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An Open Letter in Support of Harm Reduction

By Luke Nealley

Photo by Andrea Piacquadio on Pexels.com

Author’s Note: This essay, written as an open letter to Pennsylvania’s Governor Tom Wolf, serves as boilerplate so that other like-minded citizens might easily express their concerns. The letter is intended to be sent to local, state, and federal politicians to help drive the acceptance of harm reduction legislation.

Dear Governor Wolf,

The opioid epidemic is an epidemic of our own making. We allowed pharmaceutical companies to misrepresent the addictive quality of new opioids, inappropriately minimizing potential risks of prescription opioid use.1 We allowed for the relatively unchecked, aggressive promotion and marketing of dangerous controlled substances, which influenced the prescription practices of physicians nationwide. 2 We allowed the pharmaceutical industry to influence medical education, redefining pain and pain management practices for a generation of doctors. 3 We enabled the unrestricted rise of the opioid epidemic in the United States. As a result, approximately 1 million people have died due to drug overdoses since 1999. 4 More importantly, the number of annual overdose deaths is continuing to rise. Since 1999, drug overdose deaths have risen from less than 20,000 to over 90,000 cases annually. 5 With the vast majority of overdose deaths being due to opioids, it is clear that we do not have control over the opioid epidemic. 6 Harm reduction programs provide the evidence-based opportunities needed to combat the opioid epidemic. However, current legislation often limits, or even inhibits, the positive effects that harm reduction programs can provide. We are responsible for allowing the opioid epidemic to take root in our country. Therefore, we must be held responsible for taking the actions necessary to control the epidemic. We need to implement legislation supporting harm reduction practices.

Harm reduction is a term used to describe any number of programs aimed at minimizing the dangerous side effects of risky behavior. 7 In terms of opioid use, harm reduction programs primarily aim to minimize the risks of disease transmission and death due to opioid use. Three different programs are commonly employed to minimize the risks associated with opioid use: opioid substitution programs, syringe service programs, and safe injection sites. Each of these unique programs has been shown in clinical settings to reduce illegal opioid use, disease spread, and death due to opioid overdose. 8 As such, all of these programs are deserving of our full support.

Opioid substitution programs aim to provide users with less harmful opioids under careful medical supervision. Methadone, one common substitute opioid, is a long-acting opioid receptor agonist with an average duration of action of 24-36 hours. 9 In other words, methadone activates the same biological pathways as recreational opioids. While this may initially seem counterproductive, careful dosing practices can eliminate the euphoric and sedative effects associated with opioid use. 10 Moreover, through the controlled activation of opioid receptor pathways, methadone treatment helps to relieve many of the cravings and symptoms (muscle aches, fever, nausea, etc.) of opioid withdrawal. 11 Finally, methadone blocks the narcotic effects of heroin by preferential interaction with the opioid receptor, thereby discouraging further illegal opioid misuse. 12 In all, methadone treatment simultaneously reduces both the negative effects of opioid withdrawal and the perceived benefits of opioid misuse. To that end, methadone treatment programs have consistently been shown in clinical studies to encourage treatment retention and abstinence from illicit opioid use. 13 In addition to encouraging abstinence from illicit opioid use, methadone treatment programs have been associated with community-wide benefits as well. For example, communities with access to a methadone treatment facility have demonstrated marked reductions in drug-related disease transmission and criminal activity. 14 Beyond methadone, other opioid substitutes have shown similarly promising results. 15 In particular, suboxone is a combined formulation of buprenorphine and naloxone. 16 Buprenorphine, a partial opioid receptor agonist, acts similarly to methadone to manage opioid withdrawal. 17 Naloxone, on the other hand, acts as an opioid receptor antagonist, shutting down the opioid pathway if suboxone is taken inappropriately, thereby minimizing the potential for suboxone abuse. 18 Opioid substitution programs have been clearly and consistently shown to be effective options in the treatment of addiction and the opioid epidemic. As such, the establishment of opioid substitution programs needs to be encouraged and supported. 

Unlike opioid substitution programs, syringe service programs do not aim to directly reduce the use of illicit drugs. Instead, they aim to reduce the spread of blood-borne diseases among injection drug users by providing users with sterile syringes and a safe syringe disposal site. 19 As such, they aim to improve the overall quality of life among those who suffer from opioid addiction. To that end, studies have shown syringe service programs have been associated with reductions in the transmission of HIV as well as hepatitis B and C. 20 Moreover, areas with access to syringe service programs have shown decreases in needle sharing as well as syringe reuse. 21 Finally, because syringe service programs act as safe syringe disposal sites, areas with access to syringe programs commonly show decreases in needles improperly discarded on the streets, rather than increases as some would expect. 22 Syringe service programs have shown no evidence indicating the potential to cause societal harm. 23 Syringe service programs primarily aim to reduce the risk of harm due to illegal drug use. Beyond providing access to clean needles, syringe service programs provide drug treatment referrals, access to educational materials, and other critical healthcare needs. To that end, syringe service programs meet addicts where they’re at. They help guide addicts to recovery at their own pace. Studies have shown significant portions of addicts have entered into detoxification and recovery programs after interacting with a syringe service program. 24 As such, syringe service programs serve as a critical bridge, linking addicts with the treatment options they’ll need when they are ready. 

Finally, safer injection sites take the mission of syringe service programs one step further. They aim to minimize the risks associated with injection drug use by providing a location for addicts to use injection drugs under close medical supervision. 25 In doing so, safer injection sites ensure the use of sterile needles, reducing the spread of blood-borne pathogens.  More importantly, they provide immediate access to medical care, thereby reducing the likelihood of death due to accidental overdose. One study monitoring a safer injection site in Vancouver recorded 0 deaths across 336 accidental overdoses in 18 months. 26 Several other studies have shown similar reductions in overdose mortality, as well as reductions in the length of hospital stays, among users with easy access to safer injection sites compared to users without access. 27 Moreover, safer injection sites have been shown to reduce rates of blood-borne pathogen transmission as well as the rate of injection-related infections. 28 Safer injection sites have shown clear evidence of reducing the harm associated with illicit opioid use. Despite the evidence indicating the benefit, safer injection sites have remained the subject of significant controversy. Safer injection sites allow addicts to use illicit drugs without the fear of legal repercussions. As such, they have garnered unwarranted criticism for encouraging illegal drug use. In reality, however, safer injection sites provide access to counseling, detoxification and recovery programs, and addiction education materials, giving addicts control over their own recovery. 29 As a result, safer injection sites have been consistently associated with increased rates of detoxification service use as well as long-term recovery program initiation. 30 Despite the stigma, safer injection sites have been proven to be effective in the reduction of harm associated with opioid use as well as the promotion of addiction recovery options. Therefore, safer injection site programs deserve our support in an effort to end the opioid epidemic in our country. 

Over and over again, harm reduction programs have demonstrated reductions in disease transmission and overdose death. Over and over again, harm reduction programs have been associated with increased rates of detoxification and long-term recovery. Over and over again, harm reduction programs have shown reduced community harm in the form of reduced crime rates and drug-related litter. Despite the clear benefit, the social and political controversy surrounding harm reduction programs remains. Local, state, and federal laws all limit, even inhibit, the efficacy and implementation of harm reduction programs. Of the harm reduction programs presented, opioid substitution programs may be the most widely accepted and supported. With that said, they face significant hurdles. The ability of physicians to prescribe methadone is strictly regulated and controlled, and the ability of patients to receive access to buprenorphine is limited by access to insurance. 31 As a result, very few drug treatment facilities in the US have the ability to offer opioid substitution therapy. 32 To that end, less than 10% of individuals suffering from opioid dependence receive access to a methadone treatment option. 33 In contrast, syringe service programs and safer injection sites remain significantly more controversial. 34 Where opioid substitution programs are currently facing an uphill legal battle, syringe service programs and safer injection sites have run into a political and legal brick wall. Several states currently have legislation banning the operation of syringe service programs. 35 Many more states, including Pennsylvania, only allow syringe services by local legislation, not statewide. 36 Only 3% of the estimated need for syringe service programs is currently being met in the United States, resulting in unnecessary deaths due to the transmission of blood-borne diseases. 37 Most controversial of the three programs, safer injection sites are currently illegal under federal legislation. 38 Moreover, very few state governments have introduced legislation legalizing the operation of safer injection sites. 39 To date, only one program is in operation in the country. 40 Evidence and scientific study have continuously shown harm reduction programs to be effective in reducing the risks associated with opioid use, and ultimately encourage addicts to seek out recovery options. However, current legislation significantly limits our ability to provide these life-saving services to those that need them most. 

The opioid epidemic is running rampant in our country. Nearly every year since 1999, we have seen a record number of deaths due to drug overdose. 41 Over the past year alone, over 100,000 people, 100,000 citizens of this country died from drug overdose. 42 Our current measures are not working to stop or even slow the opioid epidemic. Harm reduction programs, such as opioid substitution programs, syringe service programs, and safer injection sites, may represent the change we need to turn the opioid epidemic around. Strong evidence has tied harm reduction programs to reductions in overdose death, blood-borne disease transmission, and crime rates. Moreover, they have been shown to increase enrollment in detoxification and long-term recovery programs. However, despite the strong evidence in favor of harm reduction programs, current legislation limits their efficacy. How can we hope to reverse the impact of the opioid epidemic if our hands are legally tied? We need a change. Support harm reduction legislation.

Sincerely,

A Concerned Citizen

Endnotes

  1. Van Zee, Art. “The Promotion and Marketing of Oxycontin: Commercial Triumph, Public Health Tragedy.” American Journal of Public Health, vol. 99, no. 2, 2009, pp. 221–227., https://doi.org/10.2105/ajph.2007.131714.
  2. Van Zee, “The Promotion and Marketing of Oxycontin”, 221-227
  3. Van Zee, “The Promotion and Marketing of Oxycontin”, 221-227
  4. “Drug Overdose Death Statistics [2022]: Opioids, Fentanyl & More.” NCDAS, 6 Apr. 2022, https://drugabusestatistics.org/drug-overdose-deaths/.
  5. “Overdose Death Rates.” National Institutes of Health, U.S. Department of Health and Human Services, 1 Feb. 2022, https://nida.nih.gov/drug-topics/trends-statistics/overdose-death-rates.
  6. “Overdose Death Rates”
  7. Logan, Diane E., and G. Alan Marlatt. “Harm Reduction Therapy: A Practice-Friendly Review of Research.” Journal of Clinical Psychology, 2010, p. 201-214. https://doi.org/10.1002/jclp.20669.
  8. Logan and Marlatt, “Harm Reduction therapy”, 201-214
  9. Krantz, Mori J., and Philip S. Mehler. “Treating Opioid Dependence: Growing Implications for Primary Care.” Archives of Internal Medicine, vol. 164, no. 3, 2004, p. 277-288., https://doi.org/10.1001/archinte.164.3.277.
  10. Krantz and Mehler, “Treating Opioid Dependence”, 277-288
  11. Krantz and Mehler, “Treating Opioid Dependence”, 277-288

Shah M, Huecker MR. Opioid Withdrawal. [Updated 2021 Oct 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK526012/

  1. Krantz and Mehler, “Treating Opioid Dependence”, 277-288
  2. Sees, Karen L., et al. “Methadone Maintenance vs 180-Day Psychosocially Enriched Detoxification for Treatment of Opioid Dependence.” JAMA, vol. 283, no. 10, 2000, p. 1303., https://doi.org/10.1001/jama.283.10.1303.

Goldstein, Avram. “Heroin Addiction: Neurobiology, Pharmacology, and Policy.” Journal of Psychoactive Drugs, vol. 23, no. 2, 1991, pp. 123–133., https://doi.org/10.1080/02791072.1991.10472231.

  1. Connock, M, et al. “Methadone and Buprenorphine for the Management of Opioid Dependence: A Systematic Review and Economic Evaluation.” Health Technology Assessment, vol. 11, no. 9, 2007, https://doi.org/10.3310/hta11090.
  2. Logan and Marlatt, “Harm Reduction therapy”, 201-214
  3. Welsh, Christopher, and Adela Valadez-Meltzer. “Buprenorphine: a (relatively) new treatment for opioid dependence.” Psychiatry (Edgmont (Pa. : Township)) vol. 2,12 (2005): 29-39.
  4. Welsh and Valadez-Melter, “Buprenorphine”, 29-39
  5. Welsh and Valadez-Melter, “Buprenorphine”, 29-39
  6. Logan and Marlatt, “Harm Reduction therapy”, 201-214
  7. ​​Strathdee SA, Vlahov D. “The effectiveness of needle exchange programs: A review of the science and policy”. AIDScience. 2001;1:1–13.
  8. Strathdee and Vlahoc, “The effectiveness of needle exchange programs” 1-13
  9. Strathdee and Vlahoc, “The effectiveness of needle exchange programs” 1-13
  10. Strathdee and Vlahoc, “The effectiveness of needle exchange programs” 1-13
  11. Strathdee, Steffanie A., et al. “Needle-Exchange Attendance and Health Care Utilization Promote Entry into Detoxification.” Journal of Urban Health, vol. 76, no. 4, 1999, pp. 448–460., https://doi.org/10.1007/bf02351502.
  12. Logan and Marlatt, “Harm Reduction therapy”, 201-214
  13. Kerr, Thomas, et al. “Drug-Related Overdoses within a Medically Supervised Safer Injection Facility.” International Journal of Drug Policy, vol. 17, no. 5, 2006, pp. 436–441., https://doi.org/10.1016/j.drugpo.2006.05.008.
  14. Ng, Jennifer et al. “Does evidence support supervised injection sites?.” Canadian family physician Medecin de famille canadien vol. 63,11 (2017): 866.
  15. Ng et al., “Does evidence support supervised injection sites?”, 866
  16. Ng et al., “Does evidence support supervised injection sites?”, 866
  17. Ng et al., “Does evidence support supervised injection sites?”, 866
  18. Nadelmann, Ethan, and Lindsay LaSalle. “Two Steps Forward, One Step Back: Current Harm Reduction Policy and Politics in the United States.” Harm Reduction Journal, vol. 14, no. 1, 2017, https://doi.org/10.1186/s12954-017-0157-y.
  19. Nadelmann and LaSalle, “Two Steps Forward, One Step Back”
  20. Nadelmann and LaSalle, “Two Steps Forward, One Step Back”
  21. Logan and Marlatt, “Harm Reduction therapy”, 201-214
  22. Logan and Marlatt, “Harm Reduction therapy”, 201-214

Nadelmann and LaSalle, “Two Steps Forward, One Step Back”

  1. Nadelmann and LaSalle, “Two Steps Forward, One Step Back”

Innamorato, Rep. Sara. “Innamorato, Struzzi Introduce Legislation to Establish Syringe Service Programs in Pa..” Pennsylvania House Democratic Caucus, 27 Jan. 2022, https://www.pahouse.com/InTheNews/NewsRelease/?id=122508.

  1. Nadelmann and LaSalle, “Two Steps Forward, One Step Back”
  2. Nadelmann and LaSalle, “Two Steps Forward, One Step Back”
  3. Nadelmann and LaSalle, “Two Steps Forward, One Step Back”
  4. Mann, Brian, and Caroline Lewis. “New York City Allows the Nation’s 1st Supervised Consumption Sites for Illegal Drugs.” NPR, NPR, 30 Nov. 2021, https://www.npr.org/2021/11/30/1054921116/illegal-drug-injection-sites-nyc.
  5. “Overdose Death Rates”
  6. “Drug Overdose Deaths in the U.S. Top 100,000 Annually.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 17 Nov. 2021, https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2021/20211117.htm.

Bibliography

Connock, M, et al. “Methadone and Buprenorphine for the Management of Opioid Dependence: A Systematic Review and Economic Evaluation.” Health Technology Assessment, vol. 11, no. 9, 2007, https://doi.org/10.3310/hta11090.

“Drug Overdose Death Statistics [2022]: Opioids, Fentanyl & More.” NCDAS, 6 Apr. 2022, https://drugabusestatistics.org/drug-overdose-deaths/.

“Drug Overdose Deaths in the U.S. Top 100,000 Annually.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 17 Nov. 2021, https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2021/20211117.htm.

Goldstein, Avram. “Heroin Addiction: Neurobiology, Pharmacology, and Policy.” Journal of Psychoactive Drugs, vol. 23, no. 2, 1991, pp. 123–133., https://doi.org/10.1080/02791072.1991.10472231.

Hubbard, Robert L., et al. “Overview of 5-Year Followup Outcomes in the Drug Abuse Treatment Outcome Studies (Datos).” Journal of Substance Abuse Treatment, vol. 25, no. 3, 2003, pp. 125–134., https://doi.org/10.1016/s0740-5472(03)00130-2.

Innamorato, Rep. Sara. “Innamorato, Struzzi Introduce Legislation to Establish Syringe Service Programs in Pa..” Pennsylvania House Democratic Caucus, 27 Jan. 2022, https://www.pahouse.com/InTheNews/NewsRelease/?id=122508.

Kerr, Thomas, et al. “Drug-Related Overdoses within a Medically Supervised Safer Injection Facility.” International Journal of Drug Policy, vol. 17, no. 5, 2006, pp. 436–441., https://doi.org/10.1016/j.drugpo.2006.05.008.

Krantz, Mori J., and Philip S. Mehler. “Treating Opioid Dependence: Growing Implications for Primary Care.” Archives of Internal Medicine, vol. 164, no. 3, 2004, p. 277-288., https://doi.org/10.1001/archinte.164.3.277.

Lieberman, Amy, and Corey Davis. “Harm Reduction Laws in the United States.” Network for Public Health Law, 3 Dec. 2020, https://www.networkforphl.org/resources/harm-reduction-laws-in-the-united-states/.

Logan, Diane E., and G. Alan Marlatt. “Harm Reduction Therapy: A Practice-Friendly Review of Research.” Journal of Clinical Psychology, 2010, p. 201-214. https://doi.org/10.1002/jclp.20669.

Mann, Brian, and Caroline Lewis. “New York City Allows the Nation’s 1st Supervised Consumption Sites for Illegal Drugs.” NPR, NPR, 30 Nov. 2021, https://www.npr.org/2021/11/30/1054921116/illegal-drug-injection-sites-nyc.

Nadelmann, Ethan, and Lindsay LaSalle. “Two Steps Forward, One Step Back: Current Harm Reduction Policy and Politics in the United States.” Harm Reduction Journal, vol. 14, no. 1, 2017, https://doi.org/10.1186/s12954-017-0157-y.

Ng, Jennifer et al. “Does evidence support supervised injection sites?.” Canadian family physician Medecin de famille canadien vol. 63,11 (2017): 866.

“Overdose Death Rates.” National Institutes of Health, U.S. Department of Health and Human Services, 1 Feb. 2022, https://nida.nih.gov/drug-topics/trends-statistics/overdose-death-rates.

Sees, Karen L., et al. “Methadone Maintenance vs 180-Day Psychosocially Enriched Detoxification for Treatment of Opioid Dependence.” JAMA, vol. 283, no. 10, 2000, p. 1303., https://doi.org/10.1001/jama.283.10.1303.

Shah M, Huecker MR. Opioid Withdrawal. [Updated 2021 Oct 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK526012/

Strathdee, Steffanie A., et al. “Needle-Exchange Attendance and Health Care Utilization Promote Entry into Detoxification.” Journal of Urban Health, vol. 76, no. 4, 1999, pp. 448–460., https://doi.org/10.1007/bf02351502.

​​Strathdee SA, Vlahov D. The effectiveness of needle exchange programs: A review of the science and policy. AIDScience. 2001;1:1–13.

Van Zee, Art. “The Promotion and Marketing of Oxycontin: Commercial Triumph, Public Health Tragedy.” American Journal of Public Health, vol. 99, no. 2, 2009, pp. 221–227., https://doi.org/10.2105/ajph.2007.131714. 

Welsh, Christopher, and Adela Valadez-Meltzer. “Buprenorphine: a (relatively) new treatment for opioid dependence.” Psychiatry (Edgmont (Pa. : Township)) vol. 2,12 (2005): 29-39.

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