation on what even federal policy can do given that we have states' rights and federalist societies, so despite federal changes, there may need to be local changes as well.
Robert Heimer: And there need to be other methods other than the programmatic approaches we've taken so far to get people the things they need, whether it's arranging for secondary exchange by the drug users themselves, mailing packages of needles and syringes to the lock zone to people, or setting up community drives to do this. It will require what it took in the very beginning – very creative work by people who are committed to the work.
Kimberly Sue: So many activists who've been working in this field for a long time have been advocating for dedicated funds. Thirty million has been set aside [for harm reduction], and it does look like that that money will be able to be utilized for sterile syringes, which is pretty important. So many syringe service programs are scrappy. There's one or two people in the Northern California Desert, serving indigenous populations. There are people that are homeless, people that are doing sex work. They're often doing syringe service out of their car unpaid because they've been touched by overdose or their family or their communities have been. The work is very difficult and sometimes very traumatizing, so really, dedicated funds to pay for their efforts is a pretty big deal. The COVID pandemic has made everything worse. We've lost a lot of ground. Substance use and overdose deaths are up across the board in so many regions, so it's just been really wonderful to be able to be a part of conversations [at the federal level] to get people money, supplies, infrastructure, and support.
Q: Dr. Hawk, what reflections do you have on harm reduction from the emergency medicine side?
Kathryn Hawk: Harm reduction is about patient autonomy and individual autonomy. [There is a] shift from Medicine being a physician-centric interaction to being more really about how to identify the unmet needs of the patient in front of you when you're in a clinical setting. When I think about what that looks like in the Emergency Department, it's certainly different than in other clinical interactions. People wind up in the Emergency Department for a variety of issues, sometimes substance-related, sometimes not. In general, most people did not intend to be there that day. One of the things that's most important is to identify what an individual's priorities are and how you can help, realistically, get them where they need to be. Sometimes that is offering treatment or initiating treatment. Sometimes it's just establishing that this is a safe place to come when and if you are ready for treatment or you have any other medical need. When you talk to individuals, there is no shortage of traumatic experiences that people can recount where they felt highly stigmatized or they felt like it wasn't a safe place for them to discuss their drug use or whatever it may be. I find that if we acknowledge that when we see patients, it goes a long way to trying to help establish that this is a safe place to seek care.
Q: How widely implemented are harm reduction practices in the emergency departments around the US? Which practices are being used and which practices are we still ramping up?
Kathryn Hawk: A really exciting thing to see over the past three to five years has been a huge increase in the willingness and ability of emergency clinicians to prescribe and distribute naloxone. When I first started looking into this probably five or six years ago, it was something that was very rarely done in most EDs around the country, and there are unfortunately lots of regulations around distributing naloxone, around where you get it from, who provides it, who pays for it and how you bill for it. And so there's been all burdens on the ability to set up a program to put naloxone into people's hands when they're in the ED. We've been able to distribute naloxone [in Yale EDs] since 2016. As far as other harm reduction things, it's a big tap. Part of it is providing a safe space for people, being willing to talk to people about drug use and treating people's withdrawal. Like anything else in this space, there is still much, much, work to do, but I think that there has been a lot of progress.
Q: Dr. Robinson, can you share what you are learned, if anything, about harm reduction in medical school or are learning currently during your primary care residency?
Darvé Robinson: To be honest, in general house staff are unfamiliar with starting or managing medications for substance use disorder and the whole topic of harm reduction is kind of a nebulous place for most house staff. I've been pretty fortunate because through the CHAMP Program, which allows us to get addiction experiences in our primary care treatment, and actually through the REACH Program, I have gotten increased exposure to patients with severe substance use disorders. I have had the pleasure of working with Dr. Sue for two weeks on our inpatient addiction consult service, where we really think very granularly and very critically about ways to keep our patients safe as they continue to contemplate engagement in care. I would say that it's a very unique experience that I've been very thankful for and I hope that future general practitioners will become more and more familiar with this topic.