Lessons in harm reduction for the Emergency Department

Opioid overdose deaths in the United States have dramatically increased over the past two decades (1,2). Between 2001 to 2016, there was a 345% increase in opioid-related deaths, with an overwhelming burden among adults between the ages of 24 and 35 years (1,2). Of the 52,404 drug overdose deaths reported in 2016, more than 60% involved an opioid (3). In 2022, preliminary reporting indicates that illegally manufactured fentanyl and fentanyl analogs continue to contribute to nearly 70% of the more than 109,000 drug overdose deaths across the United States (4). This underscores the importance of broad commitment from varied points of care across our national health care continuum with focus on prevention, harm reduction, treatment, and policy development to address this ongoing public health crisis.

The Emergency Department (ED) serves as the safety net for society’s most vulnerable members, and is at the frontline of public health, including pandemics like coronavirus disease 2019 (COVID-19), the epidemic of gun violence in the US, and the current opioid overdose epidemic. The ED frequently serves as the initial point of management for the health consequences of drug use, addressing concerns such as overdose, endocarditis, spinal epidural abscess, skin and soft tissue infections, human immunodeficiency virus (HIV), and hepatitis C virus. For many who face risk of overdose, the ED may also be their only point of entry to our healthcare system. To date, there has been a lack of perspectives from ED patients who suffer from opioid use disorder (OUD) about the barriers and facilitators of engaging in treatment and harm reduction practices. With U.S. federal laws, such as the 1986 Emergency Medical Treatment and Labor Act (EMTALA), and state laws, such as California SB 1152 (“Dignity in Discharge”), the role of the ED has expanded beyond just treating acutely life-and-limb threatening illness and injury.

Westafer et al. in their 2024 Annals of Emergency Medicine article, “Barriers and Facilitators to Harm Reduction for Opioid Use Disorder: A Qualitative Study of People with Lived Experience”, interviewed 25 patients with OUD in order to elicit qualitative feedback as to how EDs can best help at-risk patients (5). This included asking about knowledge of harm reduction practices, perceived barriers and facilitators to implementation of these practices, and experiences with the healthcare system. The researchers implemented the Fogg Behavioral Model, a behavioral science model stating that a person can achieve behavior change when motivation, ability, and a trigger (or prompt) converge (6). Using this model, the team identified several key themes that affected participants’ ability and motivation to engage in harm reduction practices. Namely, these themes included (I) a lack of accessibility and anonymity when receiving harm reduction supplies and interventions, (II) a lack of self-care and difficulties managing the physical sequelae of opioid withdrawal, (III) the role of ritual and habit in OUD and related lack of medical knowledge, and (IV) the impact of stigma in the medical community.

With an enhanced understanding of the biological underpinnings of substance use disorder (SUD), addiction is now treated more as a chronic illness and public health concern, as opposed to an individual’s moral failing. Decreased use of drugs, in addition to the implementation of harm reduction practices, are recognized as valid health outcomes in SUD, in contrast to abstinence-only models of SUD treatment. In a patient with diabetes, we would not consider complete abstinence from junk food as the only measure of a successful outcome, as a parallel example.

OUD in the US has been exacerbated by the healthcare and pharmaceutical industry, and there currently exists a gap in the implementation of the best practices in treatment, likely due to a combination of patient mistrust of the healthcare system, stigma, clinician bias, helplessness, and a lack of knowledge. Although SUD care is not traditionally a core element of emergency medicine training curricula, promoting harm reduction, prescribing medications for opioid use disorder (MOUD), and opioid overdose education and naloxone distribution (OEND) are all interventions that fall within emergency medicine’s public health mission, and should be of interest to health systems and communities.

Study data and results

The study provides a nuanced exploration of factors influencing engagement in harm reduction strategies among individuals with OUD, emphasizing that proximity to and accessibility of harm reduction supplies may be crucial motivators, while stigma, withdrawal avoidance, and hopelessness may be significant de-motivators for behavior change. The findings showcase the importance of leveraging personal experiences with drug use complications as powerful motivators for engagement with harm reduction strategies, suggesting a need for interventions that include personal narratives. The study also reveals significant knowledge gaps among participants, especially regarding risk of soft tissue infections and endocarditis. This signals a need for more comprehensive harm reduction education extending beyond basic information (e.g., needle sharing). Stigma within healthcare settings and the community emerges as a significant barrier, suggesting an urgent need for multi-level harm reduction interventions that address stigma and enhance accessibility and utilization of harm reduction services. Additionally, the impact of socioeconomic factors and accessibility issues on the ability to engage in harm reduction practices calls for strategies that address broader social determinants of health.

The researchers describe the ED as a potential setting where harm reduction interventions can effectively occur, particularly among a population that faces unstable housing, suffers from concurrent mental illness, and is often disengaged from primary care systems (5,7). However, there are some study limitations that must be considered. First, only 6 of the 25 patients interviewed for this study were recruited in the ED, and the remaining 19 came from opioid agonist clinics in the community. Therefore, it may be challenging to fully understand patient perspectives on the potential role the ED could play in harm reduction interventions, as well as barriers and facilitators unique to this setting. Future research should aim to explore this perspective more thoroughly. Additionally, it is possible that people already engaged in OUD treatment are at a different behavioral change state than other individuals who are not, potentially limiting the generalizability of findings from this qualitative study. Further, the demographic characteristics of most participants—primarily English-speaking, white individuals with a median age of 34 years, residing in Western Massachusetts, and with at least a high school/General Educational Development (GED) education level—may limit the relevance of the study’s findings to other to populations. For example, these results may not be applicable to a city such as Los Angeles (LA), where geriatric homelessness is increasing due to inability to afford rent in retirement, and has more Latino and Black individuals experiencing homelessness (8). Future research is needed in more diverse settings and among more diverse samples.

While the patients interviewed in this paper faced challenges with OUD, there are emerging threats from other types of illicit drugs, including stimulants and pressed pills being contaminated with fentanyl and its analogues (9). In other parts of the country where stimulant use disorder is more prevalent, for example, the West Coast and Southwest, opioids and xylazine may not be a sought-after contaminant as described by the participants in this study, and harm reduction tools like testing strips may be more readily adopted (10). Per a report released by the LA County Department of Public Health in November 2022, accidental fentanyl overdose deaths increased 1,280% between 2016 and 2021 (11). Therefore, harm reduction efforts for other types of SUDs may be needed in some settings in addition to OUD.

Discussion

The study raises discussion about factors that can facilitate harm reduction efforts from the healthcare system, and particularly from the ED. Wide, anonymous distribution of Narcan (naloxone) coupled with education about factors that increase risk of overdose is known as opioid OEND and has been shown in several pilot programs to increase ED distribution and likely reduce overdose deaths. This is an emerging area of research, and difficulties in follow up make it challenging to know the true effectiveness; however, from a harm reduction and public health perspective, it is plausible that increasing the availability of naloxone likely decreases opioid overdose in our population (12).

Harm reduction efforts can be further aided by incorporating de-stigmatizing language in emergency care. For example, when naloxone is framed as a public health tool that is used to save lives, like a seatbelt, an automated external defibrillator (AED), or stop the bleed campaigns, use of this lifesaving intervention is normalized. The Westafer et al. study identifies stigmatizing language as a significant barrier to engaging individuals in SUD care. Several additional studies report similar findings and also offers endorsement for the potential impact that healthcare providers’ personal biases can have on people with SUD (13). Normalizing our patients’ current state as a modifiable medical condition and using person-first language that separates a person from their diagnosis, are best practices that individual clinicians can incorporate into their practice (see Table 1).

Some harm reduction strategies from the ED include the distribution of safe use supplies and syringe services programs (SSPs), distribution of fentanyl/xylazine test strips, and evidence-based medical treatment of withdrawal symptoms and cravings. The ED is already involved with harm reduction and public health interventions, including violence interventions, vaccine administration, screening for elder and child abuse, helmet and seatbelt use, and housing insecurity, to name a few. SUD harm reduction therefore is in the purview of patient advocacy and public health practice.

Syringe service programs initially were implemented in response to hepatitis outbreaks in the 1970s and 80s, and reduce HIV infections, decrease syringes ‘on the street,’ and increase rates of participation and retention in substance use treatment programs (14,15). In locations with different regulations (e.g., Canada), evidence shows hospital-based harm reduction interventions “improve patient-clinician experiences, reduce stigma, reach populations missed by traditional interventions, and advance health knowledge” (16). Additionally, the distribution of fentanyl test strips from the ED has been found to be a feasible practice associated with changes in drug use behavior and perceptions of overdose safety (17-19).

By approaching a substance use disorder as a medical illness, with a spectrum of treatment options beyond abstinence-only approaches, we become more likely to frame treatments for SUD as a means to improve patient health. This includes the ED prescribing of medications like naltrexone and acamprosate to decrease binge drinking episodes and cravings, and by considering alternative regimens for the treatment of alcohol withdrawal including gabapentin and carbamazepine. In cases of OUD, buprenorphine can be initiated in the ED, and bridge doses of methadone can be provided, in addition to adjunctive medications for symptom control including diphenhydramine, loperamide, ondansetron, ibuprofen, and acetaminophen.

ED based programs

To meet the rising demand, various ED-based programs have been implemented to meet the needs of patients with SUD. In 2008, the ED and addiction medicine departments at Yale New Haven Hospital collaborated to initiate treatment for patients with OUD directly from the ED. Through their randomized clinical trial, D’Onofrio et al. demonstrated that early detection and treatment initiation, specifically through SBIRT (screening, brief intervention, and referral to treatment) and buprenorphine, increased addiction treatment engagement and reduced self-reported illicit opioid use (20). At Highland Hospital in Oakland, the ED-based Bridge Substance Use Clinic provides services ranging from medication induction (buprenorphine, naltrexone, etc.) to various recovery services, including one-on-one counseling, support groups, and drug and alcohol education. The Bridge Clinic increases overall access by offering both same-day walk-in or telehealth services, and provides harm reduction services including naloxone, safe injection kids, HIV/hepatitis C education and resources (21).

In a post-COVID healthcare system, the utilization of telehealth has proven to be convenient and effective in reaching patients with multiple barriers to care. At the start of the global pandemic, patients who suffer from substance use disorders were disproportionately affected, as there was little to no access to direct care, life-saving medications (naloxone, buprenorphine, methadone, for example), and harm reduction services (22). In a decade long cross-sectional study examining unintentional opioid related deaths in the US, mortality (measured in years of life lost) increased by 62.9% between 2019 and 2021 (2). As the healthcare system adapted to the pandemic, and regulations were relaxed toward various OUD treatment modalities, virtual treatment for patients with substance use disorders have become pivotal to providing life-saving treatment (23). A comprehensive SUD treatment protocol would include all of the aforementioned elements to address patients’ motivators and ability to engage in harm reduction. However, the fragmented nature of the healthcare system can make it difficult for individual EDs to initiate these processes.

One integrated healthcare system that has had success in implementing such programs is the U.S. Department of Veteran’s Affairs, which has implemented programs for OEND, SSP’s, fentanyl and xylazine test strip distribution, clinician education, and community engagement (24,25). To address clinician level barriers, the VA Emergency Medicine Addiction Hotline (VEMAH) has emerged as a resource for emergency clinicians facing challenges with treating SUD. The program was developed in Southern California as a part of a regional system of VA health care facilities that covers Southern California, Arizona and New Mexico. The primary goal of the program is to provide real-time support to physicians directly treating patients with substance use disorders. The VEMAH program, staffed by emergency medicine physicians with experience in addiction medicine, is a hotline that works directly with clinicians to discuss diagnostic and treatment options, in addition to facilitating outpatient follow up, and performing check-ins with patients.

There are several patient-level and systemic barriers to address in the ED implementation of harm reduction programs, including: access to naloxone, MOUD treatment, stigma, lack of accessibility to clean supplies, clean water, lack of knowledge, treatment of concurrent infections, and safe injection technique (26). Additionally, the ED faces barriers such as clinician apprehension to start MOUD, limited referral pathways to outpatient treatment facilities, and slow adoption of naloxone prescribing and overdose education (27-30). Furthermore, stigma associated with OUD in both the medical system and society may discourage patients from seeking treatment (31). There is also a paucity of comprehensive infectious screening programs and delivery of preventative services, including SSPs in the ED, that can help with treatable concomitant infections, or prevent them in the first place (32,33). The findings from Westafer et al. highlight that the need to avoid opioid withdrawal is a powerful motivator. Though opioid withdrawal has traditionally been framed in medical training as something that is not as immediately deadly compared to alcohol withdrawal, when we explore first-hand patient testimonials, these subjective reports paint a more serious, near-death perspective. Further, the downstream medical consequences of drug use can certainly lead to premature death.

Conclusions

This study represents one of the first systematic efforts to understand barriers and facilitators of harm reduction and OUD treatment in the ED patient. The study finds that stigma, inadequate treatment of withdrawal symptoms, inaccessibility of supplies, and lack of knowledge emerge as factors that can be addressed by ED staff and health system leadership. This can, in turn, help increase motivation and ability, and help patients move towards meaningful behavioral change.

Social determinants of health affecting SUD include lack of stable housing and personal safety, childhood trauma, economic inequality, structural discrimination and racism, stress, social isolation, and lack of access to quality education (34). Some patients may partly suffer from OUD due to previous over-prescribing by the healthcare system, as evidenced by recent national opioid lawsuits. As an individual clinician, or hospital system, addressing these societal level issues can seem daunting. At the same time, confronting these issues can help clinicians and health systems regain a sense of agency in the practice of medicine, and help us better serve our local communities. By meeting patients where they are, an opportunity exists to begin to address some of these upstream determinants by treating the medical issues that the patients are acutely facing. The ED is a unique location where novel harm reduction interventions are being successfully implemented.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Public Health and Emergency. The article has undergone external peer review.

Peer Review File: Available at https://jphe.amegroups.com/article/view/10.21037/jphe-24-61/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jphe.amegroups.com/article/view/10.21037/jphe-24-61/coif). The views expressed are those of the authors and do not reflect official policy of the United States Government or the United States Department of Veterans Affairs. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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