Mind and Body

A strategy of reducing harm and saving lives on the road to recovery

In its third report to the community, RICARES offers a roadmap of potential harm reduction strategies

Image courtesy of RICARES

The cover of the third report to the community by RICARES, released on Jan. 22, offering a comprehensive discussion and roadmap for implementing a statewide harm reduction strategy.

By Ian Knowles
Posted 1/22/18
A third in a series of community reports by RICARES offers detailed recommendations of what could be contained in a statewide harm reduction strategy for Rhode Island, the apparent missing piece from the current strategy being undertaken to intervene and prevent drug overdose deaths.
What is the best way to integrate discussions of harm reduction strategies into the efforts of the Governor’s Task Force on Overdose Prevention and Intervention? What are the current costs of EMS transports to Rhode Island hospitals for patients with impressions of “alcohol intoxication?” Is there a need to address not just “recovery from” but “recovery to,” as a pathway toward health and wholeness? How can the action plans by health equity zones in Rhode Island be integrated in strategies to combat substance use and abuse? How can the current conversation be expanded to include what is known as “the diseases of despair,” connecting the mortality data from alcohol, suicide and drugs with economic and social dysfunction? Is there a need to look beyond the clinical medical model for treating addiction and see potential solutions in building healthy, resilient communities?
Tom Coderre begins work on Jan. 22 as a senior staff member of Gov. Gina’s Raimondo team. His policy expertise will no doubt reshape and sharpen the focus around addiction and recovery efforts, as the 2018 election season begins in earnest.
The Rhode Island Medical Society recently convened an initial meeting of stakeholders to discuss medical safe injection sites in Rhode Island.
The proposed expansion of medical marijuana dispensaries in Rhode Island, with additional provisions for its use to treat pain, raises the broader question about the creation of a more holistic pain treatment clinical facility as a potential state strategy. One research question to be answered is what are the demographics of treatment of chronic pain in Rhode Island, and its relationship to an aging population.
As the state considers making more investments in its mental health and behavioral infrastructure, does there also need to be similar kinds of investment in looking at how best to prevent toxic stress in infants and children, thought by some neuroscience researchers to be a key component of how the brain gets “rewired” and becomes more susceptible to addiction.

Editors note: The apparent lack of a statewide harm reduction strategy, as identified as a task to complete under the July 12, 2017, executive order by Gov. Gina Raimondo, has been a missing component in the policy efforts of the Governor’s Task Force on Overdose Prevention and Intervention.

In response, RICARES has written its third Report to the Community, to be released on Monday, Jan. 22, with its recommendations for a statewide harm reduction strategy.

ConvergenceRI is publishing the report in its entirety as a way to spark community conversation beyond what occurs at the monthly Task Force meetings.

Yes, the report is wonkish; it is in the weeds; it is a long read; and it is controversial. It is also something that does not translate easily into a 750-word news story. But, without the context provided by the report and its recommendations, the conversation around harm reduction strategies all too often gets swallowed up in the stigma surrounding treatment and recovery.

The R.I. Department of Health recently sponsored an impressive community gathering on Jan. 15, “Owning Our Story: About The Opioid Epidemic,” which drew hundreds of attendees to the Veterans Memorial Auditorium in Providence.

One of the messages, in part, was that the community would help to write the end of the epidemic, as a way to develop a constituency of consequence.

But, without an engaged community discussion around how best to implement harm reduction strategies in Rhode Island, the story promises to remain unfinished and incomplete.

Implementing strategies to reduce harm and to save lives are intertwined with treating addiction as a disease and the belief there are many roads leading to recovery.

PROVIDENCE – The Governor’s Executive Order, signed on July 12, 2017, states that Rhode Island “must recommit to developing new strategies and devoting all necessary resources to address the overdose epidemic,” and, as part of that effort, the R.I. Department of Behavioral Healthcare, Developmental Disabilities and Hospitals and the R.I. Department of Health “shall examine existing harm reduction efforts and propose a comprehensive harm reduction strategy for intravenous drug users to decrease the risk of overdose, infection, and assault.”

We have not yet seen a response and hope that this report can be helpful in the development of a comprehensive strategy.

The state has already successfully implemented a number of harm reduction strategies. [An analysis of the strategies can be found in the first two RICARES Reports to the Community, at the website, www.ricares.org.]

We believe the strategies have contributed to the recently announced 9 percent drop in the overdose mortality rate during the first eight months of 2017.

However, [as] the Governor warned, “We’re not out of the woods yet.” She is correct – we are still deep in the woods.

We all recognize that our state’s longstanding addiction epidemic and its present acute symptom, the [current] accidental opioid overdose death epidemic, require a continued and dynamic response.

Given the unacceptable ongoing mortality rate associated with the present epidemic, and the introduction of fentanyl into the drug supply, the priority is now for additional and enhanced harm reduction strategies. We must avoid moving further into the woods.

We recognize that people’s engagement in drug use is often fluid and that people frequently move in and out of active drug use over long periods of time even if their ultimate goal is to quit using. It is critical during this process that people have access to harm reduction services that they can access without fear of exposure or shame.

It is critical that they can feel safe accessing harm reduction services without potentially threatening their access to drug treatment services or living in fear of losing their children, their job, their housing, etc., because they are scared of the potential to be reported for or seen accessing the harm reduction services.

We accept the reality that people do and will use drugs. We want to focus on reducing the harmful consequences that include HIV, Hepatitis C, criminal activity, incarceration, and death. That acceptance of reality should not be conflated with our endorsing or condoning illegal drug use. We do not.

Understanding harm reduction
Example: A successful harm reduction initiative
In the 1980s, heroin IV drug users were contracting HIV/AIDS due to sharing infected needles. In response to that epidemic, syringe exchange programs were established and the spread of HIV/AIDs via this population was minimized and people’s lives were saved.

The response was successful in that it did not attempt to stop the heroin use, and did not attempt to force or cajole people into treatment. It simply tried to keep people as safe and healthy as possible.

Harm reduction is a long established public health strategy. The World Health Organization [in 1974] suggested: “The broad purpose of preventive measures should be to prevent or reduce the severity of problems associated with the non-medical use of dependence-producing drugs.”

The Harm Reduction Journal [in 2017] stated: “Harm reduction refers to interventions aimed at reducing the negative effects of health behaviors without necessarily extinguishing the problematic health behaviors completely.”

For our purposes, “harm reduction” refers to policies, programs, and practices that seek to reduce the adverse health, social and economic consequences of the use of legal and illegal psychoactive substances.

Harm reduction is pragmatic and focuses on keeping people safe and minimizing death, disease, and injury associated with higher risk behavior while recognizing that the behavior may continue despite the risks. It seeks to lessen the harms associated with substance use while recognizing that many individuals may not be ready or in a position to cease use.

Harm reduction does not require, nor does it exclude, abstinence from drug use as an ultimate goal.

Harm reduction is an essential part of a comprehensive public health response to problematic substance use that complements prevention, treatment, and enforcement. A harm reduction philosophy should inform strategies directed at the whole population, as well as specific programs aimed at sub-populations of vulnerable people.

Harm reduction acknowledges the ethical imperative of helping to keep people as safe and healthy as possible, while upholding human rights, respecting individual autonomy and supporting informed decision-making in the context of active substance use.

We need enhanced and additional harm reduction strategies
Treatment is, of course, one of the four major strategies of the Task Force, and Rhode Island continues to be a national leader in the provision of medication-assisted treatment. However, there are at least five considerations regarding the treatment strategy for which we should adjust.

We are one of the 43 states that have at least one service provider who gives all three of the current approved opioid agonist or antagonist medications (methadone, buprenorphine, and vivitrol). However, according to the 2017 SAMHSA [report], we offer all three medications at only three facilities. The President’s Commission on Combating Drug Addiction and the Opioid Crisis recommends a requirement that “all modes of MAT are offered at every licensed MAT facility.”

It is a given that methadone maintenance treatment has clearly been shown to reduce the major risks associated with untreated opioid dependence in patients who are willing to undergo and are successfully retained in treatment. However, from 15 percent to 25 percent to 40 percent of the most adversely affected patients with opioid use disorder do not have a good response to this treatment. Such persons are either not retained in methadone maintenance treatment for very long or continue to use illicit opioids while in treatment.

73 percent of people who meet the criteria for needing treatment for drugs [and 88 percent of people who meet the criteria for needing treatment for alcohol use] perceive no need for treatment. They admit, on a self-administered test, that life areas [job, family, health, law] are adversely affected by their use [of alcohol or other drugs] but they see no need for treatment.

For a range of reasons, only about 10 percent of people with a substance-use disorder receive any type of specialty treatment.

Patients in RI with opioid use disorders [and other substance use disorders] are kicked out of treatment for essentially confirming their diagnoses [i.e., use of substances while in treatment; not following program ‘rules’ that have no locus with recovery].

This is a shockingly common and accepted practice, supported by licensing regulations, that does not seem to be a standard of practice with any other chronic medical condition.

Our perspective is that an important element of successful harm reduction programs in health care settings is that providers apply harm reduction principles by practicing accountability without termination as a critical component of care. In short, patients are seen as being responsible for their own health choices and outcomes but are never “fired” from care.

Factors to consider in the implementation of a harm reduction program in Rhode Island
The general quality program indicators [need to] include:

Acknowledge the need for evidence-informed policies and/or programs.

Recognize the importance of preventing drug-related harm – rather than just preventing drug use.

Discuss low-threshold approaches to service provision.

Specifically address overdose.

Recognize that reducing or abstaining from substance use is not required.

Consider harm reduction approaches for a variety of drugs and modes of use.

Discuss harm reduction’s human rights dimensions [e.g., dignity, autonomy].

Consider the social determinants that influence drug-related behaviors.

People who inject drugs must be involved
Rhode Islanders who have injected drugs and have survived must be part of any planning process that intends to develop effective and feasible strategies.

People with opioid use disorder that have survived, or are continuing to survive, obviously used successful personal harm reduction strategies.

Further, they would have critical informed opinions of the various strategies.

There are at least two studies to look at as starting points in considering the input of this group.

The larger context: two alternate approaches
A harm reduction program can be reframed within an expanded purpose of health promotion – [either] the Philadelphia model; or, the program can be considered as an end in itself, the Australia model.

[In the Philadelphia model], several factors distinguish its harm reduction programs from traditional addiction treatment and recovery support programs, including:

Minimal if any service eligibility or service fee requirements.

Multiple points of service entry (versus a centralized intake).

Service delivery within the locations where clients live and use drugs.

Service goals set by each client rather than the program; abstinence not a requirement for service entry or retention.

Broad service menu encompassing numerous areas of life functioning.

Less hierarchical service relationships than in traditional professional service settings.

The option of anonymity, [both] in [in terms of] participation and duration [from the beginning to the end of the services], are to be defined by the customer [being served], not by the program or external funding or regulatory authorities.

Harm reduction programs have the responsibility of enhancing coping methods and increasing social supports as drug use decelerates or ceases. Such supports are critical to prevent inadvertent harm resulting from the service intervention.

Harm reduction principles and practices provide a way to reach, engage, and support positive change across the arenas of drug use, addiction, and recovery.

Harm reduction represents an approach to reaching different populations and reaching the same individuals at different stages of their drug use, addiction, and recovery careers.

Harm reduction principles and practices are particularly important for addressing multiple, severe, complex, and chronic [often intergenerational] problems.

The integration of harm reduction and recovery perspectives is especially noteworthy [in the Philadelphia model].

The Philadelphia program exemplified this with a trauma-informed perspective that recognizes the impact that violence and victimization may have on individuals’ capacity to minimize the harm associated with their substance use, while [at the same time] partnering with them to strengthen their capacity to initiate and maintain their recovery.

Harm minimization can be viewed as an end in itself or as a first step towards recovery.

The Australia model
The two basic components of harm reduction [in the Australia model] are pragmatism – providing policies and services that are effective – and respect for the human rights of persons who use drugs.

One of the main reasons why harm reduction services are so effective in supporting people in this way is due to the core principles that sit at the very heart of harm reduction as a concept, including:

It meets people where they are, not where we might like them to be

It is tailored to the needs of the individual

It is non-judgmental in its approach

In more than 20 years of harm reduction practice in Australia, no other health promotion activity has come even close to demonstrating the levels of effectiveness and return on government investment achieved by harm reduction.

The government is obligated to focus on addressing the systemic factors that create drug-related harm, and therefore adverse outcomes for the individual and the broader community. This involves providing a range of appropriate, non-judgmental and accessible AOD [alcohol and other drugs] and BBV [blood-borne virus] prevention services and programs across the full spectrum of service models and approaches, including harm reduction.

Proposed elements in a Rhode Island harm reduction strategy
We propose an enhancement of some existing strategies, the development of some additional strategies, and the consideration of some specific substance-related strategies that have been successful or have demonstrated some merit elsewhere in the nation and/or internationally.

As these proposals are considered, please remember: historically, harm reduction neither excludes nor presumes the long-term treatment goal of abstinence.

Enhance existing strategies:
One of the most successful elements of the Governor’s Task Force strategy has been the Naloxone distribution initiative, led by the Preventing Overdose and Naloxone intervention [PONI] Program. We recommend an enhancement of the program.

There is significant literature that recommends expanded access to intranasal naloxone, given the potential hazards and issues associated with needle-sticks. The literature includes studies that found only minimal differences between the intranasal and intramuscular administration of naloxone in treating opiate-induced respiratory depression.

An additional Naloxone strategy could replicate the Chicago Recovery Alliance program that started distributing Naloxone through a mobile van-based harm reduction program in 1996.

Expand the Syringe Exchange Program into other targeted areas:
This could be a component of the expansion of the existing Anchor Recovery Community Center’s MORE [Mobile Outreach Recovery Efforts] program that provides targeted outreach. Our impression is that MORE continues to be under-funded and thus primarily reactive.

We believe that an expanded and comprehensive outreach program could engage in proactive efforts that would minimize the outbreaks that occur. Outreach and education programs can involve assistance with access to services, peer mentoring or treatment, provision of educational materials on harm reduction, and safe drug use.

The addition of a mobile assessment unit(s) would be consistent with one of the quality indicators of harm reduction programs, as it would provide service delivery within the locations where clients live and use drugs. We do not understand why outreach continues to be a low priority of the Task Force.

Develop additional strategies:
Access to justice: evidence suggests that access to legal aid, paralegal services, and legal empowerment can greatly enhance the health of drug users.

Access to medical services: people who inject drugs are deterred from accessing services for a variety of reasons, including experience of discrimination and judgment.

Law Enforcement Assisted Diversion Programs (LEAD): pre-booking diversion that immediately directs people committing low-level offenses into community-based services rather than processing them through the criminal justice system. LEAD programs are operating in Seattle and Santa Fe and are emerging in multiple other states.

Route-transition interventions: e.g., promote smoking heroin rather than injecting.

Medically supervised injection facilities [SIF]: The time has come for the introduction of supervised injection facilities in our state. It has been a successful strategy in many countries since the 1980s [at approximately 100 sites in Europe, Canada, and Australia], is being considered nationally in California, Maryland, Vermont, Massachusetts, and in the cities of Ithaca and Seattle; it has been recommended in Rhode Island in a recent study.

Successful supervised injection facilities include the presence of, but not forcing of, treatment exposure and related resources. These resources could include sterile equipment, moral support or positive interaction with staff, information and counseling, and a comfortable space or sense of connection with the community. The facility can be a locus for accessing a range of community health and social services.

Specific substance-related strategies:
There is a range of alternative substance-related strategies to opioid replacement treatment, i.e., using other drugs as possible substitutes for opioid agonists that are used and/or proposed internationally. These include:

Diacetylmorphine maintenance for heroin-assisted treatment is used in at least seven countries and is presently being considered in Maryland, Nevada and New Mexico. A Canadian study, published in the New England Journal of Medicine, reported that injectable diacetylmorphine is more effective than MMT as a maintenance treatment for long-term, treatment-refractory heroin use [i.e., that 15-25 percent to 40 percent of the most adversely affected patient who do not have a positive response to MMT].

The study reported that the test group was more likely to stay in treatment and to reduce their use of illegal drugs and other illegal activities than the patients assigned to receive oral methadone.

In addition, the diacetylymorphine group had greater improvements with respect to medical and psychiatric status, economic status, employment situation, and family and social relations. These results are particularly noteworthy in view of the nature of the population and the time frame. The fact that patients who received diacetylmorphine had significant improvement in these areas suggests a positive treatment effect beyond a reduction in illicit drug use or other illegal activities.

The study concluded that prescribed, supervised use of diacetylmorphine appears to be a safe and effective adjunctive treatment for this severely affected population of patients who would otherwise remain outside the health care system. The results of this study are consistent with a subsequent study reported in The British Journal of Psychiatry,

Injectable hydromorphone (Dilaudid), slow-release morphine or codeine: [These alternatives] are suggested as a means to reduce the issues involved with Schedule I controlled substances.

Cannabis for Therapeutic Purposes (CTP): Although research is thus far inconclusive on the potential of cannabis to treat opioid addiction, some doctors, and even rehabilitation centers, are recommending medical cannabis as a means of helping their patients use less, or abstain entirely, from opioids.

CTP is utilized in reducing opioid use and interrupting the cycle toward opioid use disorder prior to opioid introduction in the treatment of chronic pain; as an opioid reduction strategy for those patients already using opioids; and as an adjunct therapy to methadone or suboxone treatment in order to increase treatment success rates.

Phillipe Lucas, a research affiliate with the Center for Addictions Research of British Columbia, has suggested that: “The growing body of research supporting the medical use of cannabis as an adjunct or substitute for opioids creates an evidence-based rationale for governments, health care providers, and academic researchers to seek the immediate implementation of cannabis-based interventions in the opioid crisis at the regional and national level, and to subsequently assess their potential impacts on public health and safety.”

Ibogaine: It seems to be effective for some people. It is a psychedelic alkaloid often extracted from the root bark of the Central African shrub tabernanthe iboga. It possesses a unique ability to block the physiological symptoms of opioid withdrawal, and when combined with psychotherapy can stop or significantly reduce opioid use in the longer term. It is used clinically or medicinally – often for treatment of opioid use disorder and other addictions – in other countries, e.g., New Zealand, Mexico, Canada, Australia, Spain, Brazil, Costa Rica, and South Africa.

Studies from New Mexico and New Zealand show a range of salutary effects. A single treatment can halt opioid withdrawal and cravings for heroin in many subjects who were unsuccessful in previous rehabilitation attempts.

One study reports significant reductions (75 percent) in drug use 30 days following treatment, and 33 percent reported no opioid use three months later. One study showed cessation or sustained reduced opioid use for up to 12 months following treatment, and concluded that for some opioid-dependent individuals, Ibogaine treatment can be effective in significantly reducing opioid withdrawal, craving, and depressed mood, and reducing or ceasing opioid use.

The studies seem to indicate that a single treatment of Ibogaine, for reasons unknown, halts opioid withdrawal and cravings for heroin, cocaine, nicotine, and alcohol in many subjects unsuccessful during previous drug rehabilitation attempts. These results indicate that some set of persons with intractable opioid use disorder may benefit from Ibogaine treatment.

Potential obstacles
We acknowledge that there may be bureaucratic, legal and ideological obstacles to some of these interventions/strategies. These include: the misunderstanding, or the mistaken insistence, that harm reduction programs appear to “condone” drug use; existing laws and regulations; funding considerations; and the archaic, but enduring, conviction that treatment failure is due to the patient ‘not being ready’ or ‘not motivated’ for treatment.

This perspective, unfortunately, continues to exist both among treatment providers and in the addiction recovery communities.

We acknowledge that there may be significant federal obstacles to some of these strategies, but we know that progressive drug policy has usually been made at the state and local level first, often in spite of federal obstacles.

Rhode Island continues to be a national leader in our integrated and sustained response to the opioid overdose epidemic. We believe that it is time to take the next step of that leadership role.

Two more significant issues
We believe that, given the present situation and for complete context, we must present two additional, and controversial, issues. These are issues for which we recognize that there is the same continuum of opinion within the recovery communities as there is in the general population.

So, [as a result], we do not intend to represent the opinion of the recovery communities, nor do we present a RICARES position. However, we feel that no responsible harm reduction policy can omit them. We merely urge that serious discussion and thought continue and that we remain open to developing new opinions and attitudes. The continuation and escalation of ineffective or counterproductive policies merely move us deeper into the woods

Marijuana:

The continued Controlled Substances Act Schedule I status of marijuana is counterproductive simply due to the prohibition of research around Schedule I drugs. There is clearly the potential for medical use as demonstrated by its effective pain management utilization and its possible efficaciousness in dealing with some types of serious seizure disorders.

Further, it is clear that its addictive potential, while undeniable, does not
attain the dangerous severity of other Schedule I drugs such as heroin, LSD,
and bufotenine, a highly toxic and hallucinogenic toad venom that can cause
cardiac arrest [in contrast, cocaine and methamphetamine are Schedule II
drugs, i.e., they have a ‘legitimate medical use.’]

Criminalization:
It is difficult to imagine a more harmful effect on us than the 44-year ‘War on Drugs’ that began in 1974. The United Nations Special [Report] on the Right to Health states: “People invariably continue using drugs irrespective of criminal laws, even though deterrence of drug use is considered the primary justification for imposition of penal sanctions.

Second, drug dependence, as distinct from drug use, is a medical condition requiring appropriate, evidence-based treatment – not criminal sanctions.

Finally, punitive drug control regimes increase the harms associated with drug use by directing resources toward inappropriate methods and misguided solutions, while neglecting evidence-based approaches.”

The War on Drugs quickly morphed into a War on Drug-Users, and it has heartbreakingly ruined the lives of millions of young people and their families, and deprived our society of the contributions that they could have made. We feel that loss because of the example of the hundreds of thousands of Rhode Islanders in recovery who have contributed, and continue to contribute, to the well-being and vitality of our state.

Among the most odious aspects of the conduct of the War on Drugs are the shocking racial disparities. For example, studies consistently show that blacks and whites use marijuana at roughly the same rates. However, according to a 2013 ACLU report, blacks are [nationally] 3.7 times more likely to be arrested [Rhode Island ranked 40th in the arrest rate at 2.6 times more likely to be arrested).

The response to the crack cocaine epidemic of the late 1980s/early 1990s was that more than 90 percent of those sentenced under the harsh crack cocaine laws were black, even though a majority of crack users were white.

In 2012, the racial/ethnic breakdown of inmates in state jurisdictions for drug charges (possession, trafficking and ‘other drug crimes’) was: White – 14 percent; Black – 15.9 percent; and Hispanic/Latino – 15.2 percent. In 2013, Whites comprised 77.7 percent of the population, Blacks 13.3 percent, and Hispanic/Latino’s 12 percent, according to the U.S. Census. The racial disparities are self-evident.

Finally, we derive inspiration from Arthur Evans, who wrote: “While harm reduction can be viewed as an end in itself with a focus on mitigating harm to individuals, families and the community as a whole, harm reduction strategies can also be viewed collectively as a platform or point of access for promoting long-term health, and, for those with severe alcohol and other drug problems, long-term personal and family recovery. If our goal is to promote health and reclaim lives, then we must understand the direct and sometimes circuitous paths through which individuals and families achieve and sustain such health. We must meet each individual and family with fresh eyes in every encounter with a belief that each encounter is an opportunity for movement, no matter how small, toward health and wholeness.”

Ian Knowles is the project director at RICARES, the Rhode Island Community for Addiction Recovery Efforts.

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