Make Harm Reduction Federal Health Policy Now, Says Yale Experts

Since the start of the COVID-19 pandemic over a year ago, alcohol and substance use has surged in the United States, along with overdoses from opioids. To save lives, using practical strategies to reduce the negative effects of substance use, or harm reduction strategies should become federal health policy now, urges experts Kimberly Sue, MD, PhD, and David Fiellin, MD, from the Yale Program in Addiction Medicine.

In a new commentary, “Bringing Harm Reduction into Health Policy — Combating the Overdose Crisis,” published in The New England Journal of Medicine, they urge the Biden administration to name, embrace, and implement harm reduction programs to save American lives. In addition to expanding treatment, they argue, there is a need for additional measures to abate the tidal wave of death from overdoses. Additionally, they say funds should be allocated to combat the health inequities and racial injustice for Black Americans who are suffering from a disproportionate rise in deaths from substance use disorders, along with COVID-19.

Sue is an instructor (general medicine) at Yale and medical director of the National Harm Reduction Coalition. Fiellin is a professor of medicine (general medicine), emergency medicine, and public health at Yale, and director of the Yale Program in Addiction Medicine.

In a conversation they discuss how COVID-19 has worsened what was already a dire national crisis, strategies that help reduce harm in vulnerable populations, and how federal policies can reduce overdose deaths. The below conversation was condensed and edited.

Q: How has COVID-19 affected people with alcohol or substance use disorders?

David Fiellin: Substance use disorders and the overdose crisis were the country’s “pre-existing condition” coming into the COVID-19 pandemic. The COVID-19 pandemic has essentially collided with the opioid epidemic. We know that during the pandemic, there’s been increased use of substances, and increased isolation due to physical and social distancing. Unfortunately, there have been restrictions on access to treatment and the entire treatment paradigm has changed to a more virtual approach from a direct in-person approach. As well, we’ve seen a rise in fentanyl and deadly fentanyl analogs and rapid changes in drug supplies. These are all on top of the increased economic and family stressors that all individuals are experiencing during this time. So the collision of these two epidemics has been a real challenge for individuals who use substances.

Q: What are harm reduction strategies and how might they help this population?

Kimberly Sue: Harm reduction strategies are simply a variety of tips and techniques that we can use where we don’t ask that people have or require abstinence, but really rather that people can use more safely and avoid harmful outcomes. Harm reduction strategies range from a variety of programs, including syringe service programs where people can exchange used syringes for sterile syringes. We have overdose education and naloxone distribution (OEND), which are community-based programs that distribute naloxone, a medication used to reverse opioid overdose, as well as trains people who use drugs and their family and friends to recognize opioid overdoses and use the medication. Drug-checking, which is a strategy that people use around the world, examining substances for purity and for the presence of contaminants or impure aspects of the supply, like fentanyl, as David mentioned. And overdose prevention sites or centers, safer consumption spaces, which are places where people can use substances and trained people will respond and take care of them in case they overdose or have another untoward outcome.

Q: You both recently co-authored a commentary in New England Journal of Medicine, where you talk about harm reduction strategies or policies in the United States. So can you explain the history or lack thereof of harm reduction strategies or policies in the U.S.?

Fiellin: The United States has had a fluctuating history of recognizing and endorsing harm reduction strategies, especially as they relate to people who use substances and have substance use disorders. We use harm reduction strategies all the time in other parts of medicine and public health. Unfortunately, we tend to think of substance use disorders in non-medical terms. As a primary care physician and somebody who treats patients who have depression, schizophrenia, diabetes, asthma, I recognize that in…

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