1
|
Abstract
Harm reduction is an approach to reduce the risk of harms to an individual using substances without requiring abstinence. This review discusses substance-specific interventions for opioids, alcohol, and stimulants that can minimize harms for individuals who use these substances. Topics discussed include overdose prevention, infection prevention, and low-barrier substance use disorder treatment.
Collapse
Affiliation(s)
- Carolyn A Chan
- Program in Addiction Medicine, Section of General Internal Medicine, Department of Medicine, 367 Cedar Street, Harkness Hall A Suite - Suite 305, New Haven, CT 06510, USA
| | - Bethany Canver
- Section of General Internal Medicine, Department of Medicine, 367 Cedar Street, Harkness Hall A Suite - Suite 305, New Haven, CT 06510, USA
| | - Ryan McNeil
- Program in Addiction Medicine, Section of General Internal Medicine, Department of Medicine, 367 Cedar Street, Harkness Hall A, New Haven, CT 06510, USA
| | - Kimberly L Sue
- Program in Addiction Medicine, Section of General Internal Medicine, Department of Medicine, 367 Cedar Street, Harkness Hall A Suite - Suite 417A, New Haven, CT 06510, USA.
| |
Collapse
|
2
|
Thakarar K, Nenninger K, Agmas W. Harm Reduction Services to Prevent and Treat Infectious Diseases in People Who Use Drugs. Infect Dis Clin North Am 2021; 34:605-620. [PMID: 32782104 DOI: 10.1016/j.idc.2020.06.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
This article reviews the principles of harm reduction, evidence-based harm reduction strategies such as syringe service programs and supervised injection facilities, and provides approaches to integrating a harm reduction approach into clinical practice. As providers strive to increase capacity to treat underlying substance use disorder, we must also recognize that some people may continue to use drugs. In this setting, providers can still deliver nonjudgmental, individualized care, and advocate for the health and safety of people who inject drugs.
Collapse
Affiliation(s)
- Kinna Thakarar
- Infectious Disease and Addiction Medicine, Maine Medical Center/Tufts University School of Medicine, 50 Foden Road, South Portland, ME 04106, USA.
| | - Katherine Nenninger
- Preventive Medicine, Maine Medical Center/Tufts University School of Medicine, 22 Bramhall Street, Portland, ME 04102, USA
| | - Wollelaw Agmas
- Infectious Disease, Maine Medical Center/Tufts University School of Medicine, 22 Bramhall Street, Portland, ME 04102, USA
| |
Collapse
|
3
|
Jauffret-Roustide M, Chollet A, Santos A, Benoit T, Péchiné S, Duplessy C, Bara JL, Lévi Y, Karolak S, Néfau T. Theory versus practice, bacteriological efficiency versus personal habits: A bacteriological and user acceptability evaluation of filtering tools for people who inject drugs. Drug Alcohol Rev 2017; 37:106-115. [DOI: 10.1111/dar.12564] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 03/20/2017] [Accepted: 04/05/2017] [Indexed: 12/20/2022]
Affiliation(s)
- Marie Jauffret-Roustide
- Cermes 3 (Inserm U988, UMR CNRS 8211; Paris Descartes University; EHESS) Paris France
- French Public Health Agency; Paris France
| | - Aude Chollet
- Cermes 3 (Inserm U988, UMR CNRS 8211; Paris Descartes University; EHESS) Paris France
| | - Aurélie Santos
- Cermes 3 (Inserm U988, UMR CNRS 8211; Paris Descartes University; EHESS) Paris France
| | - Thérèse Benoit
- Cermes 3 (Inserm U988, UMR CNRS 8211; Paris Descartes University; EHESS) Paris France
| | | | | | | | | | | | - Thomas Néfau
- SAFE; Paris France
- OFDT-French Monitoring Centre for Drugs and Drug Addiction; Paris France
| |
Collapse
|
4
|
Roy É, Arruda N, Bertrand K, Dufour M, Laverdière É, Jutras-Aswad D, Perreault M, Berbiche D, Bruneau J. Prevalence and correlates of prescription opioid residue injection. Drug Alcohol Depend 2016; 166:69-74. [PMID: 27397582 DOI: 10.1016/j.drugalcdep.2016.06.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 06/17/2016] [Accepted: 06/23/2016] [Indexed: 01/04/2023]
Abstract
BACKGROUND There is growing evidence of intravenous administration of prescription opioids (POs) in several countries. Preparation of POs for injection may leave residues in containers and filters used by people who inject drugs and may lead to adverse health outcomes if they are injected. METHODS This exploratory study used cross-sectional data from the COSMO study, a prospective cohort of out-of-treatment cocaine users carried out in Montréal (Canada) between October 2010 and August 2015. For this analysis, only one visit per participant was selected, that is, the first time the participant reported PO injection during the study. The outcome of interest, "injection of PO residues", was defined as having injected PO residues from a filter and/or a container in the last month. Correlates of this outcome were identified using logistic regression analyses. RESULTS Of the 122 participants who reported PO injection during the study period, 41.8% had injected PO residues. Reporting an unstable source of income (AOR=4.26; 95% CI: 1.03-17.69), a recent overdose (AOR=5.45; 95% CI: 1.50-19.88) and a preponderant use of opiates (mostly opiate use versus other drugs excluding alcohol and cannabis) (AOR=2.46; 95% CI: 1.08-5.63) increased the risk of PO residue injection. The odds of reporting PO residue injection rose by 7% per unit increase in the score of psychological distress (AOR=1.07 per unit increase; 95% CI: 1.01-1.12). CONCLUSIONS The findings of this study suggest that PO residue injection is associated with markers of vulnerability. Further investigation is needed in order to better understand this understudied drug injection practice.
Collapse
Affiliation(s)
- Élise Roy
- Faculty of Medecine and Health Sciences, Université de Sherbrooke, Longueuil, Québec, Canada; Institut national de santé publique du Québec, Montréal, Québec, Canada.
| | - Nelson Arruda
- Faculty of Medecine and Health Sciences, Université de Sherbrooke, Longueuil, Québec, Canada
| | - Karine Bertrand
- Faculty of Medecine and Health Sciences, Université de Sherbrooke, Longueuil, Québec, Canada
| | - Magali Dufour
- Faculty of Medecine and Health Sciences, Université de Sherbrooke, Longueuil, Québec, Canada
| | - Émélie Laverdière
- Faculty of Medecine and Health Sciences, Université de Sherbrooke, Longueuil, Québec, Canada
| | - Didier Jutras-Aswad
- Research Centre, Centre Hospitalier de l'Université de Montréal (CRCHUM), Montréal, Québec, Canada; Department of Psychiatry, Université de Montréal, Montréal, Québec, Canada
| | - Michel Perreault
- Douglas Mental Health Institute, Montréal, Québec, Canada; Department of Psychiatry, McGill University, Montréal, Québec, Canada
| | - Djamal Berbiche
- Faculty of Medecine and Health Sciences, Charles-Le Moyne Hospital Research Centre, Longueuil, Québec, Canada
| | - Julie Bruneau
- Research Centre, Centre Hospitalier de l'Université de Montréal (CRCHUM), Montréal, Québec, Canada; Department of Family Medecine, Université de Montréal, Montréal, Québec, Canada
| |
Collapse
|
5
|
Thakarar K, Weinstein ZM, Walley AY. Optimising health and safety of people who inject drugs during transition from acute to outpatient care: narrative review with clinical checklist. Postgrad Med J 2016; 92:356-63. [PMID: 27004476 PMCID: PMC4967553 DOI: 10.1136/postgradmedj-2015-133720] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 02/29/2016] [Indexed: 12/20/2022]
Abstract
The opioid epidemic in the USA continues to worsen. Medical providers are faced with the challenge of addressing complications from opioid use disorders and associated injection drug use. Unsafe injection practices among people who inject drugs (PWID) can lead to several complications requiring acute care encounters in the emergency department and inpatient hospital. Our objective is to provide a narrative review to help medical providers recognise and address key health issues in PWID, who are being released from the emergency department and inpatient hospital. In the midst of rises in overdose deaths and infections such as hepatitis C, we highlight several health issues for PWID, including overdose and infection prevention. We provide a clinical checklist of actions to help guide providers in the care of these complex patients. The clinical checklist includes strategies also applicable to low-resource settings, which may lack addiction treatment options. Our review and clinical checklist highlight key aspects of optimising the health and safety of PWID.
Collapse
Affiliation(s)
- Kinna Thakarar
- Department of Medicine/Infectious Diseases, Maine Medical Center, Portland, Maine, USA
| | - Zoe M Weinstein
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine/Boston Medical Center, Boston, Massachusetts, USA
| | - Alexander Y Walley
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine/Boston Medical Center, Boston, Massachusetts, USA
| |
Collapse
|
6
|
Hepatitis C virus and HIV seroprevalences, sociodemographic characteristics, behaviors and access to syringes among drug users, a comparison of geographical areas in France, ANRS-Coquelicot 2011 survey. Rev Epidemiol Sante Publique 2016; 64:301-12. [PMID: 26904917 DOI: 10.1016/j.respe.2015.10.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Revised: 09/10/2015] [Accepted: 10/19/2015] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND People who use drugs (PWUDs) are at a high risk for hepatitis C virus (HCV) and human immunodeficiency virus (HIV), but they have different characteristics depending on the local context. In France, seroprevalence, sociodemographic, and behavior information have only been studied at a national level rather than at a local level. The aim of this study was to describe and examine profile and drug use practice differences in seven French cities and departments and to assess whether these differences can explain HCV and HIV seroprevalence variations between French geographical areas. METHODS Data were collected from the cross-sectional ANRS-Coquelicot survey conducted for the second time in 2011 among drug users having injected or snorted drugs at least once in their life. Professional interviewers administrated a face-to-face questionnaire in six different areas in France: Paris, Marseille, Bordeaux, Lille, Strasbourg and the Seine-Saint-Denis department (Paris suburbs). Participants were asked to self-collect a fingerpick blood sample in order to search for the presence of anti-HIV and anti-HCV antibodies and to estimate seroprevalence in PWUDs. RESULTS Overall, HCV and HIV seroprevalence was 44% [95% CI: 39.6-47.9] and 10% [95% CI: 7.5-12.6] respectively. The highest HCV seroprevalence was 56% in Marseille and the lowest was 24% in Bordeaux and for HIV the highest was 18% in Seine-Saint-Denis and the lowest was 0% in Lille. The population's age differed between areas and could mostly explain HCV seroprevalence variation but not exclusively. Profiles and practices, different in each area, can also explain this variation. In multivariate analysis, HCV seroprevalence was lower in Bordeaux (prevalence ratio [PR]=0.64), Strasbourg (PR=0.76), and Seine-Saint-Denis (PR=0.8) than in Paris. Nearly one-third of injectors declared having had difficulties to obtain syringes in the 6 previous months, but disparities existed between areas. CONCLUSION HCV risk exposure in PWUDs remains high in France and varies between different areas. Innovative harm reduction strategies including educative programs about safe injecting and supervised consumption rooms need to be developed.
Collapse
|
7
|
McLean S, Patel R, Bruno R. Injection of Pharmaceuticals Designed for Oral Use: Harms Experienced and Effective Harm Reduction Through Filtration. Curr Top Behav Neurosci 2016; 34:77-98. [PMID: 28401523 DOI: 10.1007/7854_2016_470] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Several pharmaceutical products are liable to 'abuse' or use outside their prescription, which frequently involves their injection. Examples are slow-release forms of morphine and oxycodone, and sublingual buprenorphine. During injection preparation, the drug is extracted into water, after crushing and heating the tablet if considered necessary. Since these products are designed for oral administration, they can contain excipients (ingredients other than the drug) which are poorly soluble, resulting in suspension of particles in the injection solution. Injected particles are able to produce medical complications such as the blockage of small blood vessels leading to ischaemia (inadequate blood flow) and tissue damage. Filtration can be used to remove particles from the suspension; including bacteria if the porosity is small enough (0.2 μm). However, filters are liable to blockage when overloaded, especially if the pore size is small. This problem can be minimised by using a larger pore size (e.g. 5-10 μm), but the resulting filtrate will contain many residual small particles. The use of two filters, coarse and fine, either sequentially or in a double membrane device, enables removal of the majority of particles as well as bacteria, although not quite meeting pharmaceutical standards for safe injection. Although not yet evaluated by a clinical trial, this highly effective filtration process would be expected to greatly reduce the risk of vascular and related complications, as well as non-viral infections. Careful technique ensures that drug is not lost by filtration, a priority for most drug consumers. Practical issues that affect acceptability of filtration by injecting drug users, including ease of use and cost, will need to be considered. However, given the laboratory evidence demonstrating the effectiveness of filters it is time to consider these tools as essential for safe injection as sterile needles/syringes for the world's approximately 16 million people who inject drugs.
Collapse
Affiliation(s)
- Stuart McLean
- School of Medicine, University of Tasmania, Hobart, Australia
| | - Rahul Patel
- School of Medicine, University of Tasmania, Hobart, Australia
| | - Raimondo Bruno
- School of Medicine, University of Tasmania, Hobart, Australia.
| |
Collapse
|