A recent report reveals California’s “Death Certificate Project,” is terrorizing doctors into under‐prescribing or even abruptly terminating medication for acute and chronic pain patients. The project investigates doctors who have treated patients identified as overdoses on death certificates and considers rescinding their licenses or charging them with homicide.
It is scandalous that we doctors and our patients are the latest victims of America’s war on drugs, while deaths from nonmedical use of licit and illicit drugs continue their exponential and perpetual climb—with no end in sight. It is time to change the prevailing approach to the crisis. The goal should shift from reducing production and prescription of painkillers to reducing death and harm.
Harm reduction strategies begin with the realistic, nonjudgmental premise that there has never been and will never be a drug‐free society. Akin to my profession’s credo—“First, do no harm”—harm reduction seeks to mitigate the harms caused by black market drugs, fueled by drug prohibition. Instead it aims at reducing the spread of disease and death from drug use.
The U.S Centers for Disease Control and Prevention recently released the latest results of the current strategy: opioid‐related overdose deaths in 2017 continued their steady climb, increasing 13 percent over 2016 totals. This happened despite the fact that per capita high‐dose opioid prescriptions fell 58 percent from 2008 to 2017, while the number of all opioids dispensed fell 29 percent from 2010 to 2017.
The focus on prescription opioids has only served to change the make‐up of the overdose numbers. In 2017, fentanyl or heroin accounted for 75 percent of opioid‐related overdose deaths and, according to CDC data, 68 percent of deaths from prescription opioids involved heroin, fentanyl, cocaine, barbiturates, benzodiazepines, or ethanol. More people take increasingly greater risks with nonmedical drug use. Some might even be self‐medicating to deal with stress or despair.
But while the prohibition strategy has been unsuccessful, harm reduction strategies have been used in much of the developed world, and to a very small degree in the U.S, for over forty years. A deep dive into the data from decades of experience with harm reduction shows a range of methods that are successful in reducing overdose deaths, the spread of infectious diseases, and, in many cases, the nonmedical use of dangerous drugs.
Medication‐assisted treatment is one harm reduction technique in use since the 1960s. This employs a medical replacement for the opioid on which a patient has become dependent, allowing that person to avoid the nightmare of withdrawal—often the chief reason they continue using the drug—without experiencing the fogginess or “high” they get from injecting. The first drug used for this was the synthetic opioid methadone. In recent years, buprenorphine combined with the overdose antidote naloxone (brand name Suboxone) has also proven effective. Research shows more than 50 percent of people with substance abuse disorder have psychiatric co‐morbidities. MAT lets people escape harmful street use, think more clearly, stabilize their lives, and work with therapists while gradually weaning off the substitute. A comprehensive 2017 study found methadone treatment associated with a 69 percent reduction in all‐cause mortality, while buprenorphine treatment led to a 55 percent drop. For those who fail, heroin‐assisted treatment has found a fair amount of success in Switzerland (since 1994), Germany, the UK, Netherlands, and Canada, as noted in a 2018 RAND study.
“Safe Syringe Programs,” endorsed by the CDC, reduce the spread of HIV, hepatitis, and other infectious diseases. One form, needle‐exchange, has existed in the U.S since 1988, and has reduced the spread of HIV by up to 58 percent. Unfortunately, in about half the states anti‐paraphernalia laws stand in the way. Supervised Injection Facilities, also called “safe consumption sites,” ensure needles don’t subsequently get shared or sold because they are used under supervision and returned after use. Staff are close by with the overdose antidote naloxone at the ready if needed, and nudge users into rehab programs. The Lancet reported a 35 percent drop in overdoses resulting from the safe injection site in Vancouver, British Columbia. Over a hundred safe consumption sites exist throughout Europe, Canada, and Australia. Unfortunately, federal drug laws block them in the U.S.
Naloxone is still not accessible enough to opioid users. The overdose antidote is bought off the shelf in Australia and Italy. Unfortunately, it is still a prescription‐only drug in the U.S, despite suggestions from the Food and Drug Administration that it should be reclassified.
Most developed countries recognize the value of harm reduction and make it central to drug policy. Portugal had one of the highest overdose rates in Europe in 2001 when it decriminalized nonmedical drug use and focused nearly exclusively on harm reduction. Now it has the lowest overdose rate in Europe and saw a 75 reduction in heroin use and a 95 percent drop in HIV infections since the policy change.
Critics like Grayson County, KY Sheriff Norman Chaffin dismiss harm reduction as “offering a drunk the keys to his car.” As the decades pass and the deaths mount, it is time to view harm reduction as a way to help the driver get home safely.