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Harm Reduction

in OB/GYN

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Harm Reduction Principles

Drug use is part of our world
Drug use is multi-faceted and variable
Quality of life is the goal – not abstinence
Provide resources for safer use
Center people who use drugs
Empower PWUD via peer-to-peer support
Systemic oppression influences drug-related harm
Do not minimize the harm that can be associated with drugs

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Harm Reduction History

Needle exchange programs started during the AIDS crisis in Europe and the US in the late 1980s
Programs also provided safe sex supplies, screening for transmissible diseases (HCV, HBV, HIV, etc.), referral to treatment, naloxone, and information about safe use
Dual approach: community activists advocated for and implemented programs while scientists found evidence to support their efficacy

Data show that harm reduction works!

1970s: Women’s �Health Movement

1971: Nixon declares “War on Drugs”

1980: Reagan elected

‘80-’90s: �Crack cocaine

epidemic

1969: Black Panther Party’s Free �Breakfast program (Oakland, CA)

1971: Young Lords’ acupuncture clinic �for heroin withdrawal (Bronx, NY)

1981: AIDS �crisis begins

Late 1980s: emergence of needle exchange programs

1999: Opioid epidemic begins (wave 1)

2001: Portugal decriminalizes drugs

2010: Opioid epidemic (wave 2)

2011: Fentanyl test strips developed

2013: Opioid epidemic (wave 3)

2021: �NYC OPS

*OK I TIMED THIS AND IT’S 5 MINS TO PRESENT. IS THAT TOO LONG? DO I NEED TO CUT?*

-1960s: first methadone maintenance programs

-1969: Black Panther Party launches the Free Breakfast for School Children Program in Oakland, CA (or the People's Free Food Program, was a community service program run by the Black Panther Party that focused on providing free breakfast for children before school. The program began in January 1969 at Father Earl A. Neil's St.)

-1971: Young Lords (puerto rican civil rights group) launch acupuncture clinic for people in heroin withdrawal in the Bronx

-1970s – Women’s Health Movement activism involves increasing women's knowledge and control of their own bodies on a variety of subjects, such as fertility control and home remedies, as well as challenging traditional doctor-patient relationships, the medicalization of childbirth, misogyny in the health care system, and ensuring drug safety.

-1971 – Nixon declares “War on Drugs”

-1980: Raegan is elected – “just say no” approach to drug use

-1981 and beyond – grassroots response to AIDS crisis

-Late 1980s: syringe exchange programs start to be available at state/local level

-80’s-90’s : crack cocaine epidemic

-1999: opioid epidemic begins (three waves: prescriptions, then heroin in 2010, now fentanyl in 2013, potential fourth wave with meth / covid)

-2001: Portugal decriminalizes all drugs

-2011 first fentanyl test strips developed (for the purpose of testing prescription fentanyl in urine in the clinic)

-2021: New York (under mayor deblasio) opens overdose prevention site

https://harmreductionjournal.biomedcentral.com/articles/10.1186/s12954-017-0178-6

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Supporting Data

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MN is also experiencing an HIV outbreak in Ramsey and Hennepin Counties and the Duluth area

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Drug-related deaths are 5x lower than the EU average and 1/50th that of the US
Drug-use overall has declined among 15-24 year-olds

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HIV Infection in Portugal

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Data from the US

From early programs:

Found a lower transmission of HIV, reduced risk behavior, increase in PWUD entrance into long-term treatment and lower HBV incidence
Series of studies published by the US National Commission on AIDS, a CDC review, and others – all of which supported needle exchange as a way to decrease HIV transmission

Recently, the OPS in NYC responded to and mitigated risk in 125 overdoses in the first 2 months
Medical institutes, federal agencies, and other governing bodies (i.e. NIDA, SAMHSA, AMA, etc.) have accepted harm reduction as a cost-effective, evidence-based way to decrease harms from substance use

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Harm Reduction in Medicine

Harm reduction aims to improve outcomes

Commitment to evidence-based, cost-effective solutions to reduce harm
Goal of keeping people alive and encourage positive, incremental change

Principles of Harm Reduction in Healthcare Setting

Humanism
Pragmatism
Individualism
Autonomy
Incrementalism
Accountability without termination

Anna

Humanism - care for patients as people, understanding that people make harmful health decisions for a reason
Pragmatism - no one will ever achieve perfect health, abstinence is not the priority and a range of care options are supported
Individualism - every person is different and needs a different approach to deal with their health problems
Autonomy - respecting a person’s ability to make their own health decisions
Incrementalism - celebrating positive movement in a patient’s life and being supportive during times of plateau or downfall
Accountability without termination - providing motivation to help people meet their goals without penalizing for backward movement

How is this relevant to your work:

-Leaving the floor to go smoke a cigarette

-They came in and I did a urine drug screen and didn’t tell them about it and now they’re positive for amphetamines

-A needle fell out of a patients bag, nurse called security, she threw tea at the nurse, shew as put in restraints

-“if she’s not willing to start buprenorphine, just put her on a hold”

-how do you support someone who’s really sick with withdrawal

-how do you care for someone who is actively intoxicated on opioids

-Remind people of the empathy component! Look at them in the eyes, call them by name, etc.

-Center the patient’s emotions — they’re afraid of their kid getting taken away

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Harm Reduction in OB/GYN

Others?

“Practical strategies…”

Non-stigmatizing language
Trauma-informed care
Stay up to date with current guidelines for MOUD with pregnant people
Leverage physician power (i.e. w/ police, security)
Educate (tools, resources, housing, support)

“Respect for rights of people who use drugs…”

Autonomy

Shared decision-making
If they leave, they leave (i.e. smoking a cigarette)

Empathy

Eye contact
Validate fears/concerns (i.e. custody, withdrawal, domestic violence)

Trust

Discuss tox screens
Explain reasoning

Allison

Another example:

For patients on IV abx: alerting them that if they need to leave hospital prior to being medically discharged, to alert the nurse so the team can give oral antibiotics
Discussing ways to intermittently take high vs low dose suboxone