Editor’s Note: This is the fifth part of an ongoing series on what emergency physicians can do to combat the opioid epidemic.

Ideally, every patient would want to stop using drugs. Of course, if it were that easy, we wouldn’t be in the mess we are in now. Opioid addiction is much more complicated than that; changes in the frontal cortex and the hour-to-hour search for more dopamine to just feel normal lead to poor decisions and continued use.

So what do you do if your patient isn’t ready to go to treatment?

Harm Reduction

Opioid overdose treatment falls under the approach of harm reduction, or the idea that we should try our best to keep this population safe until they are ready to accept help. Put simply, they can’t get help if they are dead.

Critics will argue these practices just enable addicts, but the experts dispute that line of thinking. People with substance-use disorders will use drugs whether you do things to make it safer for them or not. Safety is not something that factors into their decision tree prior to using drugs. In fact, not only do harm-reduction strategies save lives, decrease HIV and hepatitis transmission, and reduce needle sticks to first responders, they do not appear to increase drug use.^1–4

Over the past few years, increased naloxone distribution has gained the most attention as a form of harm reduction. Community distribution of naloxone appears to be successful.⁵ It’s been demonstrated that first responders and lay providers can learn to recognize the signs of an opioid overdose and safely administer naloxone. The data demonstrate a significant number of individuals surviving who otherwise might have died.⁶

Additionally, emergency departments are dispensing more and more naloxone. In some places, state grants have helped purchase the medication because it is unfortunately ridiculously expensive (which is a completely different conversation). In many places, Medicaid and private insurance will pay for it. Some states even allow over-the-counter access. The website PrescribeToPrevent.org is a great source to see if there are laws in your state allowing for increased naloxone distribution and Good Samaritan protection for prescribers and laypersons who may administer the drug.

Needle exchanges have been around since the late 1980s and early 1990s and have also decreased infectious disease transmission without increasing drug use. A report funded by the National Institute on Drug Abuse demonstrated a 70 percent decrease in new HIV cases due to injection drug use in Washington, D.C.² A review of programs in both North America and Europe demonstrated a 56 percent reduction in hepatitis C and a 74 percent reduction in transmission when combined with medication-assisted therapy.⁷

The Substance Abuse and Mental Health Services Administration (SAMHSA) also supports these programs; not only does it give out needles, it also encourages patients to seek treatment. Programs have been successfully started in many states, including West Virginia, Kentucky, and North Carolina.⁸

Although not everyone is ready to accept these concepts, many are starting to open their eyes to their value. After what can only be described as a devastating rise in newly diagnosed cases of HIV in Indiana due to oxymorphone and heroin, clean needle exchanges were introduced in 2015, which helped reduce new hepatitis C cases in one county by 50 percent.⁹ However, even with that impact, county officials did not vote to reapprove the program this year. In Missouri, needle exchange legislation passed the state’s House of Representatives this year, and we hope it will pass the Senate next year.

Safe Injection

But what else can you do in the emergency department for patients who aren’t ready to quit? Well, you can start by having a short discussion about drug use and safe injection practices. You can discuss how to properly clean the skin with alcohol swabs and use clean water. Drug users will commonly use a filter such as cotton, but it may be dirty or have blood products on it, which can lead to infectious complications. The benefit, in addition to decreased transmission of hepatitis C and HIV, should include fewer admissions for soft tissue infections and endocarditis.
If it is possible and doesn’t place someone else at risk, patients shouldn’t use alone. If they overdose, no one will be available to administer naloxone or call 911. You can frame this discussion along the lines of, “We want you to quit and hope you do, but we understand you might use again.”

Once again, you are not expected to condone drug use, but judgment may stand in the way of public health and individual patient safety. It’s somewhat analogous to what you might tell patients with diabetes or hypertension who need to lose weight but aren’t ready to change their diet.

Finally, consider safe injection facilities. US Surgeon General Jerome Adams, MD, MPH, recently spoke to emergency physicians at ACEP’s Leadership & Advocacy Conference in May. Among the topics of conversation were addiction and the opioid epidemic. He discussed harm-reduction strategies, including safe injection facilities.¹⁰ At these facilities, injection drug users can bring their own heroin, get clean needles and alcohol swabs, and safely inject. Facility providers can dispense naloxone should an overdose occur. They can also try to intervene and discuss referral to treatment with those interested.

Such facilities are operating in Europe and Canada, with data demonstrating decreases in mortality, infectious disease, and possibly crime.^11–13 Although there is rumor of an underground facility in California and discussion in states including Washington, Pennsylvania, and New York, safe injection facilities remain illegal in the United States, and of course, they remain controversial. Critics worry they condone drug use and that you never know what people are actually injecting. Keep in mind people will inject that same substance by themselves at home or elsewhere in a much less safe environment.

Health care organizations are now beginning to discuss their role in harm-reduction strategies. The American Medical Association (AMA) voted to “support the development of private facilities where people who use intravenous drugs can inject self-provided drugs under medical supervision.” At the ACEP Council meeting last year, Resolution 31 was adopted: Development and Study of Supervised Injection Facilities. The resolution joins the AMA in supporting the development and study of pilot facilities in the United States.

If any of these facilities ever go operational in the United States, we’ll have to see if the results are similar to those in other countries.

References

1. Syringe services programs. CDC website. Available at: www.cdc.gov/hiv/risk/ssps.html. Accessed Aug. 20, 2018.
2. Access to clean syringes. CDC website. Available at: www.cdc.gov/policy/hst/hi5/cleansyringes/index.html. Accessed Aug. 20, 2018.
3. Reducing harms from injection drug use & opioid use disorder with syringe services programs. CDC website. Available at: www.cdc.gov/hiv/pdf/risk/cdchiv-fs-syringe-services.pdf. Accessed Aug. 20, 2018.
4. Syringe exchange programs: research shows they do not increase crime rates. Harm Reduction Coalition website. Available at: http://harmreduction.org/wp-content/uploads/2012/01/SEPandCrimeFactSheet2006.pdf. Accessed Aug. 20, 2018.
5. Walley AY, Xuan Z, Hackman HH, et al. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis. BMJ. 2013;346:f174.
6. Wheeler E, Jones TS, Gilbert MK, et al. Opioid overdose prevention programs providing naloxone to laypersons–United States, 2014. MMWR Morb Mortal Wkly Rep. 2015;64(23);631-635.
7. Platt L, Minozzi S, Reed J, et al. Needle syringe programmes and opioid substitution therapy for preventing hepatitis C transmission in people who inject drugs. Cochrane Database Syst Rev. 2017;9:CD012021.
8. Bixler D, Corby-Lee G, Proescholdbell S, et al. Access to syringe services programs – Kentucky, North Carolina, and West Virginia, 2013–2017. MMWR Morb Mortal Wkly Rep. 2018;67(18):529-532.
9. Lopez, G. An Indiana county just halted a lifesaving needle exchange program, citing the Bible. Vox website. Available at: www.vox.com/policy-and-politics/2017/10/20/16507902. Accessed Aug. 20, 2018.
10. Johnson SR. Surgeon general urges ER docs to advocate for evidence-based opioid treatment. Modern Healthcare website. Available at: www.modernhealthcare.com/article/20180523/NEWS/180529976. Accessed Aug. 16, 2018.
11. Marshall BD, Milloy MJ, Wood E, et al. Reduction in overdose mortality after the opening of North America’s first medically supervised safer injecting facility: a retrospective population-based study. Lancet. 2011;377(9775):1429-1437.
12. Dolan JK, Kimber J, Fry C, et al. Drug consumption facilities in Europe and the establishment of supervised injecting centres in Australia. Drug Alcohol Rev. 2000;19(3):337-346.
13. Wood E, Tyndall MW, Lai C, et al. Impact of a medically supervised safer injecting facility on drug dealing and other drug-related crime. Subst Abuse Treat Prev Policy. 2006;1:13.

Dr. Schwarz is associate professor of emergency medicine and medical toxicology section chief at Washington University School of Medicine in St. Louis.

Dr. Waller is a fellow at the National Center for Complex Health and Social Needs and managing partner at Complex Care Consulting LLC.