Principles of harm reduction for young people who use drugs

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Principles of harm reduction for young people who use drugs.

Kimmel S.D., Gaeta J.M., Hadland S.E. et al.
Pediatrics: 2021, 147, S240.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Kimmel at simeon.kimmel@bmc.org.

[Consultation draft subject to amendment and correction.] A group of paediatric addiction medicine experts in the US review the evidence base and agree on practice considerations for harm reduction for young adults. The principles of care identified in this document include a role for physicians to integrate harm reduction services into their medical practice.

Summary The objective of the featured article was to communicate a series of evidence-informed principles of care for young adults (defined as people aged 18–25) with substance use disorders, agreed by a national group of paediatric addiction medicine experts in the United States. The featured paper focuses on harm reduction, and specifically on strategies directly linked to safer drug use practices.

Principle 1: Harm reduction services are critical for keeping young adults alive and healthy and can offer opportunities for future engagement in treatment

Evidence. There is robust evidence to support the use of harm reduction interventions for improving the health of people who use drugs. Distribution of sterile syringes and injecting equipment reduces HIV transmission and soft tissue infections. In fact, the volume of syringes distributed and made available is directly linked to proportionally lower rates of subsequent HIV infections. Hepatitis C infections can also be dramatically decreased when distribution of sterile syringes is paired with ready access to medication to treat opioid use disorder. When syringe service programs close or are not scaled up in the setting of outbreaks, behaviours associated with increased risk for HIV and subsequent HIV infections increase. Additionally, community-based programs that distribute naloxone dramatically reduce fatal opioid overdose. A strong body of evidence from outside the United States reveals that supervised consumption facilities are acceptable to marginalized and structurally vulnerable individuals, promote safer injection practices, reduce overdose mortality and public injecting, and increase access to treatment without increasing overall drug use or crime in a neighbourhood. Growing evidence suggests that drug checking, in which the contents of a drug is confirmed before consuming, may promote harm reduction behaviours. Although most harm reduction programs are located outside the hospital setting, emerging evidence suggests many of these interventions, including syringe distribution and hospital-based supervised consumption, are of interest to people who use drugs and can be integrated into traditional clinical settings, including clinics and hospitals. Abstinence-only approaches and stigma associated with drug use drive individuals at high risk for drug-related complications away from services and care. Nearly half of individuals who died of opioid overdose in Massachusetts in 2014 did not have an encounter in the health care system related to opioid use disorder. Harm reduction programs and approaches offer an opportunity to engage these individuals and, if and when they are able, ultimately offer subsequent opportunities for treatment and services. Additionally, harm reduction programs can provide valuable infrastructure for broader public health interventions, such as HIV and hepatitis C testing and immunisations.

Practice considerations. Harm reduction programs and approaches are needed to reduce the negative consequences from substance use for all young people. Existing interventions with strong evidence need expansion to better reach young adults who use drugs, and additional studies are needed to evaluate novel harm reduction interventions for these populations. However, harm reduction programs require additional financial and human resource investments. Additionally, in many states, syringe distribution is illegal34; as of late 2019, the country still does not have a legally sanctioned supervised consumption facility.35 Past experiences with stigma, pain, trauma, and restrictions in the traditional health care and addiction treatment system often prevent individuals from seeking care.28,29,31 Harm reduction programs offer important opportunities to engage these individuals who may not otherwise seek care. Integrating clinical services to address the needs of individuals who access service in syringe service programs may be desirable in some facilities. For example, some syringe service programs would benefit from integrating primary care and infectious disease care (eg, pre- and post-exposure prophylaxis, abscess care, HIV and hepatitis C virus [HCV] treatment), as well as low barrier buprenorphine prescribing, into these settings. Clinicians should be mindful that such integration of clinical services should be driven by syringe service program staff and participants, who have expertise about their programs and service needs, respectively.36 New funding streams may be needed to support the expansion of these clinical services. Additionally, clinicians should integrate harm reduction principles into their routine clinical work in every setting, especially for young adults who use drugs. The adoption of harm reduction approaches may counter the fear of medical care and addiction treatment and begin to confront the stigma that keeps many people who use drugs from accessing needed clinical care.28,37 Clinicians must develop the skills, approaches, and referral capacity to successfully engage and treat people who use drugs to improve their overall health. Clinicians and clinical programs should learn to provide harm reductioncentred, pragmatic, humanistic care without abstinence as a precondition for engagement. Additional trainings may be necessary not only to teach about harm reduction principles but also to increase capacity to counsel directly with patients about injection practices and overdose risk.

Principle 2: All evidence-based harm reduction strategies available to older adults should be available to young adults

Evidence. Young people access harm reduction resources less frequently than older people who use drugs, despite riskier injection practices, including reuse or sharing of syringes and higher rates of concurrent sexual risk factors. As a result, young people are at disproportionate risk of HIV and hepatitis C infection compared with older people who use drugs. Rather than access existing community services, young people often employ harm reduction approaches within their social networks. For example, young people may attempt to minimise risk by using with other people around or using intra-nasally rather than by injection to reduce risk of harm. Young people who do use harm reduction services are particularly vulnerable. They are more likely to experience homelessness, incarceration, and psychological distress than older participants. Young people also frequently report that programmes focus too narrowly on the harm from drug use rather than on their broader social and psychological needs. Notably, girls and young women may be even less likely to be engaged in harm reduction services and more concerned about having their substance use exposed and having their service use tied to male partners. Finally, youth may lack information or may believe that services are not needed, despite higher overdose risk, or may prefer to access services from friends or pharmacies.

Several harm reduction models have emerged to address disparities and ensure that young people have access to resources that can improve their health. Peer-led naloxone trainings improve attitudes, altruism, and perceptions of programming among youth at risk for overdose. In addition to ensuring that peers are involved, establishing harm reduction programming in locations and venues that are easily and safely accessed by young adults can also improve treatment acceptance. For example, including harm reduction services in community pharmacies, in mobile units, and at venues where young people are likely to use drugs (eg, festivals, universities, and colleges) may improve service uptake. Incorporating harm reduction education into health curriculum and services in schools has also been attempted and requires further study. Although young adults use social networking sites at high rates, and social media venues have been used effectively to recruit study participants, further studies are needed to understand whether these sites can serve as effective mediums for engaging young people who use drugs in harm reduction education and services. Internet-based sexual health and risk reduction education has been used effectively to reach diverse young populations. The Internet and social media may provide an opportunity to deliver overdose prevention and safe injection practice education to a broader group of young people who use drugs. Despite barriers and obstacles, when harm reduction services are available and youth focused, young adults will access them.14 In one study, high-risk youth who lived or spent time near a supervised consumption facility were more likely to use the services than young people using drugs who lived farther away. Additionally, in other studies, young adults accessed naloxone and fentanyl test strips if they were available at sites they used. In addition to reducing harm from drug use, these programs also engage young people with the highest risk of drug-related harms. To ensure that programs for youth achieve the greatest public health impact, young people who use drugs must be involved at every level of harm reduction programming, including in planning, staffing, implementation, and evaluation, in all harm reduction programs designed for young adults.

Practice considerations. To ensure equitable access for young adults, harm reduction programmes designed for and targeted at young people are needed. Young adults will need to be trained as harm reduction peers and will need to develop the capacity to engage at every level of programming, including evaluation and dissemination. Additionally, there may be opportunities for peer workers to be based in clinical settings, with the goal of improving clinical engagement and clinicians to establish relationships with community programmes. In the United States, federal and state laws prohibiting harm reduction or restricting access to funding have long impeded the implementation of such interventions, particularly in areas hardest hit by the opioid crisis. The expansion of certain approaches (eg, harm reduction education in the school curriculum, nurse distribution of harm reduction materials, and naloxone access in schools) may require changes to local laws, paired with legal and political efforts to ensure that harm reduction interventions reach young people most at risk.

The authors’ conclusions

Given the scale and scope of the opioid crisis in the United States, support for harm reduction programmes among policymakers, public health professionals, and clinicians is overdue. This should include programmes that are commonplace in other countries, including needle and syringe programmes, supervised consumption facilities, and drug safety testing programmes. Moreover, to reach a broader population of young people at risk, harm reduction approaches should be extended into non-traditional venues, such as pharmacies, schools, drop-in centres, clubs, social service agencies (including shelters), and online environments.

Harm reductions interventions will often require strong community and institutional support and, in some cases, may necessitate changes to local or state laws. Paediatricians, family physicians, addiction medicine providers, and other clinicians who work with young adults will need to join these efforts. As screening and treatment of substance use disorders are increasingly integrated into medical settings, youth-focused clinicians will inevitably work with young adults who would benefit from harm reduction services. Although physicians are often not taught the principles of harm reduction in traditional medical training, they are nonetheless familiar with the medical considerations underlying overdose and transmission of blood-borne diseases. They also routinely counsel young adults on harm reduction in other contexts, such as using condoms during sexual intercourse. Thus, they are well poised to integrate harm reduction services for people who use substances into their medical practice. Given their clinical understanding of adolescent and early adult development, clinicians can also support community-based harm reduction programmes in designing developmentally-appropriate and youth-friendly services.

Ultimately, because young adults are among those most heavily impacted by the national addiction and overdose epidemics, organisers of both established and emerging harm reduction programmes should identify ways to ensure that their programming is youth-friendly and, if possible, youth centred. Because youth are active agents in their own health promotion and in the broader community, the meaningful inclusion of young adults who use drugs in harm reduction planning, service delivery, and evaluation is paramount to the effectiveness and success of these programmes.


Findings logo commentary The featured paper described recovery services for young adults. This is the fifth in a set of papers covering the principles of care for young adults with substance use disorders. See the full set below:

  1. Evidence-based substance use treatment of young adults with substance use disorders
  2. Engaging the family in the care of young adults with substance use disorders
  3. Support services for young adults with substance use disorders
  4. Principles of care for young adults with co-occurring psychiatric and substance use disorders
  5. Principles of harm reduction for young people who use drugs
  6. The justice system and young adults with substance use disorders

This collection of papers provides an up-to-date review of the evidence base and offers policy and practice considerations from the perspective of a working group of paediatric addiction professionals in the US.

In the UK, there is no more important document for UK clinicians involved in treating problem drug use than the ‘Orange guidelines’ (last published in 2017) – based on evidence and professional consensus on how to provide treatment for most patients, in most instances. These guidelines highlight considerations for children and adolescents as well as older people, but do not specifically address the population of young adults with substance use problems.

An Effectiveness Bank hot topic offers background and analysis on the topic of harm reduction, an extract of which is included below:

“In these debates the fundamental question is whether harm reduction is a primary goal, a second-best outcome when recovery is for the moment unattainable, or valid only as an engagement strategy and platform for recovery. The answer flows down to operational issues, such has how to weight the alternatives when harm reduction gains are threatened by trying for ‘full recovery’, riskily entailing the end of substitute prescribing and treatment exit.”
“Peacemakers try to gloss over the divides with, ‘We are all in the same game in the end, aren’t we?’, posing harm reduction and abstinence-based recovery as ends of an unbroken continuum of helping the patient, to which all can sign up. But in reality these are different games, their rules and aims deriving from differences in what we value most and how we see drug use: as always bad, or only bad if it causes harm.”

Last revised 19 February 2021. First uploaded 19 February 2021

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