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Do No Harm and Help to Reduce It: Why Harm Reduction is Primary

Monday, September 16, 2019   (0 Comments)
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Written By: Eliza Hutchinson, Country Doctor Community Health Center


Eliza Hutchinson will be presenting at NWRPCA/CHAMPS 2019 Fall Primary Care Conference


When was the last time you advised a patient with diabetes to check their feet, continued to prescribe insulin despite a rising A1c, or provided a statin to decrease cardiac morbidity?


How often have you advised a patient who injects heroin to use clean needles and works, do a test shot, or continued to prescribe buprenorphine despite missed appointments and benzodiazepines in a urine sample?


If you were trained as I was, your answer to the former questions is likely “all the time;” your answer to the latter set would be far less frequent. Although as primary care providers (PCPs) we are well versed in comprehensive management of chronic disease, most of us were not taught to treat addiction with a similar approach. We now have abundant evidence that addiction is a chronic disease that requires management paralleling that of other chronic conditions. When a patient develops diabetes, we don’t ask them to return when they are ready to dramatically change their diet and exercise routine. Instead we engage them and aim to minimize risks to their health via multidisciplinary interventions – nutritionists, foot exams, pharmacotherapy. In other words, we adopt a harm reduction approach. Yet we often fail to do so in the case of substance use disorders (SUDs).


Until recently, I was not well versed in harm reduction approaches to SUDs, nor did I understand how vital they are to successful management of SUDs. I now realize that our more traditional approach to SUDs, founded in an abstinence-only framework, runs counter to the chronic disease model of care. It also fails to care for the many people whose recovery follows a non-linear path. Just as in diabetes or any other chronic disease, our patients with SUDs will have periods of relapse and remission; they will not always be 100% adherent to their medications; they will miss appointments. These common health behaviors are often considered “strikes” leading to dismissal in the traditional model of SUD treatment with buprenorphine, even though we would never dismiss a patient with diabetes who deviated from their diet or stopped their metformin. As a physician at a FQHC, the realization that this traditional model of care fails to reach the most at-risk populations in our community stands in sharp opposition to my mission to care for these very people. Our organization, Country Doctor Community Health Centers (CDCHC), felt a similar dissonance and thus embarked on a collaboration to address this gap in care.


We joined forces with Hepatitis Education Project (harm reduction organization) and Sound (behavioral health agency) to offer opioid use disorder (OUD) medications (buprenorphine and naltrexone), infectious disease testing, behavioral health services, peer support, and case management in a low barrier setting. Our approach is founded on harm reduction principles: that drug use is a reality; the attempt to minimize harms despite ongoing use; acceptance of each individual as they are and recognizing their goals as valid and worthwhile; the understanding that social inequities influence propensity for SUDs and the ability to recover from them; and most importantly dignity, respect, empowerment, and relationships.


We operate on a walk in basis thus avoiding strict and impractical appointment times; encourage people to come back regardless of missed appointments or ongoing substance use; inquire about each person’s goals and align our work accordingly; strive for language that minimizes stigma; and we prioritize the strength of our relationships with patients. We educate patients on safe use techniques in the case of ongoing substance use despite medication; use urine drug screens not as grounds for dismissal but as a tool for motivational interviewing and respectful conversation; and we continue prescribing despite missed appointments or ongoing substance use. This structure has allowed us to reach patients at high risk of overdose who otherwise generally lacked treatment access.


You may ask why incorporating harm reduction into clinical practice and developing low barrier programs fall in the domain of PCPs and community health centers (CHCs). The reasons are many. First, we are chronic disease experts, and SUD treatment should follow a similar management strategy. Second, we are acquainted with the medical and social complexities of our patients’ lives by virtue of long-term relationships and thus are best positioned to assess how these factors may impact treatment outcomes. Third, low barrier, harm reduction work allows us to more robustly carry out the mission of CHCs – to provide high quality care to the most vulnerable community members. Fourth, implementing harm reduction approaches and seeking community collaborations to pursue low barrier work are antidotes to provider burnout. Aligning our care with our patients’ realities and goals is deeply satisfying; working with a multidisciplinary team allows us to address the highly impactful, non-medical components of our patients’ lives.


Finally, we cannot afford to continue with status quo treatment approaches in the midst of a public health emergency. Drug overdose is now the leading cause of accidental death for adults in the U.S., with opioids responsible for the majority of these deaths. The use of buprenorphine and methadone reduces the risk of overdose death by half. We do not have any other pharmacotherapy in our toolkit that decreases mortality this profoundly. We see first-hand the devastating effects of SUDs on the health of our patients and community thus understand the urgency of re-thinking and expanding our strategy to provide this lifesaving treatment to everyone who needs it.


As PCPs and CHCs we can use our clinical skills, history of innovative problem solving, and mission-driven orientation to continue improving care for our most vulnerable community members. We can start by incorporating harm reduction language into any encounter with a patient using drugs, such as inquiring if they know where to get clean needles. More broadly, we can collaborate with community partners who offer complementary services in order to better meet patients where they are, literally and figuratively. Through these efforts, we can lead change such that every patient using drugs will experience the same high quality care as does their neighbor with diabetes.








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