Harm Reduction’s Place In And Among Prevention Treatment And Recovery
A comprehensive prevention strategy, harm reduction is part of the continuum of care. Harm reduction approaches have proven to prevent death, injury, disease, overdose, and substance misuse. Harm reduction is effective in addressing the public health epidemic involving substance use as well as infectious disease and other harms associated with drug use. Specifically, harm reduction services can:
- Connect individuals to overdose education, counseling, and referral to treatment for infectious diseases and substance use disorders.
- Distribute opioid overdose reversal medications to individuals at risk of overdose, or to those who might respond to an overdose.
- Lessen harms associated with drug use and related behaviors that increase the risk of infectious diseases, including HIV, viral hepatitis, and bacterial and fungal infections.
- Reduce infectious disease transmission among people who use drugs, including those who inject drugs by equipping them with accurate information and facilitating referral to resources.
- Reduce overdose deaths, promote linkages to care, facilitate co-location of services as part of a comprehensive, integrated approach.
- Reduce stigma associated with substance use and co-occurring disorders
- Promote a philosophy of hope and healing by utilizing those with lived experience of recovery in the management of harm reduction services, and connecting those who have expressed interest to treatment, peer support workers and other recovery support services.
Section : Prenatal Care
Accessing prenatal care is the single most important thing you can do not only for parental, fetal, and infant health, but also to prepare for any legal challenges that may occur. If you are labeled by healthcare providers as late to care you can face additional barriers when seeking quality healthcare and are more likely to be referred to child welfare. Be prepared to advocate for yourself and your family. Keep records of phone calls, appointments, and any other information relating to your prenatal care. Be sure to start taking prenatal vitamins as directed by your medical provider and get enrolled for prenatal care with your health insurance provider as soon as possible.
Medicaid in New York State
New York State Medicaid can help you get the care you need for you and your baby. Pregnancy care and other healthcare services are available for people who live in New York State and are eligible for Medicaid. To see if you can access Medicaid programs for pregnant people, call the Growing Up Healthy Hotline 522-5006 or go to the website:health.ny.gov/health_care/medicaid/.
Download: My Pregnancy and Prenatal Care Worksheets
What Treatment Options Are Available For Stimulant Use Disorder During Pregnancy
Currently, there are no FDA-approved medications for the treatment of stimulant use disorder. However, there are some off-label uses of medications that may be helpful. The off-label use of medications is common and is the norm for medication taken during pregnancy and lactation because few drugs are tested on pregnant and lactating people. Off-label prescribing is when a physician gives you a drug that the U.S. Food and Drug Administration has approved to treat a condition different than your condition or approved for your condition when someone is not pregnant or lactating.
Topiramate , modafinil , ondansetron , and prescription stimulants amphetamine , dextroamphetamine and dexedrine , atomoxetine , methylphenidate have been studied in non-pregnant people and have been helpful in some cases but not all.
Some people find that group or individual therapy is helpful especially when done with those who understand substance use and substance use disorders. Others use 12 step or mutual support programs such as Cocaine Anonymous or Narcotics Anonymous but these can sometimes be stigmatizing or shaming to pregnant people.
Contingency management has been shown useful in the treatment of people with stimulant use and other substance disorders.
TOBACCO + NICOTINE
TOBACCO + NICOTINE + PREGNANCY
This is a list of tobacco and nicotine products, from most harmful to least harmful:
- Gum and lozenges
TOBACCO + NICOTINE + LACTATION
CHILDREN + SMOKE EXPOSURE
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What Are Some Examples Of Harm Reduction
Some practices that take a harm reduction approach include: using a nicotine patch instead of smoking, consuming water while drinking alcohol, using substances in a safe environment with someone they trust, and needle exchange programs for people who inject drugs. Harm reduction doesnt just apply to the use of substances. We engage in harm reduction in our everyday lives to minimize a risk, such as wearing a helmet when riding a bike or enforcing seatbelts when driving in a car.
In order to further understand the philosophy behind Harm Reduction, it is important to discuss the main features, which include:
- Pragmatism: Harm Reduction recognizes that substance use is inevitable in a society and that it is necessary to take a public health-oriented response to minimize potential harms.
- Humane Values: Individual choice is considered, and judgement is not placed on people who use substances. The dignity of people who use substances is respected.
- Focus on Harms: An individuals substance use is secondary to the potential harms that may result in that use. iv
What Treatment Options Are Available For People With Alcohol Use Disorder Who Are Pregnant
There are many approaches to treatment for people who want to change their drinking or stop drinking completely. A few common ways are:
- Medications to treat alcohol use disorder
- Group therapy and individual counseling
- Attending 12 Step meetings such as Alcoholics Anonymous or other free community meetings like Moderation Management, SMART Recovery, or Harm Reduction for Alcohol .
Sometimes, 12 Step groups can be unwelcoming or shaming toward pregnant people or people using medication for opioid use disorder, so its important to find a group or a method that is supportive of your needs.
The medications available for the treatment of alcohol dependence are naltrexone tablets or injections , acamprosate , disulfiram and gabapentin . We dont have good information on how safe these medications are during pregnancy, but some of them are likely to be much safer than continuing to drink. Acamprosate is likely safe, as is naltrexone , while disulfiram is not recommended. Consult with a provider before taking any of these medications while pregnant.
ALCOHOL WITHDRAWAL
In some cases alcohol dependency and withdrawal are associated with serious complications such as seizures. If you are alcohol-dependent and are trying to decrease your alcohol consumption, dont quit cold turkey. Work with a medical provider, especially if you have had seizures before. In rare cases, alcohol detox can lead to death. Ask for help.
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The Need To Reduce Substance Use Stigma In The Health System
Key message 1: Substance use stigma is prevalent throughout the health system and contributes to poorer quality of care and negative health outcomes.
Substance use is a cross-cutting theme across the Canadian health system, and for various reasons. Most Canadians use substances in one form or another and in diverse contexts. Many Canadians access care settings for treatment or management of health conditions related to substance use, including substance use disorders and infectious and chronic diseases for which substance use is a risk factor. Patients substance use often is discussed during routine medical history taking within various health settings. Further, health professionals commonly prescribe substances to their patients to treat and manage pain and other health conditions. Despite these realities, substance use stigma is salient within the health system .
Harm Reduction In Marginalized Communities
We may not realize the degree to which our society is built to fail most of us until multiple pandemics come along and highlight just how underserved some of us are in significant ways.
These cumulative stressors make Black, Latinx, and LGB/TGNC individuals more inclined toward risk-taking behaviors, including alcohol and other substance use . Meanwhile, the stigma and violence targeted toward people who use substances prompted by the racially-discriminatory war on drugs is still the predominant barrier preventing lifesaving harm reduction education and materials from reaching the vulnerable populations who benefit from them the most.
Harm reduction education and resources respect the self-determination, autonomy and human dignity of every individual while also emphasizing public health and reducing the risks of using substances. Much like using a seatbelt while riding in a car reduces the risk of death or serious injury in the event of a car accident, evidence-based harm reduction practices reduce the risk of overdose while using substances.
Whether safety practices are in place or not, people are going to drive cars and people are going to use substances. We must do our best to use compassionate care to save lives. As the National Harm Reduction Coalition says, its not what drugs you do, but how you do them. Abstinence-only paradigms and the societally-conditioned stigma around substance use ignore the complexity of human behavior and society .
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Reduce The Harms Of Drug Laws And Policy
Harm reduction seeks to improve drug laws, policies and law enforcement practices, so that they are not detrimental to the health and wellbeing of people who use drugs and their communities. Many policies around the world create and exacerbate the potential risk and harms of drug use. These include: the criminalisation of people who use drugs abusive and corrupt policing practices the denial of life-saving medical care and harm reduction services restrictions on possession of injecting paraphernalia forced urine testing and detention in the name of rehabilitation and, discrimination based on drug use, class, race, and gender. Harm reduction challenges international and national laws, and policies that contribute to drug-related harms.
Fighting Back Against Stigma
People report perceived stigma from healthcare providers, loved ones, and the general public. No matter the situation, no one likes to feel judged or devalued. In order to encourage people to reach out for addiction help and get on the path to recovery, it is important to reduce the stigma surrounding their situation. Educational programs and modeling of nonstigmatizing behavior can help people provide nonjudgmental, empathic support.
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Overview Of Included Studies
Our searches identified 23 papers : 22 published papers , and one grey literature study . Four papers were from two studies , meaning the findings from 21 studies were synthesised.
Fig. 1
Characteristics of the included papers are detailed in Table . In this table, we highlight the differences in these included studies, in terms of setting, participant demographics and intervention/service. Briefly, the 21 studies were conducted between 2002 and 2018 in the USA , Canada and the UK , involving 462 participants ranging from 18 to 62 years. Three studies focused entirely on women , and five involved men only . In the remaining studies, although women were involved, 50% to 84% of participants were male only one study reported a majority of female participants .
Table 4 Characteristics of included studies
Study findings reciprocally translated into our a priori categories as follows.
What treatments/interventions are perceived as effective by those using them, and why?
Table provides details of participant experiences with harm reduction and abstinence-based interventions, delivered in different settings. Participants in the study by McNeil et al. discussed the merits of a hypothetical harm reduction intervention drawing on their experiences of other interventions such as Twelve Step programmes.
Table 5 Substance use interventionsparticipant experiences and perceptions of effectiveness
How does effective treatment work from the perspective of people who are homeless?
Section : Navigating The Healthcare + Legal Systems
Substance use during pregnancy is a complicated medical and legal situation to navigate. You might be anxious about what may happen if you are open about your substance use. In this section, we present you with the federal laws around this issue and some information about what might happen if you do or do not tell your provider about substance use. You can use this information to understand the risks, weigh the benefits and make a plan. Please note that laws will vary widely by state and some providers and agencies might interpret the law differently than it is written. So please consult with local agencies that have expertise.
New York State Resources:
BUILDING A RELATIONSHIP
For pregnant people, there are some potential risks that a provider can help with if they are informed of the whole picture. Starting methadone or buprenorphine can help reduce many of the risks of illicit opioid use while improving both parental and infant outcomes.
LEARN ABOUT YOUR TREATMENT OPTIONS
In New York State, if you are pregnant and want to get on buprenorphine or methadone you can skip the waitlists. For more about pregnancy and substance use in New York State, visit the Office of Addiction Services and Supports website or call 473-3460.
- 24/7 HOPEline: Call 1-877-8-HOPENY or text 467369
ADVOCACY
DISCLOSURE
TALKING TO YOUR HEALTHCARE PROVIDERS ABOUT SUBSTANCE USE
TYPES OF DRUG TESTING
MAKING A PLAN
IF THERE ARE PROBLEMS
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What Treatment Options Are Available For Opioid Use Disorder During Pregnancy
Opioid Use Disorder and Pregnancy fact Sheets from SAMHSA: Substance Abuse and Mental Health Administration
Treatment for opioid use disorder with methadone, buprenorphine , or a buprenorphine-naloxone combination medication is safe for pregnancy and lactation and is the best treatment for pregnant people. Buprenorphine and methadone initiation during pregnancy can vary by state and region. Some healthcare providers might require you to go inpatient to get monitoring on the OB-GYN floor and others might feel comfortable with you doing it as an outpatient.
During pregnancy, the body goes through changes that can make drugs and medications work differently. This means drugs may feel more or less strong than they used to. For example, many people need to adjust their methadone or buprenorphine dose during pregnancy because they start to experience withdrawal symptoms or feel overly-sedated. Report any withdrawal, cravings, or changes in sleep patterns to your doctor. You might need to split your dose of medication into twice a day or three times a day instead of once a day.
In New York State according to the law, you have priority access to treatment if you are pregnant. This means that you are able to skip any waitlists for treatment.
- Medication-assisted Treatment from the New York Office of Addiction Services and Supports
DETOX
MEDICALLY-SUPERVISED WITHDRAWAL
No one should ever be pressured or coerced into detox, especially when pregnant.
OPIOID OVERDOSE + PREGNANCY
Key Harm Reduction Issues
Drug OverdoseAccidental drug overdose is currently the leading cause of death in the United States for those under 50. Most of these deaths are preventable. We are leading the national effort to reduce drug overdose deaths by promoting sensible solutions and better policy at the state and federal level.
NaloxoneNaloxone is an inexpensive, FDA-approved generic drug that works to reverse an opioid overdose without any potential for abuse. Far too many people are still unable to access naloxone. Were working to save lives by ensuring that more people are equipped with naloxone and are able to help in overdose emergencies.
Good Samaritan LawsPeople using illegal drugs often fear arrest if they call 911 when they witness an overdose. The best way to encourage them to seek medical help is to provide them immunity for drug law violations, an approach often referred to as Good Samaritan. We push for the broadest protections possible to ensure people do not hesitate to get live-saving help for someone who has overdosed.
Supervised Consumption ServicesSupervised consumption services , also called overdose prevention centers and supervised injection facilities , are legally sanctioned facilities designed to reduce the health and public order issues often associated with public drug consumption by allowing on-site, supervised use of drugs. We advocate for supervised consumption pilot programs in the U.S.
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Effective Ways For Individuals To Help Reduce Stigma Include:
- Offering compassionate support.
- Displaying kindness to people in vulnerable situations.
- Listening while withholding judgment.
- Seeing a person for who they are, not what drugs they use.
- Doing your research learning about drug dependency and how it works.
- Treating people with drug dependency with dignity and respect.
- Avoiding hurtful labels.
- Replacing negative attitudes with evidence-based facts.
- Speaking up when you see someone mistreated because of their drug use.
- Sharing your own stories of stigma.
Why Are Harm Reduction Services Needed
The U.S. is experiencing the most significant substance use and overdose epidemic it has ever faced, exacerbated by a worldwide pandemic, and driven by the proliferation of highly potent synthetic opioids containing primarily fentanyl and other analogues.
Provisional data from CDC show that we have crossed the tragic milestone of a predicted 100,000 overdose deaths in 12 months from May 2020 to April 2021 this represents a nearly 29 percent increase compared to the same window of time last year.
Harm reduction services save lives by being available and accessible in a matter that emphasizes the need for humility and compassion toward people who use drugs. Harm reduction plays a significant role in preventing drug-related deaths and offering access to healthcare, social services, and treatment. These services decrease overdose fatalities, acute life-threatening infections related to unsterile drug injection, and chronic diseases such as HIV/HCV.
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What Treatment Options Are Available For People With Cannabis Use Disorder Who Are Pregnant
There is no FDA-approved medication specifically for cannabis use disorders or dependence. If you are using cannabis to medicate for pain, anxiety or nausea, discuss with your healthcare provider whether there is a safer treatment method. Many people who continue to use cannabis during pregnancy including those who use it daily might have a cannabis use disorder which might make it more difficult for them to stop. Most people who want to quit cannabis do so without formal treatment, but others have found counseling or group therapy helpful.
Section : Quality Perinatal Care Is Your Right
Pregnant and parenting people who use substances are one of the most stigmatized and demonized subsets of the population. Experience with bias, judgment, and scrutiny especially from healthcare workers, loved ones, family, and friends can isolate people and make it harder to seek prenatal care, mental health counseling, social services, and community support. People dont like to go to places where they dont feel welcomed. They may fear for their safety, or the safety of their children, or their pregnancy.Thats why having even one nonjudgmental and trustworthy person to support them can make all the difference in the world.
You deserve to have providers and support people who affirm you and your gender identity. People of all genders can become pregnant and have healthy birth outcomes.
Check out these resources for you and your providers on fertility, pregnancy, and postpartum support for trans and non-binary folks:
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