Harm Reduction

Harm Reduction enables choices, possibilities, and opportunities without imposing change. 

Harm reduction is a set of practical public health strategies that reduce negative consequences of drug use and promote healthy individuals and communities by incorporating a spectrum of practices from safer use, to managed use, through abstinence. Harm reduction strategies meet drug users where they are, addressing conditions of use along with the use itself.

We consider the following principles central to harm reduction practice:

  • Accept, for better and for worse, that licit and illicit drug use is part of our world and choose to work to minimize its harmful effects rather than simply ignore or condemn them.

  • Understand drug use as a complex, multi-faceted phenomenon that encompasses a continuum of behaviors from severe abuse to total abstinence, and acknowledge that some ways of using drugs are clearly safer than others.

  • Establish quality of individual and community life and well-being–not necessarily cessation of all drug use–as the criteria for successful interventions and policies.

  • Call for the non-judgmental, non-coercive provision of services and resources to people who use drugs and the communities in which they live in order to assist them in reducing attendant harm.

  • Ensure that drug users and those with a history of drug use routinely have a real voice in the creation of programs and policies designed to serve them.

  • Affirm drugs users themselves as the primary agents of reducing the harms of their drug use, and seek to empower users to share information and support each other in strategies, which meet their actual conditions of use.

  • Recognize that the realities of poverty, class, racism, social isolation, past trauma, sex-based discrimination and other social inequalities affect both people’s vulnerability to and capacity for effectively dealing with drug-related harm.

  • Do not attempt to minimize or ignore the real and tragic harm and danger associated with licit and illicit drug use.

Harm Reduction is supporting any positive change.

Good public health policy reflects many things that are the core principles of harm reduction. Healthcare systems strive to meet people where they are, in hopes of bringing them to a healthier place. Doctors will often work with their patients’ substance use in incremental steps, realizing that drastic lifestyle change usually fails. Public health policy has begun to embrace holistic, person-centered care, which harm reduction has been practicing for years. Evidence-based practices are demanded of healthcare professionals. Public health reform and harm reduction use much of the same language and principles.  Harm reduction strategies are evidence-based, and most effective when adopted as a community-wide approach.

 Harm reduction gives basic human rights to the drug user, in a world where those are often denied. Harm reduction maximizes intervention options, recognizing that people benefit from a variety of approaches. No one method of treatment works for everyone, and harm reduction brings all the options to each participant’s table, so that they may be able to make a choice that is best suited for them. This philosophy reverberates throughout public health.

 The active participation of people who use drugs is at the heart of harm reduction.  People who use drugs are seen as the best source of information about their own drug use and are empowered to join with service providers to determine the best interventions to bring about change. Participating in one’s own treatment decisions, or volunteering in harm reduction helping others empowers drug users and motivates them to make positive change. Many healthcare providers take a similar approach with their patient’s health issues because no one is better equipped to find the best solution for one’s healthcare than the patient himself.

Overdose Prevention

Every day, 42 Americans die from an opioid overdose. That is 2 an hour and 17,000 a year. 

In the last 15 years, heroin use has dramatically increased. But, that is only part of the story. 

Prescription opioids are at the heart of the problem. First, they fueled the opioid dependency.  When the government began to crack down on the vast over-prescribing of these medications, it did not stop the epidemic, but merely caused people to turn to heroin, as a cheaper and more available alternative. More Americans overdose on prescription opioids than on heroin, and overdose is the leading cause of accidental death in the country.

What exactly is an opioid overdose?

An overdose happens when a toxic amount of a drug, or combination of drugs, overwhelms the body. An opioid overdose happens when there are too many opioids or the combination of opioids and other drugs. The body becomes unresponsive and because the opioids also bind the receptors that control breathing, breathing is suppressed. Lack of oxygen can quickly cause brain damage and death, so it is important to administer rescue breaths in an overdose situation. Naloxone is an opiate antidote/antagonist with a very high affinity for the opioid receptor so it goes in and kicks off the opiates, and because it antagonizes (blocks) the receptor, rather than agonizing (activating) it, the overdose is reversed. 

Tips for Preventing Overdose

The best way to not overdose is not to use drugs, but if you do, please follow the below recommendations.

Know what you are taking, if you don’t call Poison Control at 1-800-222-1222 or look it up on the net here:  http://www.drugs.com/pill_identification.html

  • Know the strength of the drug you are taking (Is it 2mg vs. 80mg).
  • Know how long the drug will affect you (Is it short acting, long acting or extended release?).
  • Don’t mix your drugs (this includes alcohol, benzos, antidepressants, cocaine).
  • If you don’t use for a while (couple days, weeks, months) start with a low dose.  When you don’t use for a little while your tolerance goes down.
  • Use with other people: If something goes wrong they can have your back.  Don’t use alone!
  • Find out where you can get Naloxone.

Source: North Carolina Harm Reduction Coalition

Risk factors for opioid overdose

People dependent on opioids are the group most likely to suffer an overdose. The incidence of fatal opioid overdose among opioid-dependent individuals is estimated at 0.65% per year. Non-fatal overdoses are several times more common than fatal opioid overdoses.

People at higher risk of opioid overdose

  • people with opioid dependence, in particular following reduced tolerance (following detoxification, release from incarceration, cessation of treatment);

  • people who inject opioids;

  • people who use prescription opioids, in particular, those taking higher doses;

  • people who use opioids in combination with other sedating substances;

  • people who use opioids and have medical conditions such as HIV, liver or lung disease or suffer from depression;

  • household members of people in possession of opioids (including prescription opioids).

People likely to witness an opioid overdose

  • people at risk of an opioid overdose, their friends, and families;

  • people whose work brings them into contact with people who overdose (health-care workers, police, emergency service workers, people providing accommodation to people who use drugs, peer education and outreach workers).

Risk factors for overdoses with prescribed opioids include a history of substance use disorders, high prescribed dosage (over 100mg of morphine or equivalent daily), male gender, older age, multiple prescriptions including benzodiazepines, mental health conditions, and lower socioeconomic status.

Source: World Health Organization

Recognizing Opioid Overdose

Sometimes it can be difficult to tell if a person is just very high or experiencing an overdose. The following will present some information on how to tell the difference. If you’re having a hard time telling the difference, it is best to treat the situation like an overdose – it could save someone’s life.

If someone is really high and using downers like heroin, or pills:

  • Pupils will contract and appear small

  • Muscles are slack and droopy

  • They might “nod out”

  • Scratch a lot due to itchy skin

  • Speech may be slurred

  • They might be out of it, but they will respond to outside stimuli like loud noise or a light shake from a concerned friend.

If you are worried that someone is getting too high, it is important that you don’t leave them alone. If the person is still conscious, walk them around, keep them awake, and monitor their breathing.

The following are symptoms of an overdose:

  • Awake, but unable to talk

  • Body is very limp

  • Face is very pale or clammy

  • Fingernails and lips turn blue or purplish black

  • For lighter skinned people, the skin tone turns bluish purple, for darker skinned people, it turns grayish or ashen.

  • Breathing is very slow and shallow, erratic, or has stopped

  • Pulse (heartbeat) is slow, erratic, or not there at all

  • Choking sounds, or a snore-like gurgling noise (sometimes called the “death rattle”)

  • Vomiting

  • Loss of consciousness

  • Unresponsive to outside stimulus

If someone is making unfamiliar sounds while “sleeping” it is worth trying to wake him or her up. Many loved ones of users think a person was snoring when in fact the person had overdosed. These situations are a missed opportunity to intervene and save a life.

It is rare for someone to die immediately from an overdose.  When people survive, it’s because someone was there to respond. The most important thing is to act right away!

Source: National Harm Reduction Coalition

Step by Step Instructions to Reverse an Overdose with Naloxone

  1. Make sure the person is not responsive by stimulating their chest or upper lip with a sternum rub. To do a sternum rub, make a fist with your hand and use your knuckles to rub hard on the overdosed person’s chest or upper lip. If no response, it is time to administer Naloxone. If they are responsive, you could try and stimulate them. If there is any question, give them Naloxone. It cannot hurt someone, but it will put them into precipitated withdrawal, and they will feel very sick and could be very angry or frustrated. Assure them Naloxone only lasts about 30 minutes and they won’t feel bad for long.

  2. Put the person flat on their back, with the head tilted back slightly to open up the airway.

  3. Rescue breathe for the overdose victim. Breathe 5 times, if possible. Watch for the chest to rise when you breathe.

  4. Get Naloxone ready to administer. With a 10-dose vial, you will pull the solution up to the 1mL line on the IM syringe. If you have a small, single dose vial, use all the solution.

  5. Inject the overdosed person intramuscularly. The thigh is a really good place to use if the person is on their back for rescue breathing. The IM syringes we use are large enough to go through blue jeans. The bicep is another good spot for an IM injection. If you do not have an IM syringe, you can use an insulin syringe, but you must inject the Naloxone under the tongue. (the tongue is a muscle too)

  6. You need to wait 3-5 minutes before administering the second dose. Even three minutes seems like an eternity when someone is not breathing, so look at your phone as soon as you administer the Naloxone, and track the time, if possible.

  7. Rescue breathe while waiting for the medication to take effect.

  8. Repeat until emergency services arrive, or the overdose is reversed.

Ideally, calling 911 should be the first step in the process. We strongly advise that everyone calls 911. Some people prefer to clean up all the drugs and paraphernalia before calling so they may avoid any trouble. With the right instruction on calling 911, the process almost always goes very smooth here in Austin, TX. If you choose not to call 911, please remember that Naloxone only lasts about 30 minutes, so the person could possibly overdose again, especially if they have done a lot of opiates, or they have done a long-acting opiate. Do not leave that person for at least an hour, if possible.

Tips for Calling 911

Never say “someone has overdosed,” instead simply say “someone is not breathing.” Here in Austin, TX, the first response will automatically dispatch police. The second response will not. When the EMT’s arrive, be nice, polite, and calm. They generally will not call the police unless they feel threatened. Be completely honest with them about everything that is going on. Let them know all of the drugs the overdosed person consumed and that you used Naloxone. Tell them how many doses you gave the person.

If you do not have Naloxone, and absolutely cannot stay when 911 is called, leave them in the recovery position (on their side) after calling 911. Make absolutely sure you are incredibly clear and precise when describing the person’s location!

Another good thing to do is put an overdose plan in place with the people you generally use with. Talk about what each person may feel more comfortable doing, that way everyone has an idea of what needs to happen and who may be better to perform each step. This can really cut down on the chaos of an overdose situation. Also, discuss if anyone has any warrants or absolutely would not want 911 called if they overdose and if that person with warrants plans to leave the scene when 911 is called. It is always good to discuss it all before it happens!

Source: North Carolina Harm Reduction Coalition

Medical Services

PWID often have very limited access to medical services, but they are at-risk for a variety of diseases and conditions. Many times an injection drug user faces stigma in the healthcare industry, which keeps them from navigating the maze of services available in our community. Austin Harm Reduction Coalition is breaking down the barriers and increasing the access to healthcare services for PWID.  By providing wound care on a daily basis, many of our participants are not forced to go to the hospital for minor abscesses. Additionally, our nurse has a vast repertoire of referral providers, to assist with medical care, substance abuse treatment, mental health services, housing services, and food access programs. By providing HIV and HCV testing, we are increasing access to these tests, as well as increasing the number of at-risk people who are testing on a regular basis.

The real gem of our program is our HCV patient navigation component. With recent advancements in drug treatments for HCV, the medical community has begun to call HCV a curable disease. Previously, treatment was not very effective, combined harsh regimens of interferon and ribavirin and often people were only treated when their liver had serious damage. With these new medications, everyone is encouraged to try and treat the disease if they can. PWID are an exception to this rule, as they are often denied treatment because of the unproven fear that they will simply re-infect. Many times when PWID test positive for HCV, they are brushed aside because of their active drug use and are rarely referred to follow-up blood work, fibroscans, liver specialists, or even primary care. This is not good enough for us! When our participants test positive for HCV, they are given the opportunity to work with an outreach patient navigator to get all the follow-up blood work and liver imaging. This will empower them with education about liver disease and HCV, as well as give them more information about the state of their liver and the progression of their disease. Armed with this information, the participant can better weigh their options for care. We strive to get as many people treated as possible with increasing access to primary care and liver care. Everyone deserves to be treated for his or her illness, regardless of lifestyle choices. Studies show that PWID are just as compliant with treatment as some other groups, and many who have been treated for HCV are far more cautious to not re-infect. By providing harm reduction supplies to people who have been treated for HCV, we are not only decreasing their chances of re-infection but also empowering them with knowledge and options.

Changing the way the world views a drug user will break the stigma and increase access to treatment and healthcare.