COVID-19 has drastically impacted our country at a time when we were already facing another public health crisis — the opioid epidemic. As of September 2020, The Wellbeing Trust estimates an increase of 75,000 ‘deaths of despair’ from suicide or substance use due to the pandemic and its social implications. To prevent significant harms such as increased overdoses, serious COVID-19 infections, and increased homelessness or incarcerations, it is time to better implement harm reduction in the management of substance use disorders.
For a variety of reasons, the substance use population is particularly vulnerable to the impacts of the COVID-19 pandemic. Based on data from previous financial crises, the emotional toll will increase rates of new substance use, escalate current use, and trigger relapse even among those with long-term abstinence. There may be a significant lag before these changes are detected and treated because health care resources are being funneled toward the pandemic. Furthermore, due to social isolation, opioid overdose rates may increase. While there has been a public health initiative to make naloxone widely available, it is not a helpful tool if there is no one in proximity to administer it. People with substance use may also be at higher risk for COVID-19 due to physiologic changes from their substance use. However, they may not be taken seriously or receive equal disease management due to stigma within the health care system.
As a vulnerable population, they face a higher risk of housing insecurity and incarceration, which can be detrimental to health while social distancing is key. And social distancing requirements have led to a sudden decline in the availability of inpatient treatment. Outpatient treatments and fellowship-based modalities have shifted to a virtual setting, which may not be available to all patients, especially those struggling with housing insecurity. Given all of the ways in which substance use increases vulnerability to the pandemic, it makes sense to focus our efforts on minimizing the downstream negative impact of substance use, for which harm reduction is the ideal tool.
Harm reduction is a heterogeneous approach to managing substance use disorders that revolves around a patient’s individual goals. This aligns well with the general ethos of the medical community as it shifts to a more patient-centered model. Arguably, condemning a patient to suffer negative consequences even when they do not desire sobriety is doing active harm. Harm reduction techniques allow physicians to focus on improving a patient’s quality of life rather than expecting total sobriety. Further, opting for harm reduction allows a patient to achieve goals at their own pace, potentially in a progressive manner. For example, if a patient cuts back from one pack of cigarettes per day to half, that change alone is beneficial. Once they achieve that goal, motivational interviewing can facilitate setting a new goal for continued incremental reduction.
The intention of harm reduction is not to give up entirely on the physician’s goals for a patient’s recovery either. Rather, it is setting those goals in the back seat and allowing the patient’s goals and motivations to drive. For example, a patient with intravenous drug use desires less injection site infections but is not willing to stop their use. Teaching this patient how to inject their drugs in a sterile fashion and providing clean needles can significantly lower their morbidity despite continued intravenous drug use. The benefit to the physician is a deeply-established rapport and sense of trust from a patient who may feel otherwise ostracized in our current health care system.
Resistance to this shift in treatment priorities has contributed to a history of opposition and misinformation. The first needle exchange began in 1988 in response to the AIDS epidemic and lasted one year. Also in 1988, the federal government passed legislation that stopped funding for the operation of these programs until they were deemed “safe and effective.” Since federal funding for research was also limited, programs relied almost entirely on private funds. Finally, after a decade, the programs were determined to be safe and effective, but due to political opposition, funding was still not approved. In 2015, Scott County, Indiana experienced a significant outbreak of HIV, and federal funding was finally opened; however, funds could only be used for the cost of operations, such as rent, and not to buy needles. Policy on legality also varies state-by-state, and harm reduction activists still need to navigate opposition.
Despite the rocky road in the U.S. thus far, harm reduction methods have sound data supporting their benefit. For example, needle exchange programs are cost-effective and beneficial to public health with a negligible negative impact. Despite a commonly held oppositional belief, data from multiple studies have shown no evidence that these programs enable or increase drug use. Instead, safe injection sites have been shown to decrease needle-sharing and overdose rates and increase enrollment in treatment programs. Medication-assisted treatment (MAT) also decrease total substance use, HIV risk, death and incidence of illegal activity. And housing and support programs for the homeless that do not require abstinence yield lower times spent homeless, decreased drinking and lower healthcare expenses. These collective benefits show why harm reduction should be made more available to tackle the new barriers this population is facing. In the face of COVID-19, it is time for sweeping reforms that make harm reduction more available and funded.
Since the start of social isolation, there have been some policy shifts to make this possible, mostly related to MAT for opioid use disorders. Regulation of buprenorphine, a partial opioid agonist, has been loosened by SAMHSA, which issues waivers to allow physicians to prescribe it. New federal guidance allows patients to receive 14 to 28 days of buprenorphine for home-use; buprenorphine can also be initiated through a telehealth visit. Treatment with methadone, a full opioid agonist administered through specialized programs, can be maintained, though not initiated, through telehealth. Additionally, these medications can be picked up by family or delivered to home if a patient needs to quarantine when, previously, patients were required to report in-person. These changes have made MAT more available despite barriers brought on by COVID-19.
There has been guidance issued from the National Healthcare for the Homeless Council on integrating harm reduction into alternate care sites, locations where homeless individuals can safely await COVID-19 test results. They recommend strongly against requiring sobriety to engage in these programs, as that would alienate a large portion of patients, causing significant harm. Staff should be trained in trauma-informed care and naloxone-administration. Further, meeting residents’ hierarchy of needs and providing private spaces for crisis de-escalation could prevent relapses and behavioral incidents. When possible, integrating MAT programs into these sites would also be highly beneficial.
Not all efforts need to be made by specialized services; primary care physicians can also take measures for patients unable to access other resources. Motivational interviewing can aid a patient in strengthening their internal locus of control and empower them to make their own decisions. It can also assist a patient in recognizing the consequences of decisions and planning small changes that align with their values. Patients can also be advised to take several actions that lower their risk of exposure to COVID-19. Patients using drugs should minimize sharing supplies and prepare their own drugs on a clean surface to minimize their exposure to COVID-19. Further, to socially isolate, it may be advisable to stock up on their drug-of-choice and supplies. That said, social isolation also makes overdose more likely, so patients should be advised to utilize fentanyl test strips and use in smaller doses. For patients who are insufflating (“snorting”) drugs, it is recommended they sanitize their surface and use as fine a powder as possible to minimize damage to the lung parenchyma. These simple measures can help decrease the morbidity and mortality of a patient’s substance use during the pandemic.
We must not forget this population and their needs amid this new public health crisis. Harm reduction can be a powerful tool to tackle decreased resource availability and an impending increase in substance use harms. As it has navigated complex policy and public disregard since its initiation, the harm reduction community is well-equipped to navigate the changes we are experiencing in the world today. Now more than ever, physicians should advocate for furthering policy change to make harm reduction programs more available and impactful, such as allowing full funding of needle exchange programs. Shifting the conversation about harm reduction to be one of positivity and support would be of great benefit to the substance use community during the COVID-19 pandemic.