Over the past 2 decades, drug overdose deaths have drastically increased (Centers for Disease Control and Prevention [CDC], 2017c). Illicit substance use is not restricted to urban or metropolitan areas. In fact, rural communities across America are affected. Although prevalence of illicit substance use is greater in urban areas, overdose death rates in rural areas has exceeded urban rates for the past 10 years (CDC, 2018). In addition to overdose deaths, incidence of Hepatitis C infection among individuals who inject drugs rose 294% over the years 2010–2015 (CDC, 2017b). Further, the National Institute on Drug Abuse (2017) reports that addiction and abuse of tobacco, alcohol, and illicit substances costs more than $740 billion per year in lost productivity, crime, and health care expenses. Facing a mounting public health crisis, thoughtful evidence-based interventions must be employed.
Harm Reduction Strategies
Harm reduction approaches are practical strategies used in attempt to minimize or allay the deleterious effects of substance use. The harm reduction model encompasses a multitude of approaches to reduce risk and promote healthier habits (Logan & Marlatt, 2010). Historically, some more recognized and widely accepted interventions have included encouraging smoking cessation in pregnant women, nicotine replacement therapies, smoke-free public places, consistent condom use and safe-sex practices, and designating drivers responsible for safe transportation. More recently, harm reduction models associated with illicit substance use include medication-assisted treatment (MAT) for opioid addiction, such as methadone or buprenorphine, distribution of naloxone for opioid overdose reversal, needle exchange programs that supply sterile needles and clean injection supplies, education regarding safe intravenous injection practices and phlebotomy skills. In some countries, medically supervised injection facilities are often staffed by specially trained nurses (Lightfoot et al., 2009).
Research findings validate the benefits of these harm reduction strategies, not only for individuals with substance use disorders, but also for the health of their surrounding communities. Evidence substantiates that MAT can lead to long-term recovery, improving prescribed patients' health and decreasing other risk-laden behaviors (Substance Abuse and Mental Health Services Administration, 2018). Needle exchange programs are associated with fewer discarded used syringes in the neighborhoods served, and clients accessing needle exchange programs are five times more likely to seek treatment for their substance use disorders. Further, needle exchange programs have not been associated with increased crime or surges in drug use (CDC, 2017a). Currently, needle exchange programs operate in 39 states, and at least 13 U.S. cities are considering opening safe injection sites similar to facilities currently in operation in Europe and Canada (Allyn, 2018).
Code of Ethics and Implications for Nurses
Recent federal legislation such as the Comprehensive Addiction and Recovery Act of 2016 and Substance Use Disorder Prevention that Promotes Recovery and Treatment for Patients and Communities (SUPPORT) Act of 2018 have appropriated monies and shifted policy from punitive action toward a sweeping public health response. Recognition of addiction as chronic illness rather than poor choice or bad behavior has become more widely accepted by health care professionals and public perception alike (Bartlett, Brown, Shattell, Wright, & Lewallen, 2013). Increasingly, nurses encounter opportunities to educate affected patients and families regarding harm reduction strategies—working toward ending stigma and shame and encouraging healthier habits that may moderate injury and/or infection exposure. Although some nurses may question the ethical implications of supporting harm reduction strategies, the American Nurses Association (2015) Code of Ethics includes the following statement:
Nurses establish relationships of trust and provide nursing services according to needs, setting aside any bias or prejudice. Factors such as culture, value systems, religious or spiritual beliefs, lifestyle, social support system, sexual orientation or gender expression, and primary language are to be considered when planning individual, family and population-centered care. Such considerations must promote health and wellness, address problems, and respect patients' or clients' decisions. Respect for patient decisions does not require that the nurse agree with or support all patient choices. When patient choices are risky or self-destructive, nurses have an obligation to address the behavior and offer opportunities and resources to modify the behavior or to eradicate the risk.
Further, nurse practice acts in some states justify and protect nurses seeking to educate patients regarding healthy lifestyles and promotion of health (Bartlett et al., 2013).
Overdose now represents the leading cause of injury deaths (CDC, 2018). This epidemic affects individuals regardless of their race, ethnicity, education, or social status—and marginalized or vulnerable populations, such as the homeless, pregnant women, Veterans, or individuals with co-occurring mental health diagnoses, may suffer disproportionately.
It is imperative for nurses to educate themselves regarding harm reduction interventions and the particular treatment models implemented in their own communities (Table 1). Adoption of harm reduction strategies not only advocates for patients' safety by minimizing infections and overdoses, but also promotes a comprehensive public health response to ensure the vitality and safety of communities. Psychiatric–mental health nurses with experiences and perspectives gained in the care of individuals affected by substance use are in a unique position to advocate for those affected by substance use and addiction, within families and communities, but also within the community of health care providers. Harm reduction models and strategies can aid psychiatric–mental health nurses in this important work.
Resources Regarding Harm Reduction Strategies
Dolly Pressley Byrd, MSN, CNM
Robin Bartlett, PhD, RN
Professor and Director of PhD Program
University of North Carolina Greensboro
Greensboro, North Carolina
- Allyn, B. (2018, July12). Cities planning supervised drug injection sites fear Justice Department reaction. Retrieved from https://www.npr.org/sections/health-shots/2018/07/12/628136694/harm-reduction-movement-hits-obstacles
- Allyn, B. (2019, February6). U.S. prosecutors sue to stop nation's first supervised injection site for opioids. Retrieved from https://www.npr.org/sections/health-shots/2019/02/06/691746907/u-sprosecutors-sue-to-stop-nation-s-first-supervised-injection-site
- American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. Silver Spring, MD: Author.
- Bartlett, R., Brown, L., Shattell, M., Wright, T. & Lewallen, L. (2013). Harm reduction: Compassionate care of persons with addictions. MedSurg Nursing, 22, 349–353, 358.
- Centers for Disease Control and Prevention. (2017a). Reducing harms from injection drug use & opioid use disorder with syringe services programs. Retrieved from https://www.cdc.gov/hiv/pdf/risk/cdchiv-fs-syringe-services.pdf
- Centers for Disease Control and Prevention. (2017b). State HCV incidence and policies related to HCV preventive treatment services for persons who inject drugs—United States, 2015–2016. Retrieved from https://www.cdc.gov/mmwr/volumes/66/wr/pdfs/mm6618.pdf
- Centers for Disease Control and Prevention. (2017c). Trends in deaths involving heroin and synthetic opioids excluding methadone, and law enforcement drug product reports, by census region—United States, 2006–2015. Retrieved from https://www.cdc.gov/mmwr/volumes/66/wr/mm6634a2.htm?s_cid=mm6634a2_w
- Centers for Disease Control and Prevention. (2018). Preventing opioid overdoses among rural Americans. Retrieved from https://www.cdc.gov/ruralhealth/drug-overdose/policybrief.html
- Lightfoot, B., Panessa, C., Hayden, S., Thumath, M., Goldstone, I. & Bernadette, P. (2009). Gaining insite: Harm reduction in nursing practice. The Canadian Nurse, 105(4), 16–22.
- Logan, D.E. & Marlatt, G.A. (2010). Harm reduction therapy: A practice-friendly review of research. Journal of Clinical Psychology, 66, 201–214. doi:10.1002/jclp.20669 [CrossRef]
- National Institute of Drug Abuse (2017). Trends and statistics. Retrieved from https://www.drugabuse.gov/related-topics/trends-statistics#supplemental-references-for-economic-costs
- Substance Abuse and Mental Health Services Administration. (2018). SAMHSA published guidance on clinical best practices using medication-assisted treatment to combat the opioid epidemic. Retrieved from https://www.samhsa.gov/newsroom/press-announcements/201802150200
- United States Congress. (2016). The Comprehensive Addiction and Recovery Act of 2016. Public Law 114–198. Retrieved from https://www.congress.gov/114/plaws/publ198/PLAW-114publ198.pdf
- United States Congress. (2018). H.R.6 – SUPPORT for Patients and Communities Act. Public Law 115–271. Retrieved from https://www.congress.gov/bill/115th-congress/house-bill/6/actions
Resources Regarding Harm Reduction Strategies
|Harm Reduction Coalition||Promotes advocacy and capacity building for individuals and communities affected by substance use||https://harmreduction.org|
|National Conference of State Legislatures||Provides overview of drug overdose immunity and good Samaritan laws by state||http://www.ncsl.org/research/civil-and-criminal-justice/drug-overdose-immunity-good-samaritan-laws.aspx|
|Project Lazarus||This public health model asserts two interwoven premises—that overdose deaths are preventable, and communities are responsible for their own health||https://www.projectlazarus.org|