A man walks into your office, and over the course of an office visit convinces you to prescribe for him a potent narcotic. He tells you that he has been using heroin steadily for the last two years but has been trying to quit. “It all started Doc, when I hurt my back 3 years ago, and I’ve tried to quit but can’t. I’ve applied for a methadone program but there’s a waiting list so can you just prescribe me something until I can get on methadone? I don’t want to have to commit any more crimes.” The two of you decide on MS Contin pills — the 100 mg. size– and before you know it you are prescribing 3 a day for him on a weekly basis, with each week’s excuse as to why he isn’t yet on methadone containing just enough truth to keep you engaged, though reluctantly. “Well, it’s harm reduction,” you say to yourself, starting to echo the thoughts of your new and very loyal patient. “At least he isn’t out on the streets and using needles.”What you don’t know is that your new patient has been selling most of the pills that you have been providing him with, and injecting the rest. On the streets the grey “peelers” go for $40 each, (aptly nicknamed because the outer colored coating easily peels off to make them ready for dissolving and injecting.) He’s been using the $120 a day to finance his cocaine addiction, and now he is suddenly able to afford a 2- gram-12 -fixes-a-day habit. Harm reduction? Actually the opposite– this patient was using much less before he started seeing his well intentioned doctor; he didn’t have the money, and was staying away from crime because he was on parole. This type of physician-patient interaction occurs far too frequently, especially when one substitutes Valium or Tylenol 3’s into this scenario. (Financing an alcohol dependence with Valium prescriptions for example)
So what is Harm Reduction and how might it be applied in a medical practice?
Simply put harm reduction attempts to focus on reducing the harm of using drugs rather than on reducing drug use itself. Examples of harm reduction interventions might include needle exchange, drug substitution, safe fixing sites, outreach counseling, However, as we have seen in the above example, it’s not always that simple. There is a fine line between “enabling”, or facilitating a continued addiction and “harm reduction,” and it can be difficult to determine when one has crossed that line, especially for those who do not have experience with addiction treatment. Such confusion is also evident on a macro, or policy scale, as any recent news article on harm reduction will illustrate. Compounding the confusion is a lack of a consistent definition and a measurable outcome for harm reduction.
Harm reduction implemented poorly is not harm reduction. It is now clear that harm reduction needs to take place in a treatment context in order for it to be effective. Perhaps the most obvious example of this is the Swiss experience of the late 80’s, early 90’s. It was the Swiss idea at the time to set aside an area which became “Platzspitz” or Needle Park, where addicts were allowed to buy and use drugs freely. This experiment in harm reduction included free needle exchange, condoms, medical care, and food distribution. By the time this well intentioned idea was deemed a failure and the park was closed, the numbers of addicts in the park had swelled from a few hundred in 1987 to 20,000 in 1992. Drug related violence and crime rose rapidly in the area. Doctors were resuscitating an average of 12 overdoses a day, and up to 40 on some days. In 1992 the Swiss responded with a period of increased enforcement coupled with a dramatic rise in proven addiction treatments, especially methadone treatment. By the time they were ready to embark on more controversial harm reduction trials the Swiss had a solid foundation of addiction treatment with over 15,000 patients in methadone treatment.
The parallels between the “open drug scene” of Zurich in the early 90’s and the current chaos of the “open drug scene” of downtown Vancouver in the late 90’s are striking. Unfortunately for BC, it would appear that public policy regarding drug addiction is still being guided by vocal “service provider” agencies rather than by “treatment providers.” But there is some cause for optimism as “the pendulum has swung back and a reappraisal of the adequacy of harm reduction is occurring…The limitations of a harm reduction framework implemented in isolation from other models has become increasingly evident.” “While promoting tolerance is admirable, the harm reductionists take it too far: if you should not stigmatize addicts, neither should you condone addiction. And with its learn-to-live-with-drugs approach, harm reduction offers no guidance on how to bring down the appallingly high levels of drug addiction in this country.” The challenge now facing those in the field of addiction medicine is how to integrate the strengths of the harm-reduction perspective with the strengths of the conventional use-reduction perspective in a unifying model.To bring it back to the micro level let me offer some suggestions for integrating a harm reduction perspective into your own practice: Expect something in return.
If you find yourself in a situation where you are prescribing abusable drugs with weak medical indications, start by expecting something in return. Consider treatment contracts. Link your prescriptions to measurable outcomes.
Case example: Mr. y has been seeing you for the last two years. He is HIV positive but hasn’t really been taking care of himself. He can’t make it to the lab to get his blood drawn so you have no idea what his T cell count or viral load is. Your relationship has degenerated to the point where you are engaged in intermittent crisis care, except of course for his regular visits to obtain prescriptions for Tylenol 3’s, which you reluctantly provide. “Doc, you can’t cut me off my T3’s, I ‘ve been on them for years, its the only thing that works…it keeps me off heroin….I haven’t used since I started seeing you.”
Sound familiar? (consider adding stats on BC’s Tylenol 3 consumption) In the back of you mind you remember that it is against College regulations to treat heroin dependence with anything other than methadone, but you note that you’re treating low back pain anyway, or headaches. And besides, isn’t it Harm Reduction to keep the patient engaged with you until the time he is ready to get better? Well, you don’t need to wait for this patient’s spontaneous epiphany. I have seen too many die, or become HIV positive, or lose a limb, while waiting for their epiphany. There are things you can do to help move your patient further along towards health. What you can do is tell the patient that you want to reevaluate your doctor-patient relationship, that you’re not feeling like the relationship is really benefiting him. Ask him what he wants to do, what are his goals? What would he like to get out of the relationship? Quite likely he will be able to offer some suggestions — things like “I’d like to take better care of my HIV, maybe start taking medications.” or “Stop using drugs.” The two of you could negotiate a treatment plan/contract that might contain some of the necessary steps. 1) Get bloodwork drawn. 2) Hook up with PWA 3) Start seeing a counselor etc. Down the line you might find yourself saying, ”Well I’ve given you that blood requisition 3 times now and you haven’t been able to get it done– I’m going to expect that before your next prescription is due you’ll have it done.” The goals can continue to develop as the therapeutic relationship develops.
If your treatment contract doesn’t work out, remember that sometimes terminating a relationship can be the best medicine.
Case example: Ms.L. had been seeing me for methadone treatment for 4 months. At treatment intake she told me that she was using heroin and cocaine, although her intake of cocaine was low enough that she would be able to stop it altogether, which we included in our contract agreement. By 4 months it was clear that all of our attempts to eradicate the cocaine from her urine samples had proved futile. Every urine came back positive, and her arms continued to show heavy track marks. The only intervention she hadn’t tried was a recovery house which would take patients on methadone, however Ms. L. refused to entertain that possibility. Since Ms. L. was also HIV positive (although she wasn’t interested in any HIV care), I was faced with a dilemma. Was I actually reducing harm with my relationship with her or was I simply facilitating a continuing and destructive addiction? I opted to discontinue the relationship, pointing out to her that the intent of the methadone treatment was to help her to get off the street, to stop using needles and illicit drugs, and to eliminate the need for engaging in crime. (Issues covered in our pretreatment explicit contract.)
Her next prescription began a weaning process of 1 mg. per day. After 5 days she came into the office announcing that she was ready to try a recovery house where she could stay on methadone. She was admitted that same day to Renaissance House where she stayed for the next 30 days, stabilizing on her usual dose of methadone. I debriefed her on her return from recovery, when she told me that she prior to Renaissance House she had been using 2-300 dollars of cocaine per day, not the once or twice a week she had previously been trying to convince me of. She was also grateful for having been “pushed” into treatment. “I don’t think I would have gone otherwise– I would still have been messed up, I really needed that time away from coke to clear my brain.”
This case also illustrates that the helping person’s role is not limited to continuing to supply drugs until someone “hits bottom;” or waiting for someone to “want to change,” or spontaneously recover from his/her addiction, as many of those advocating a harm reduction perspective would suggest. In this case I “raised bottom” by increasing the costs of continuing her cocaine use – she was free to continue using the cocaine, but at the cost of our relationship and methadone treatment. She chose instead to stop the cocaine.
Harm Reduction has brought the welcome concept of “meeting and accepting people where they are at” to the fore, supplanting the rigid dogma and ideology of the past “abstinence-only” perspective. However, that does not mean being relegated to a watching-and-waiting role. Even in those patients I see that “don’t want to quit,” one usually finds a split, with part of them wanting to quit while another part tries to stay addicted. I tell my patients that I want to align myself with that part of them that is trying to get better.
There are many tools in the field of addiction medicine that can make the job of treating addiction easier- learning to do a proper assessment, treatment plan, or when to refer, as well as specific tools such as Miller’s adaptation of Prochaska’s and Diclemente’s “Stages of Change.” This is a very useful framework for assessing readiness to change and how to motivate people for change. Miller offers stage specific interventions and techniques which the helping professional can use to move his patient along, one stage at a time. For instance someone who is still actively using might be in the pre-contemplative stage. Miller suggests the therapist’s role is to offer sound feedback and information in a non-judgmental fashion, and to stay away from suggesting concrete action directives which would be countertherapeutic at this person’s stage. An added strength of this framework is the conceptualization of the stages of change as a circle, or a wheel which one may have to travel around a number of times before establishing permanent behaviour change. (An average of 4.5 times for smokers, for example) This means that relapse is viewed simply as one of the stages which leads on to the next stage, and offers both the patient and therapist a productive focus. Note that this framework dovetails quite neatly with a harm reduction perspective.
Michael Massing, in a recent essay in New York Times Magazine also believes that harm reduction requires a treatment context, and carefully details the considerable potential benefits of diverting money away from enforcement and interdiction, to treatment: ”The best way to get drugs off the streets is also the cheapest: comprehensive treatment.”