Psych · Addiction psychiatry — public health and systems
Harm reduction and public health approaches
Also known as Harm minimisation · Needle and syringe programmes · Needle exchange · Opioid substitution treatment public health · Supervised consumption sites · Supervised injecting facilities · Drug consumption rooms · Take-home naloxone · Overdose prevention · Addiction stigma
Exam-exhaustive fellowship reference on harm reduction and public-health approaches to drug use — principles and ethics; needle-syringe programmes; opioid agonist treatment as population intervention; supervised consumption; take-home naloxone; stigma; combined coverage; regional policy deltas. FRANZCP-primary, globally tagged.
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Target exams
Red flags
- Conditioning sterile equipment, naloxone, or emergency care on perfect abstinence — a systems failure that raises death and BBV risk
- Opioid overdose — airway, ventilation, titrated naloxone; observe for re-sedation; then offer take-home naloxone and MOUD linkage
- Prison release, detox exit, or OAT interruption — high fatal-overdose windows; continuity and naloxone are mandatory planning items
- Stigma-driven early discharge from ED/maternity or withheld analgesia — increases self-discharge and death
- Assuming supervised consumption 'increases crime' without reviewing local evaluation data — exam and policy trap
- Punitive urine-drug-screen exclusion from OAT or primary care — undermines retention, the key mortality protector
Meet the patient
A 34-year-old man who injects heroin presents to the ED with a swollen, painful injection-site abscess. He is not ready to stop using. He has been homeless for four months, was released from custody eight days ago, and his partner died of an overdose last winter.[1][18]
The fellowship skill is not to wait for him to "be ready." It is to treat the abscess, offer testing, hand over naloxone, and start opioid agonist treatment today if he will take it — because the eight days since release are the highest-fatality window he will ever walk through. This topic teaches you to do all of that without moral theatre.[9][15][18]
References18ShowHide
- [1]Hawk M, Coulter RWS, Egan JE, Fisk S, Reuel Friedman M, Tula M, et al. Harm reduction principles for healthcare settings Harm Reduct J, 2017.PMID 29065896
- [2]Marlatt GA, Witkiewitz K Update on harm-reduction policy and intervention research Annu Rev Clin Psychol, 2010.PMID 20192791
- [3]Aspinall EJ, Nambiar D, Goldberg DJ, Hickman M, Weir A, Van Velzen E, et al. Are needle and syringe programmes associated with a reduction in HIV transmission among people who inject drugs: a systematic review and meta-analysis Int J Epidemiol, 2014.PMID 24374889
- [4]Des Jarlais DC, Marmor M, Paone D, Titus S, Shi Q, Perlis T, et al. HIV incidence among injecting drug users in New York City syringe-exchange programmes Lancet, 1996.PMID 8855855
- [5]Wodak A, Cooney A Do needle syringe programs reduce HIV infection among injecting drug users: a comprehensive review of the international evidence Subst Use Misuse, 2006.PMID 16809167
- [6]Fernandes RM, Cary M, Duarte G, Jesus G, Alarcão J, Torre C, et al. Effectiveness of needle and syringe Programmes in people who inject drugs - An overview of systematic reviews BMC Public Health, 2017.PMID 28399843
- [7]Mattick RP, Breen C, Kimber J, Davoli M Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence Cochrane Database Syst Rev, 2009.PMID 19588333
- [8]Mattick RP, Breen C, Kimber J, Davoli M Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence Cochrane Database Syst Rev, 2014.PMID 24500948
- [9]Sordo L, Barrio G, Bravo MJ, Indave BI, Degenhardt L, Wiessing L, et al. Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies BMJ, 2017.PMID 28446428
- [10]MacArthur GJ, Minozzi S, Martin N, Vickerman P, Deren S, Bruneau J, et al. Opiate substitution treatment and HIV transmission in people who inject drugs: systematic review and meta-analysis BMJ, 2012.PMID 23038795
- [11]Platt L, Minozzi S, Reed J, Vickerman P, Hagan H, French C, et al. Needle syringe programmes and opioid substitution therapy for preventing hepatitis C transmission in people who inject drugs Cochrane Database Syst Rev, 2017.PMID 28922449
- [12]Kerr T, Tyndall M, Li K, Montaner J, Wood E Safer injection facility use and syringe sharing in injection drug users Lancet, 2005.PMID 16039335
- [13]Marshall BDL, Milloy MJ, Wood E, Montaner JSG, Kerr T Reduction in overdose mortality after the opening of North America's first medically supervised safer injecting facility: a retrospective population-based study Lancet, 2011.PMID 21497898
- [14]Potier C, Laprévote V, Dubois-Arber F, Cottencin O, Rolland B Supervised injection services: what has been demonstrated? A systematic literature review Drug Alcohol Depend, 2014.PMID 25456324
- [15]McDonald R, Strang J Are take-home naloxone programmes effective? Systematic review utilizing application of the Bradford Hill criteria Addiction, 2016.PMID 27028542
- [16]Strang J, Metrebian N, Lintzeris N, Potts L, Carnwath T, Mayet S, et al. Supervised injectable heroin or injectable methadone versus optimised oral methadone as treatment for chronic heroin addiction (RIOTT): a randomised trial Lancet, 2010.PMID 20511018
- [17]Volkow ND Stigma and the Toll of Addiction N Engl J Med, 2020.PMID 32242351
- [18]Degenhardt L, Grebely J, Stone J, Hickman M, Vickerman P, Marshall BDL, et al. Global patterns of opioid use and dependence: harms to populations, interventions, and future action Lancet, 2019.PMID 31657732