Harm Reduction Strategies and the Opioid Epidemic

The Opioid Epidemic: A Story in Three Waves

In the early 1990s, there was a movement against the outdated concept that pain was an "existential phenomenon." Medical professionals started recognizing pain as the "fifth vital sign," increasing the demand for pain relief-centric treatments. Pharmaceutical companies took advantage of the situation and began pushing their products to a medical field that was scared of not providing adequate pain relief treatment. What started as a well-intentioned movement toward modern medicine eventually led to the birth of unregulated opioid prescriptions in the medical field and its subsequent effects.

This was exacerbated by an aggressive marketing campaign by Purdue Pharmaceuticals for their product, OxyContin, which was marketed as the ideal pain killer. The rise in prescriptions of OxyContin led to more Americans becoming dependent on opioid products for their pain relief. When the prescriptions of opioid-dependent individuals ran out, they were forced to turn to other opioid sources: typically heroin.

Decades after the introduction of OxyContin, Purdue Pharmaceuticals has plead guilty to criminal charges regarding their marking of OxyContin and the intentional lack of disclosure about how addicting their formula was.

An advertisement for OxyContin, an opioid product produced by Purdue Pharmaceuticals. Source: Genetic Literacy Project

According to the CDC, the gradual rise in deaths involving opioid overdose can be outlined in three waves. The first wave was in the 1990s and involved the overuse of prescription opioids. In 1999 the death toll due to prescription opioids was 3,442; in 2020, more than 16,416 people lost their lives to the latter. The second wave in early 2010 resulted in an increased death toll due to the newfound use of heroin. Nearly 143,000 people died from a heroin overdose from 1999 to 2020. The current third wave, and the deadliest, is responsible for the rise in synthetic opioids, especially "illicitly manufactured fentanyl." In 2020 alone, more than 56,000 people died from overdoses relating to the third wave.

In 2017, the HHS declared a public health emergency due to the misuse of these highly addictive synthetic opioids and their impacts. The effect these drugs have on their users include changes in behavior, dependence on the drug, and severe pain and discomfort during withdrawal, among other often fatal consequences. Unfortunately, the number of deaths due to opioid overdose continues to rise despite public health efforts to prevent addiction and increase awareness. The CDC recorded that from 1999 to 2020, more than 564,000 Americans died from opioid overdose.

In 2021, the Massachusetts Department of Public Health recorded an 8.8% increase in opioid-related deaths compared to 2020. The latter was a lower trend than the national data, which saw a rise of 15%. Therefore, if the United States has not been able to combat the ongoing opioid epidemic after nearly thirty years, what should be the next steps? The answer may lay in the concept of harm reduction strategies, proven successful in other countries and just recently financially supported by the Biden Administration.

Saving Lives and Destigmatizing Substance Use Disorders

As stated by Harm Reduction International, harm reduction refers to "policies, programs, and practices" created to decrease the "health, social and legal impacts associated with drug use, drug policies, and drug laws." Harm reduction strategies are not meant to replace treatment but serve as a human rights-centric approach to diminish the adverse effects of drug use.

Among the different "health and social services and practices" offered are safe injection sites, needle exchange programs, and opioid treatment programs, as outlined by the American Addiction Centers.

Furthermore, apart from saving lives through a humane and non-coercive evidence-based approach, the movement towards harm reduction aims to destigmatize drug use and improve drug-related laws and policies.

Even though harm reduction has been well-received in the international community, only eighty-seven countries have at least one initiative in place. For instance, in Latin America, the country with the most initiatives in place is Mexico; they have explicit reference to harm reduction in their national policy, needle and syringe programs, opioid agonist therapy, and peer distribution of naloxone. In Sub-Saharan Africa, however, most countries only have explicit support for harm reduction in national policy but lack the infrastructure to further their initiatives—like in Ghana. Nevertheless, despite the newfound support for harm reduction, some communities significantly reject the movement.

This is due to the common misconception that harm reduction incentivizes drug use and enables those struggling with a substance disorder. As reported by the AAMC, some jurisdictions "are moving to limit harm reduction services." For instance, California's governor, Gavin Newsom, vetoed a bill allowing cities to open supervised drug injection sites as he was worried about "a world of unintended consequences."

However, as Dr. David Streem stated, "Harm reduction doesn't mean accepting the substance use…it means accepting the person who has a substance disorder." Furthermore, data from the Center for Disease Control and Prevention has shown that people that partake in syringe services programs and other harm reduction strategies are "three times more likely to reduce or stop drug use." As Boston University's School of Medicine Jessie Gaeta, MD, remarks “people should not have to stop using for us to start helping."

An example of a harm reduction advertisement. Source: Drug Policy Alliance

What Comes Next?

Harm reduction policies in the United States have "advanced substantially in recent years but still lag behind more advanced jurisdictions." Nevertheless, the Biden-Harris Administration's inclusion of evidence-based harm reduction in their National Drug Control Strategy sets a precedent for more targeted action to halt the growing death rate due to opioid overdose. The initiatives from the latter strategy include $30 million in grants for harm reduction services, expanding access to naloxone, allocating federal funding to purchase fentanyl test strips, and supporting the FDA approval of higher-dose naloxone products.

Similarly, the City of Boston's harm reduction toolkit outlines the city's aims to expand harm reduction services in healthcare settings, incorporate harm reduction strategies in housing and homelessness programs, expand safe injection sites in high-impact areas, and educate the public on harm reduction strategies.

As time progresses and the death toll of the opioid epidemic increases, it appears that more communities will join the movement toward facilitating harm reduction programs and strategies.