Harm Reduction

Kishore and colleagues in NEJM, including Josiah Rich from a university well known to me, discuss the harm reduction approach to injection drug use (IDU). Basically, this means using evidence to guide practice so as to minimize as much as possible the adverse public health consequences of addiction. In addition to the risk of overdose, which is getting most of the attention nowadays, IDU is a means of transmission of Hepatitis C and HIV, and contaminated needles transmit other common infectious organisms that can result in abscesses, and very serious consequences such as myocarditis.

So, assuring that users have access to sterile needles is an obvious way to reduce the damage caused by addiction. But the common reaction among citizens and politicians is that giving addicts injection equipment, or even allowing them to legally possess it, enables and encourages drug abuse and crime. Consequently, possession of hypodermic needles without a prescription is illegal in most states, and only 21 states have authorized any form of needle exchange. These are programs in which addicts can receive clean needles in exchange for used ones. Often they allow only one-to-one exchange, however, which does result in some re-use. According to the linked article, only 47 of 220 rural counties found by CDC to be most vulnerable to HIV and HCV outbreaks had needle exchange programs.

The truth is that there is no evidence that needle exchange programs increase the prevalence of injection drug use, or crime, and plenty of evidence that they reduce the transmission of disease and, by creating contact between users and service providers, they facilitate entry to treatment and can actually contribute to reducing IDU and controlling the epidemic.

The basic reason that these true facts fail to produce good public policy is that people still see addiction as a moral issue. Illicit drug use is stigmatized and many people seem to think that if addicts become infected or die that's their own fault. They seem to think that doing anything to help people who are sick and in desperate need signals approval of conduct that is morally wrong.

So get this straight. It is not a moral failure. In fact, in most cases these days, we are talking about iatrogenic disease -- a disease caused by physicians. Addicts cannot just stop. Their brains have been rewired and their behavior is compulsive. People need help and compassion, not condemnation and abandonment. We need to change both federal and state law. I'm not even going to safe injection sites, which are illegal thanks to congress. Maybe we'll discuss that later.