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Poor Results in Overdose Crisis Management Call for a Shift to Harm Reduction

12 Feb 2019

Jeffrey A. Singer

A recent report reveals California’s “Death
Certificate Project,” is terrorizing doctors into
under-prescribing or even abruptly terminating medication for acute
and chronic pain patients. The project investigates doctors who
have treated patients identified as overdoses on death certificates
and considers rescinding their licenses or charging them with
homicide.

It is scandalous that we doctors and our patients are the latest
victims of America’s war on drugs, while deaths from
nonmedical use of licit and illicit drugs continue their
exponential and perpetual climb—with no end in sight. It is
time to change the prevailing approach to the crisis. The goal
should shift from reducing production and prescription of
painkillers to reducing death and harm.

Harm reduction strategies begin with the realistic,
nonjudgmental premise that there has never been and will never be a
drug-free society. Akin to my profession’s
credo—“First, do no harm”—harm reduction
seeks to mitigate the harms caused by black market drugs, fueled by
drug prohibition. Instead it aims at reducing the spread of disease
and death from drug use.

It is scandalous that we
doctors and our patients are the latest victims of America’s war on
drugs, while deaths from nonmedical use of licit and illicit drugs
continue their exponential and perpetual climb-with no end in
sight.

The U.S Centers for Disease Control and Prevention recently
released the latest results of the current strategy: opioid-related
overdose deaths in 2017 continued their steady climb, increasing 13
percent over 2016 totals. This happened despite the fact that per
capita high-dose opioid prescriptions fell 58 percent from 2008 to
2017, while the number of all opioids dispensed fell 29 percent
from 2010 to 2017.

The focus on prescription opioids has only served to change the
make-up of the overdose numbers. In 2017, fentanyl or heroin
accounted for 75 percent of opioid-related overdose deaths and,
according to CDC data, 68 percent of deaths from prescription
opioids involved heroin, fentanyl, cocaine, barbiturates,
benzodiazepines, or ethanol. More people take increasingly greater
risks with nonmedical drug use. Some might even be self-medicating
to deal with stress or despair.

But while the prohibition strategy has been unsuccessful, harm
reduction strategies have been used in much of the developed world,
and to a very small degree in the U.S, for over forty years. A deep
dive into the data from decades of experience with harm reduction
shows a range of methods that are successful in reducing overdose
deaths, the spread of infectious diseases, and, in many cases, the
nonmedical use of dangerous drugs.

Medication-assisted treatment is one harm reduction technique in
use since the 1960s. This employs a medical replacement for the
opioid on which a patient has become dependent, allowing that
person to avoid the nightmare of withdrawal—often the chief
reason they continue using the drug—without experiencing the
fogginess or “high” they get from injecting. The first
drug used for this was the synthetic opioid methadone. In recent
years, buprenorphine combined with the overdose antidote naloxone
(brand name Suboxone) has also proven effective. Research shows
more than 50 percent of people with substance abuse disorder have
psychiatric co-morbidities. MAT lets people escape harmful street
use, think more clearly, stabilize their lives, and work with
therapists while gradually weaning off the substitute. A
comprehensive 2017 study found methadone treatment associated with
a 69 percent reduction in all-cause mortality, while buprenorphine
treatment led to a 55 percent drop. For those who fail,
heroin-assisted treatment has found a fair amount of success in
Switzerland (since 1994), Germany, the UK, Netherlands, and Canada,
as noted in a 2018 RAND study.

“Safe Syringe Programs,” endorsed by the CDC, reduce
the spread of HIV, hepatitis, and other infectious diseases. One
form, needle-exchange, has existed in the U.S since 1988, and has
reduced the spread of HIV by up to 58 percent. Unfortunately, in
about half the states anti-paraphernalia laws stand in the way.
Supervised Injection Facilities, also called “safe
consumption sites,” ensure needles don’t subsequently
get shared or sold because they are used under supervision and
returned after use. Staff are close by with the overdose antidote
naloxone at the ready if needed, and nudge users into rehab
programs. The Lancet reported a 35 percent drop in overdoses
resulting from the safe injection site in Vancouver, British
Columbia. Over a hundred safe consumption sites exist throughout
Europe, Canada, and Australia. Unfortunately, federal drug laws
block them in the U.S.

Naloxone is still not accessible enough to opioid users. The
overdose antidote is bought off the shelf in Australia and Italy.
Unfortunately, it is still a prescription-only drug in the U.S,
despite suggestions from the Food and Drug Administration that it
should be reclassified.

Most developed countries recognize the value of harm reduction
and make it central to drug policy. Portugal had one of the highest
overdose rates in Europe in 2001 when it decriminalized nonmedical
drug use and focused nearly exclusively on harm reduction. Now it
has the lowest overdose rate in Europe and saw a 75 reduction in
heroin use and a 95 percent drop in HIV infections since the policy
change.

Critics like Grayson County, KY Sheriff Norman Chaffin dismiss
harm reduction as “offering a drunk the keys to his
car.” As the decades pass and the deaths mount, it is time to
view harm reduction as a way to help the driver get home
safely.

Jeffrey A.
Singer
a surgeon in Phoenix, AZ, and a senior fellow at the
Cato Institute, is the author of Harm Reduction-Shifting From a War
on Drugs to a War on Drug-Related Deaths from the Cato Institute

Click here to view the full article which appeared in CATO Journal