Harm Reduction and Prevention

What is Harm Reduction?

Harm Reduction describes a positive approach to reduce the harm that may come from substance use and high-risk sexual behaviors. It includes individual and community-based safety practices aimed to improve overall health and wellness. This is driven by the promotion of acceptance instead of abstinence. Basic principles include:

• The acceptance of substance use in communities around us, in addition to the delivery of non-judgmental care. This values all people and their journey, and minimizes harm through education without fear of shame.
• The belief that people using substances should be empowered to seek and receive quality healthcare, regardless of their use status
• Recognition of social differences that impact people’s ability to change behaviors to reduce the risk of harm

How can it be incorporated into primary care?

Use of Non-Stigmatizing Language

The words we choose matter, and often carry power in surprising ways. Quality harm reduction strategies include the use of universal, non-judgmental language throughout healthcare systems. Words are delivered in thoughtful, deliberate ways to empower others to share their needs without fear or shame. Both parties genuinely listen to one another in an effort to better connect. This builds better relationships, encourages honest discussion, and assists healthcare professionals with risk assessment and care coordination.

Priority Screenings for Persons Who Use Drugs Illicitly

American Indian/Alaska Native (AI/AN) people in the U.S. who use drugs experience a health disparity in elevated rates of blood-borne viruses (BBV), such as Hepatitis C Virus (HCV) and Human Immunodeficiency Virus (HIV) compared to the drug using population overall. Injection drug use (IDU) is a major risk factor for HIV and HCV exposure in AI/AN populations. Recent national reports indicate a strong connection among opioid abuse, IDU, and BBV.

People who inject drugs (PWID) are at risk for HCV and HIV infection through sharing needles and drug-preparation equipment. Rates of HIV infection, viral hepatitis, Sexually Transmitted Diseases (STDs), and Tuberculosis (TB) are much higher among people who use drugs illicitly compared to those who do not. Additionally, Hepatitis A infection outbreaks have been reported among PWIDs, and are thought to occur through both skin exposure and oral routes. Screenings for these diagnoses can be completed or discussed by a wide variety of healthcare professionals, and are considered best practice for patients with known high-risk behaviors.

Risk Assessment for Illicit Use of Drugs

Due to the high rate of HIV infection, viral hepatitis, STDs, and TB among people who use drugs illicitly, prevention and care providers should complete risk assessments for illicit use of drugs for everyone seeking services for these diseases. Many people use multiple drugs, as well as alcohol or tobacco. Information on use of these substances can assist with prevention and treatment services. Since patients might not be forthcoming about illicit use of drugs for many reasons (including confidentiality concerns and fear of legal action), they need to feel comfortable about their data and privacy in order to share behaviors with providers.

Risk assessment and reduction interventions are vital for the adoption of safer behaviors. They also direct the referral of clients to relevant prevention and treatment programs. The Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) can be used as a screening instrument for drug use.

IHS, the US Preventive Services Task Force, Centers for Disease Control and Prevention (CDC's) STD treatment guidelines and the American Medical Association (AMA) guidelines for adolescents, all recommend that health care providers screen adolescents for substance abuse during preventive visits and medical care for infectious diseases.

Risk Assessment for Infectious Diseases

People who use drugs illicitly should receive appropriate screening for other infectious disease risk factors (e.g., risky sexual behaviors or being a known contact of a person with active TB). They should also receive relevant preventive services and risk-reduction counseling. The CDC's 2010 STD treatment guidelines support this approach by recommending that STD health care service providers routinely obtain sexual histories from their patients. Health care providers can perform infectious disease risk assessments at venues serving people who use drugs illicitly.

Screening, Diagnosis, and Counseling for Infectious Diseases

Infectious disease screening services are critical to any comprehensive strategy to reduce and eliminate infections among people who use drugs illicitly. These services identify those who are unaware of their infections, provide them with counseling and education, and refer and link them to treatment. Knowing one's infection status can help uninfected people who use drugs illicitly make behavioral changes to reduce infection risk and can help those who are infected reduce the likelihood of transmission of infection to others. During infectious disease screening, screening for illicit use of drugs (including offering brief interventions and providing referrals) and misuse of prescription drugs, can be useful. Screening and counseling recommendations for preventing HIV infection, viral hepatitis, STDs, and TB infection in those who use drugs illicitly are summarized below.

Medication Disposal

Medication disposal programs provide a safe, reliable mechanism to remove unused or expired medications from the home. This reduces the risk of medication misuse or abuse, and therefore decreases the risk of unintentional injury. Read our disposal page to learn more learn more about these programs.

How can it be incorporated into acute care?

Provision of Post-Overdose Care Coordination

While community resources and available treatment options vary across the country, all persons experiencing an overdose should be met with kindness and concern. Acute care providers, nurses, and other healthcare professionals can express this concern and create conversation to reduce harm through Screening, Brief Intervention, and Referral to Treatment (SBIRT). The use of this evidence-based practice often helps patients better understand their motivation for substance use and desire for change. It is also a billable service in many states.

Initiation of Buprenorphine

Additional consideration should be given to buprenorphine initiation in emergency departments and outpatient settings. Providers in both locations frequently see patients in critical times of need, with a short window of opportunity to act on their desire for change. The prompt initiation of buprenorphine for opioid withdrawal management can lead to a dramatic increase in positive outcomes, especially when provided in coordination with mental health support. Providers can access training resources at a variety of sites, including those provided by IHS and the National Institute on Drug Abuse, Exit Disclaimer: You Are Leaving www.ihs.gov  for more information to get started.

Naloxone Provision

Naloxone should be offered to anyone at risk for or whom has recently experienced an opioid overdose. This can be done for all patients regardless of their readiness for change, with education provided in acute or chronic care settings. Healthcare professionals of all backgrounds can help to save lives through consistent messaging regarding the benefits of naloxone, in addition to proactive prescribing and dispensing efforts.

Fentanyl Test Strip Education and Provision

Illegally made fentanyl is a potent opioid that greatly increases the risk of overdose and unintended death. It can be added to other substances without users knowing it, making an expected "safe" amount extremely dangerous. DEA reveals criminal drug networks are flooding the U.S. with deadly fentanyl by mass-producing counterfeit pills and falsely marketing them as legitimate prescription pills. DEA lab testing discovers that 4 out of every 10 pills with fentanyl contain a potentially lethal dose. Learn more about counterfeit pills from the DEA Fact Sheet [PDF - 5.3 MB] Exit Disclaimer: You Are Leaving www.ihs.gov  and their One Pill Can Kill website.Exit Disclaimer: You Are Leaving www.ihs.gov 

Fortunately, users can take additional steps to protect themselves by testing their supply with Fentanyl Test Strips (FTS). These strips are easy to use and interpret, telling users if fentanyl is present in their supply before using a dose. They can be distributed in a variety of settings, and should be considered as a valuable harm reduction tool when offering coordinated care services. To learn more, please see the sample education document below. For questions regarding purchasing and procurement of FTS, see the funding document below for guidance.

Resources

CDC Syringe Service Program Fact Sheet Exit Disclaimer: You Are Leaving www.ihs.gov 

Harm Reduction Coalition Exit Disclaimer: You Are Leaving www.ihs.gov  is an extensive and diverse network of allies who advocate for policy and public health reform on behalf of people who use drugs.

Infectious Diseases and Opioid Use Disorder (OUD) Policy Issues and Recommendations Approved: March 2018 Exit Disclaimer: You Are Leaving www.ihs.gov  [PDF - 566 KB] - from Infectious Diseases Society of America (IDSA), the HIV Medicine Association (HIVMA), and the Pediatric Infectious Diseases Society

Infectious Diseases and Opioid Use Disorder (OUD) Exit Disclaimer: You Are Leaving www.ihs.gov  [PDF - 157 KB]

Fentanyl Test Strip Funding [PDF 1.2 MB]

Fentanyl Test Strip Education [PDF 1.5 MB]

Harm Reduction Education [PDF 1.4 MB]