Harm Reductionist

[Mikael Langner 0]

Hello,

I am a harm reductionist interested in buprenorphine prescribing to keep users alive because a dead user can never recover.

I hope to glean practice tips from this website.

I came to this website through the SAMHSA webinars held to educate prescribers.

I am particularly interested in learning more about precipitated withdrawal, likely sources of community pushback, billing practices, and, of course, harm reduction.

Mikael Langner, M.D.

 

[Seth Acton 70]

Welcome to the board Dr. Langner!

[Pamela Dunkin Baker 0]

I have struggled with the concept of harm reduction vs complete abstinence from all substances in our program.  How is that struggle playing out for you?  

Pam Baker

[Mikael Langner 0]

I think it is fair to say that most programs have that struggle, and mine is no exception.  I think that a harm reduction approach is a pragmatic approach compared to abstinence-only programs.  I would like to see data comparing the two approaches.  

[Adam Bisaga, MD 103]

This is an important topic and I am glad it was brought up, so please allow me to make a comment. There is a broad range of opinions as to what the "harm reduction" in the context of OUD treatment means. Traditionally harm reduction involves a set of outreach activities to people using drugs that occur before the individual enters treatment, done by peers or a non-medical staff. This includes provision of food/shelter, health education on drug effects and risk reduction, drug supply testing, needle exchange and condom distribution but also screening for SUD and other medical/psych disorders, motivational interventions and referral to treatment. Treatment involves administering evidence-based medical interventions aimed to eliminate symptoms of the disorder and improvement of quality of life which by definition "reduce harms".  Harm reduction and treatment form a continuum of care, and there is an overlap, but in essence those are two distinct interventions.

It is sometimes argued that prescribing/dispensing opioid agonists without a formal treatment contract/structure as defined in guidelines (e.g, no toxicology monitoring and no concerns if the medication is diverted)  constitutes a "harm reduction" interventions and should be used in crisis situation but I am not sure if there is evidence to support benefits of such approach, both for individuals and communities. Moreover, there may be several adverse outcomes of such approach. One that comes to mind was a consequence of the movement to expand access to methadone in early 1970's where for-profit programs with minimal outcome/safety monitoring mushroomed in many cities ("methadone mills"). This led to major concerns about diversion and a significant pushback by regulatory agencies (1973 Narcotic Addict Treatment Act) which created a highly regulated treatment system which dramatically restricted access to methadone and increased stigma of the medical treatment, which may be one of the reasons why the medical community have not been able to mount the response to this epidemic.

Treatment with buprenorphine has evolved during this epidemic, addressing some of the legitimate concerns about the ability of drug-free programs to treat OUD, and adapting to needs of individual patients but there is still a wide gap between treatment of OUD with medication and "methadone/buprenorphine vans." Sometimes well-meaning providers loose the sight of the fact that OUD is often a serious psychiatric disorder and many patients will need much more than a medication they can take whenever it works for them. The solution, as implemented in many European countries, is of course a continuum of services from supervised injection sites and heroin maintenance on one side to therapeutic communities on the other side of the spectrum, with specialty and primary care programs in the middle, with services that are available, accessible, attractive and and free to all interested individuals.