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The Opioid Crisis: Harm Reduction Strategies

Executive Summary

Harm Reduction is any program or policy designed to reduce drug-related harm without requiring the cessation of drug use. There are many established and emerging harm reduction strategies to prevent opioid overdose-related mortalities, including administering naloxone, safe injection sites, drug checking services, and opioid substitution therapy. 

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Detecting Opioid Overdose

To reduce harms related to opioid use, it is important to first recognize the signs of an opioid overdose. Opioid overdose is identified by a combination of three signs and symptoms referred to as the “opioid overdose triad”. The symptoms of the triad are:

  • Pinpoint pupils
  • Unconsciousness
  • Respiratory depression [2]

 

Treatment of overdose should be initiated if the person is not rousable and the respiratory rate is visibly slowed (i.e. less than 10 breaths per minute). In managing opioid overdose, the primary focus should be to address respiration and oxygenation, including assisted ventilation with rescue breathing or bag and mask with supplemental oxygen, if possible.[2]


Naloxone

For the treatment (reversal) of opioid overdose, WHO recommends using naloxone. Naloxone is a short-acting opioid antagonist that binds very tightly to opioid receptors, replacing other opioids that may be there and blocking other opioids from binding. It has a long clinical history of successful use for the treatment of opioid overdose. Specifically, naloxone is used in opioid overdoses to counteract life-threatening depression of the respiratory system and the central nervous system, allowing an overdose victim to breathe normally. The medication has no effect if opioids are absent and naloxone has no potential for abuse. In addition to reversing respiratory depression, naloxone may induce withdrawal symptoms in the dependent user under the influence of opioids, which, although unpleasant, are short-lived. Significant adverse effects of naloxone are extremely rare. Naloxone is on the WHO Model List of Essential Medicines and should be available in all health-care facilities that may be called upon to respond to opioid overdose.[2]

In the case of suspected opioid overdose, any respiratory arrest should be managed with assisted breathing and/or oxygen while waiting for naloxone to be administered and take effect. Naloxone is fast-acting, and adequate respiration will typically resume within 3-7 minutes of intramuscular administration of naloxone.[2]

If naloxone is not available, overdose can be treated immediately with respiratory support, either mouth-to-mouth, with a bag and mask, or with pressure-controlled ventilation.[2]


Safe Injection Sites

Supervised injection sites (SISs) are an evidence-based harm reduction measure. [3] SISs are controlled health care settings where drug users can inject their own personally acquired illicit drugs under the supervision and receive health care, counselling and referral to social, health and drug use treatment services. SISs have been established in cities with significant "open" drug scenes where large numbers of individuals with substance use disorders tend to congregate and inject in public. SISs now exist in over 70 cities in six European countries, in Sydney, Australia and in the Downtown Eastside of Vancouver. They are typically "low threshold" services in that entry rules and restrictions are kept to a bare minimum. Typically SISs have both public health and public order objectives.[5]

The benefits of offering supervised injection sites include:

  • Reduces number of overdose deaths
  • Provide a safe, clean, and secure place for users to inject while reducing the visibility of drug consumption on the street
  • Provides an opportunity for multiple contacts with health care staff, social workers, and others who can help people with substance user disorders move toward healthier choices, such as drug treatment programs, primary health care, and other social services
  • Reduces HIV and hepatitis C transmission, and ensures that injecting equipment remains inside and is not discarded in the community
  • Reduces risks to the community as the open consumption of drugs can be more easily discouraged. [6]

Drug Checking

Drug checking is a harm reduction intervention that has received attention in Canada for its potential to reduce opioid-related harms in the population and for it’s use in some regions of Europe since 1992. These services typically allow individuals to anonymously submit samples of a drug they plan to consume for the purpose of drug analysis. Depending on the purposes and organization of the service, the testing may be used to confirm whether the sample contains the psychoactive substance the individual intended to use, estimate the purity of the drug, detect novel psychoactive substances, identify contaminants, or monitor drug use patterns.[4]

When drug checking is conducted for a harm reduction purpose, it may take place at an established drug checking site or at a location or event where drugs may be used. In this environment, the testing is often paired with counselling where individuals can discuss drug use, overdose prevention, and referral to other health services as needed, as well as access harm reduction supplies.[4]


Medication-Assisted Treatment

Medication-Assisted Treatment (MAT) or Opioid Replacement Therapy, involves replacing an opioid, such as heroin, with a longer acting but less euphoric opioid. Commonly used drugs for MAT are methadone or buprenorphine which are taken under medical supervision.[1]

The driving principle behind MAT is the program's capacity to facilitate a resumption of stability in the user's life, while the patient experiences reduced symptoms of drug withdrawal and less intense drug cravings; a strong euphoric effect is not experienced as a result of the treatment drug. In practice, 40-65% of patients maintain complete abstinence from opioids while receiving opioid replacement therapy and 70-95% are able to reduce their use significantly.[1]

Medication-Assisted Treatment is endorsed by the World Health Organization, United Nations Office on Drugs and Crime and UNAIDS as being effective at reducing injection, lowering risk for HIV/AIDS, and promoting adherence to antiretroviral therapy.[1]


Public Education

Many opioid overdoses occur in public settings. Community members may not recognize overdose, may not be aware of the need for help or, depending on the culture, may not be comfortable with rescue breathing. In addition, studies have documented an unwillingness to call an ambulance when witnessing an overdose because of the high financial cost of receiving medical care; fear of police involvement, fear of arrest or fear of being placed on an official register of drug users; and the perception that emergency services will either not respond or will not treat an overdose effectively. [2] Maintaining public education on the opioid crisis can equip family, friends, and community members with the ability to contribute in combatting the opioid crisis. 


Conclusions

The aftermath of an overdose should also include discussion of ongoing drug or pain treatment after the effects of the naloxone have worn off. All people using opioids, whether by prescription or illicitly, should receive education on the factors increasing the risk of overdose and on recognition of overdose symptoms, as well as on the need for respiratory support and medical assistance in cases of overdose. In addition, negative health outcomes associated with non-fatal overdose, such as respiratory infections, may develop later. Individuals should thus be advised to seek a basic health screening in the days following an overdose.[2]


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