Harm Reduction 101 Safe talk about using drugs Scott Steiger, MD, - - PDF document

2/28/2019 1

Safe talk about using drugs

Harm Reduction 101

Scott Steiger, MD, FACP , FASAM Associate Clinical Professor of Medicine and Psychiatry - UCSF Deputy Medical Director, Opiate Treatment Outpatient Program – ZSFG Scott.Steiger@ucsf.edu

Disclosures

 No financial relationships to disclose  Trade names may occasionally be used for clarity

2/28/2019 2

Acknowledgments

 Harm Reduction Coalition  Eliza Wheeler  Charles Hawthorne  Einstein/Montefiore  Aaron Fox  University of Washington  Joe Merrill

Outline

 Language activity  “Practical” or “clinical” harm reduction activity  Resources  Questions, comments, concerns

2/28/2019 3

What is wrong with this clinical picture? What is wrong with this clinical picture?

2/28/2019 4

What is wrong with this clinical picture? Words matter LANGUAGE  BELIEFS  ACTION

2/28/2019 5

Words matter, but they’re not the only thing LANGUAGE  BELIEFS  ACTION

“Drug abusers”  “weak-willed” or “bad people”  poor medical care “PSA”  “demanding”  no treatment of OUD, AMA, missed opportunity for reducing harm from ongoing use

We do “harm reduction” all the time

 Counseling on diet, exercise  Anti-hypertensives  Oral hypoglycemic agents, insulin  anticoagulants  IVF, pressors  Dialysis  AICD

2/28/2019 6

Most people with substance use disorders are not in treatment

SAMHSA, NSDUH Data Review, Sept 2016

2/28/2019 7

Wheeler et al., MMWR, 2015

It is the law (in CA)!

AB-2760, effecitve 1/1/2019:

 Covers all people authorized to prescribe a medication  Naloxone must be offered to all patients who  High dose opioids (morphine>90 mg daily)  Opioids+benzos  h/o OD, Substance use disorder, h/o high dose opioids

2/28/2019 8

In addition to naloxone…

24 yo F presents to establish primary care. No complaints. On Nexplanon for birth control. Dropped out of job training program

• recently. Accompanied by mother who’s worried about her being

“moody.” Screens negative for depression. Screens positive for drug use. “Ballucci” to party, now 7-8x/day.

Clinical harm reduction

 “Create the space”  Privacy  Ask permission  “Can we talk about ______”  Avoid q’s and use normalizing language  “tell me more about____”  “when was the last time you _____”

THE PATIENT IS THE EXPERT ON THEIR OWN DRUG USE

2/28/2019 9

Case, continued

24 yo F presents to establish primary care. No complaints. On Nexplanon for birth control. Dropped out of job training program

• recently. Accompanied by mother who’s worried about her being “moody.”

Screens negative for depression. Screens positive for drug use. “Ballucci” to party, now 7-8x/day.  “Mom can’t know about this”  Reports single episode injection use

 “I’m scared of needles”  Doesn’t like withdrawal, but not ready for tx  “I’ve seen people on methadone and they keep using”

WHAT DO YOU DO NOW?

2/28/2019 10

Clinical harm reduction, continued

 Anticipatory guidance  “When was the last time you used alone?”  “What would you do if you saw someone have a bad reaction to their drug?”  “Can we talk about your options if you want to cut back some day?”  Learn about subjective drug effects  “What does it feel like when you…” (use/don’t use)  Educate on objective drug risks  “Can we talk about what opioids and stimulants do to your body?”  Prescribe appropriate risk reduction materials  Naloxone, syringes, etc.

Resources

2/28/2019 11

https://harmreduction.org/

https://harmreduction.org/wp-content/uploads/2011/12/SAP.pdf

2/28/2019 12 https://harmreduction.org/wp-content/uploads/2011/12/getting-off-right.pdf

2/28/2019 13

www.yestoscscalifornia.org

2/28/2019 14

“Maybe them no like your medicine”