Harm Reduction Dilemma

Harm Reduction Cat





What happens when harm reduction tenets clash with actual patient experience? That’s my recent dilemma.

Our opioid treatment center is blessed to have an organization that comes to our facility to do free testing for HIV and Hepatitis B and C. They also do needle exchange, or more precisely, they distribute clean needles to anyone who wants them.

Our patients have benefitted tremendously from the free HIV and hepatitis testing. Many of our patients have been diagnosed with active Hepatitis C. Since we now have a Federally Qualified Health Center in a neighboring town, about an hour away, our patients can get treatment for Hep C, even if they have no insurance or Medicaid. I’d estimate that two or three dozen patients have been diagnosed with Hep C, been referred for treatment, and are now cured of their Hep C.

The value of this can’t be overstated. Besides reducing the burden of Hep C in the community, these patients are free from worry that their Hep C will cause future problems. They don’t have to worry about it anymore, if they remain in recovery.

Our dilemma isn’t about this part of what they do, but about the needle exchange.

At our facility, we endorsed harm reduction as a healthy goal. If patients inject drugs, we want them to be as safe as possible, while still hoping they will be able to quit injecting once they get some traction in treatment.

However, some established patients, doing well now and free from illicit drugs, have told us the available free clean needles are a trigger for them to use drugs intravenously again.

This isn’t supposed to happen. Studies about needle exchange have not showed that clean needles influence people to inject drugs who weren’t already planning to inject drugs, which is why we’ve been supportive of the needle exchange.

But now we have some specific patients who link a relapse to intravenous drug use (usually intravenous methamphetamine or cocaine) to the available clean needles. These patient experiences contradict what the studies show us.

What should we do?

We need the services of Hepatitis and HIV testing, but we don’t patients to relapse, obviously. Do we ask the organization to keep do the free testing, but put the clean needles away and not mention them?

We had a spirited debate about the issue last week at our case staffing/treatment team meeting. This topic raised some passionate feelings both pro and con clean needle exchange, which surprised me a little. Some personnel thought patients shouldn’t be offered clean needles because, after all, these were patients in treatment who should be trying to be drug-free. Other people pointed out that continued intravenous drug use is inevitable, to some degree, in patients trying to get help, and we should want these patients to be as safe as possible while they inject, citing evidence about reduction of transmission of HIV and Hep C with needle exchange.

Some people felt the patients reporting that their drug use was triggered by being offered clean needles was an excuse, an effort to displace blame from themselves onto someone else. Those people felt these patients were going to use anyway and used needles exchange as a scapegoat.

I listened to everyone and decided there was possible truth to everything that was being said, but there was no way to know for sure.

In the end, we decided to ask our patients who were most vocal about the needle exchange program being a relapse trigger if they would talk to the personnel who work for the harm reduction agency that supplies the testing and clean needles. I thought offering information in both directions would be a good start.

Patients are often the harshest critics of other patients who aren’t doing well. Many times, I’ve had a patient tell me I ought to kick another patient out of treatment because they were still using drugs. Of course, I have to tell them I can’t talk about any other patient, but in general, we try to keep patients in treatment rather than turn them away for drug use, although sometimes we do refer them to more intense treatment.

Sometimes patients say that other patients using drugs makes them feel triggered to use drugs too. I can’t deny anyone’s experiences. If someone says they are triggered, then they are. And we do want to provide a safe treatment facility. How much drug use should we tolerate if it negatively impacts other patients’ treatment experiences?

What do my readers think? Is offering clean needles at a treatment program going too far, as some of our OTP employees think? Is it not going far enough, and should we offer safe injecting sites if it were legally allowed, as it is in Canada and elsewhere?

17 responses to this post.

  1. Posted by Cindy on May 4, 2019 at 5:04 pm

    With regards to the needle exchange I think that the patients that state it makes them want to go back to using are using that excuse as a scapegoat. I totally disagree with providing people with safe place to inject their drugs, first of all the drugs are illegal, it’s promoting drug use and who’s going to be responsible when the patient overdoses and your resuscitation attempts are fail?


    • Posted by Sparky on May 4, 2019 at 5:35 pm

      If they are gonna do it anyways might as well give them a safe place to do it,safe as possible anyways


  2. Posted by Scout on May 4, 2019 at 8:02 pm

    I think needle exchange is great but not near or part of a treatment facility.


  3. Posted by trying2liveat55 on May 4, 2019 at 8:23 pm

    It’s a damn shame, the services needed for Substances abuse is not available to those in other state’s, pain patients are dying because of government control&how much can be prescribed!
    Ignorance is not bliss & these so called Dr’s of pain clinic’s, don’t know that much at all.
    Too ypung& yhis particular onr, needs education!


  4. Posted by Mary Anne Hughes on May 4, 2019 at 8:40 pm

    I was reading this and halfway through, I was thinking I saw the truth in both sides and then I saw you did too. I like how you invited the patients to weigh in and I agree, they can sometimes be eachother’s harshest critics. After thinking it through, I remember what I just said to a patient recently, who was pretty disruptive on admission. I knew part of it was related to w/d, and I acknowledged such with her and I also cautioned her that I have a responsibility of not only protecting her but the other patients as well and if her behavior continued and others were bothered, she would be consequenced for it. I wouldn’t let her behaviors interfere with their recoveries. I thought maybe there was an analogy here. We have a challenge of a mixed group of patients at all stages of recovery, which is a challenge for any group. We want to keep our veteran recovering patients stable and also help those who are new to recovery achieve it. Maybe we can try to protect them from disruptions within the clinic and from outside sources we are inviting in, as well. And the needles could be that “outside” disruption we are inviting in.( we have free HIV, Hep C testing also, but no needle exchange). Maybe, offering info about needle exchange? Incidentally, just a NC Harm Reduction Poster we had up, caused some dissension as well. We voted to keep it up. Feels like splitting hairs. Fine line, right? It also brought to mind the day when I was comfortably sitting in my office, (the same decor for years, employer decorated), speaking with a patient when the patient started giggling, while looking at the two pictures of the fields upon fields of pretty red flowers swaying in the breeze behind me and above my head.When I asked what she was laughing at, she pointed out that the pictures behind me were of poppy fields and they were triggering her. I am glad she had a sense of humor about it and I, being thoroughly embarrassed, confessed, I was never into office decor, but I should have payed a lot more attention to it. Needless to say, they were down the next day and the patient and I had a good laugh over my ” un- mindfulness”. Jana, I know we can’t protect them from everything, as much as we’d like to, but maybe paying attention to the more obvious ( not to me, apparently) and/or common triggers might help. I’m interested, as well, to hear what others think about this. Maybe I will change my mind. It has been know to happen. Thanks for enough thought- provoking column!


  5. I hope posting this wish RIGHT when we are making headway with overall harm reduction efforts in TN, GA, and NC doesn’t add fuel to anti-HR hysteria. What a couple individuals are reporting in your one clinic do not equal any meaningful data…Have they ACTUALLY relapsed and can that definitively be tied to the syringe exchange program in the clinic? Or are they just talking about potential triggers?…also (as a clinician) this is a counseling issue around healthy coping skills. Needles are over the counter and available all over the place (just not for free and often not without a stigmatizing look from pharmacy staff) …do these patients get similarly triggered at Walgreens? I hope the anti-HR folks down here don’t start quoting you, Dr. Burson, in their opposition efforts. The ACTUAL data is very clear….syringe exchange saves lives and provides a linkage to treatment. Also, the Atlanta Harm Reduction Coalition was recently telling some of us Georgia treatment providers that a majority of clean needles don’t go to IV substance users but to individuals with diabetes, etc. who have a hard time accessing or affording enough clean syringes. They also TAKE IN way more used syringes than they hand out new ones. I thought that was interesting.


  6. Cindy,

    No one said anything about providing a place for folks to use…this is just a place to get clean syringes and safely discard of used ones. Study after study have shown lower incidence of infections in drug users as well as lower new HCV and HIV diagnoses tied to these programs.


  7. Dr. Burson you have a very thoughtful and mostly a great blog and I never miss reading it when you post it but I also can see that because of how many people read your blogs that you have a burden too. Your story of your patients experiences with having needle exchange in your building is interesting but I am afraid too that this weeks blog could really be used by your readers as evidence and it is not. We know access to clean needles saves lives and I we are finally getting them to drug users and I hope this blog is not used to prevent the progress of this finally starting to happen in more places.
    Paul Bowman
    NAMA Recovery Massachusetts


    • To both Paul and Zac,
      You both are correct, of course. Data unequivocally shows benefits to people who use drugs intravenously when they are provided with clean needles.
      But it is an odd feeling to have a patient sitting in front of me, admitting he used because free clean needles were easily available.
      What do I do with that? One patient’s experience doesn’t negate multiple studies, but I have an obligation to this patient.
      I felt very uncomfortable hearing about his experience.
      I posted this blog NOT to discourage needle exchange, but because I am conflicted and concerned about my patients. My intent was to stimulate conversation and my hope was that some other provider has confronted this issue and found a solution that both supports needle exchange while also supporting individual patients who may have triggers.


  8. Posted by Alan Wartenberg MD on May 5, 2019 at 9:55 am

    While a great admirer of Hippocrates (whose Oath we did NOT take when I graduated med school – we used what we thought was the more modern (1000 years or so) Oath of Maimonides – I have always had trouble with the idea of Primum Non Nocere (Above all, Do No Harm). Back in the days where most of the things doctors did actually hurt people more than it helped them, this was a wise dictum.

    However, the reality is, with every treatment, you can, and likely will, hurt SOME people. The idea is to get truly informed consent, and explain the far greater likelihood that it will do more good, and to more people, than any incident harm that occurs. This is an overall principle of public health – the greatest good to the greatest number. However, I agree with Dr. Burson’s concern about her patients who may be harmed, or triggered by the folks who are doing needle exchange and counseling/testing in your clinic. My own response is to work on their triggering issues, which can be approached psychotherapeutically, and are much easier to deal with in a controlled clinic setting than they are likely to be out on the streets, where they will also very likely happen. The needle exchange can also happen in a place out of public view, even if only by cubicle walls that can be put up almost anywhere.

    I know we are stuck with the language of “harm reduction,” but in many ways we stigmatize ourselves with that language. The folks who believe that they offer “recovery,” while the rest of us merely do “harm reduction,” and those of us who accept that term, are really fostering the idea that it is a dichotomy, rather than a continuum. All of health care is harm reduction, We rarely cure anything, and we are only at the forefront where true molecular prevention and even cure is possible. Everything we do is to reduce harm, and in some cases we gets spectacular results, in other cases very good results, in still others fair, in some poor or even dismal. The folks who offer “recovery” actually have the same range of results, but do not want to admit it.

    Great post, as usual.


  9. Posted by Ron on May 6, 2019 at 12:14 pm

    Thank you for the great post, Dr. Burson. I would suggest, if possible, to separate the needle exchange from daily dosing. This would depend on your facility infrastructure, of course. You could have separate times for needle exchange and dosing, so patients who don’t want to be there during needle exchange can go at a different time when needle exchange is not there. You could also have the needle exchange in a different area, like a back office, so only the people who want it would go back to it, instead of everyone being around it. This would apply to safe-injection site, if that ever becomes available in your area.


  10. Posted by Brenda Henze-Nelson on May 6, 2019 at 10:11 pm

    I enjoyed the piece and the rigorous honesty in which you are trying to approach it. I work in a medication assisted treatment program that also has a syringe exchange. It has been a wonderful way for IDU’s to get to know us and eventually feel comfortable enough to ask for an HIV or HCV test or an application for treatment. So, we as well, found it unsettling when a client in treatment voiced that the exchange was a trigger for them. We have never directly offered anyone syringes, but they have always just been available in a separate room in the building. To address the individual’s concerns, we took down the sign and tried to help the room blend into the background. As this was a singular comment/concern, we felt this step was sufficient under the circumstance and have had no further expressions of concern. Having worked in the field a long time, I would encourage you to trust your knowledge and experience. Research shows that relapse is rarely an “in the moment” thing. It is percolating prior to its occurrence. Also, as our clients get well, we want them to be actively engaged in positive health measures, including regular medical exams. I know that I see a syringe no less than once a year when getting blood drawn or getting an inoculation. If our folks have needle issues, we need to help them with them so they are not impacted by this trigger in other, healthy settings. Also, knowing relapse is a part of the disease, it is an excellent time to uncover and excavate new possible triggers. It sounds as if you are doing that. All the best.


  11. Posted by Sean on May 12, 2019 at 6:24 am

    My opinion is that the patients blaming the needle exchange are looking for an excuse. The benefit is too important and as you’ve said the studies show that the anecdotal reports of these patients are outliers. This is a good example why studies are run the way they are in order to weed out these type of anecdotal accounts.


  12. Posted by David H Berggren on August 15, 2019 at 12:29 pm


    I just found your blog. I’m a nurse working with buprenorhpine/metadon -patients. Here at the hosptial we have a needle Exchange facility in a different part of the hospital, they also have a different journaling-system so i’m not able to see wich patients are using their services.


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