Letter to the editor: Opioid Abuse and Overdose Crisis: New Treatment Available—Controversy Continues Between Harm-Reduction Treatment and Abstinence Treatment

| April 21, 2015 | 0 Comments

Innov Clin Neurosci. 2015;12(3–4):10–11.

Funding/financial disclosures: No funding was received for the preparation of this letter. The author has no conflicts of interest relevant to the content of this letter.

Dear Editor:

The current opioid abuse and overdose crisis has been a public health concern in the last decade, and is possibly reaching epidemic proportions based on recent trends. According to a Substance Abuse and Mental Health Services Administration (SAMHSA) report, in 2002, there were 166,000 past-month heroin users 12 years of age or older in the United States, and this number increased 50 percent by 2012 with 335,000 users. The rate of overdose deaths related to opioid analgesic pills in the United States quadrupled between 1999 and 2009, according to a Center for Disease Control and Prevention Report.[1] The data from the National Survey on Drug Use and Health (NSDUH) conducted between 2002 and 2011 showed that the heroin incidence rate was 19 times higher among those who reported prior nonmedical opioid analgesic use than among those who did not (0.39% versus 0.02%).[1]

There has been a long-standing debate between harm-reduction advocates and abstinence-based advocates in addiction. The scope of harm-reduction strategies is quite broad, and there are certain aspects that are more controversial than others.

The principles underpinning the term harm reduction can be traced back to the Rolleston Report of 1926 in the United Kingdom, which recommended that, in certain circumstances, physicians could prescribe morphine or heroin legally to certain opioid addicts.[4] This is still practiced in some European countries and constitutes what might be considered the extreme of the harm-reduction model. An example of a more acceptable or less extreme harm-reduction treatment model in more recent years in the United States is the methadone maintenance program. With the advent of the acquired immune deficiency syndrome (AIDS) epidemic in the 1980s, the methadone maintenance program garnered public support by seeking to reduce the transmission of human immunodeficiency virus (HIV) and other blood borne diseases often contracted through illicit drug use (i.e., via needle sharing) by offering a legal and medically supervised synthetic analgesic drug alternative to those suffering from morphine or heroine addiction. Other more recent examples of harm-reduction models of addiction treatment in the United States include the buprenorphine maintenance program* and the very recently approved device, Evzio®, a take-home, hand-held, single-use naloxone auto-injector for emergency treatment of known or suspected opioid overdose. This device received United States Food and Drug Administration (FDA) approval in April 2014.[2] The United States Department of Justice issued a memorandum at the end of July in 2014 embracing this harm-reduction model, urging federal law enforcement agencies to identify, train, and equip personnel who may come into contact with victims of opioid overdose with the Evzio device.[3] This appears to be one of the few times that a harm-reduction model has been embraced this strongly at the federal level in the United States, especially in terms of funding, as most harm-reduction–based treatments are usually only embraced at state and city governance levels.

The harm-reduction models that are generally opposed by the abstinence advocates include the syringe exchange programs and medically supervised safe injection rooms/centers.[5] Abstinence advocates argue that programs such as these encourage rather than discourage drug use and that federal money would be better spent on encouraging abstinence. Harm-reduction advocates, on the other hand, argue that abstinence-based programs do not attract the majority of the severe substance users and that such programs are negatively biased against persons with addiction who are on medication-assisted treatments even when in recovery.[4,5]

Further evidence-based studies of programs that have adopted integration of both abstinence-based and harm-reduction–based models should be encouraged.

1. Wihbey J. Heroin use in the United States: Data and recent trends. http://journalistsresource.org/studies/society/public-health/heroin-use-in-the-united-states-data-and-recent-trends. Accessed on 08/03/2014
2. FDA approves new hand-held auto-injector to reverse opioid overdose. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm391465.htm. Accessed on 08/03/2014
3. Attorney General Holder Announces Plans for Federal Law Enforcement Personnel to Begin Carrying Naloxone. www.justice.gov/opa/pr/2014/July/14-ag-805.html. Accessed on 08/03/2014
4. Hunt N. A review of the evidence-base for harm reduction approaches to drug use. www.ihra.net/files/2010/05/31/HIVTop50Documents11.pdf. Accessed on 08/03/2014
5. Evans A, White W, Lamb R. The Role of Harm Reduction in Recovery-oriented Systems of Care: The Philadelphia Experience. www.williamwhitepapers.com/pr/Recovery%20and%20Harm%20Reduction%20In%20Philadelphia.pdf. Accessed on 08/03/2014

With regards,
Adegboyega Oyemade, MD
Dr. Oyemade is a Board Certified Addiction Psychiatrist with Maryland Treatment Centers, Inc.,
Emmitsburg/Baltimore, Maryland.

*Editor’s note: For additional information on buprenorphine, see this month’s The Interface column?“Buprenorphine Treatment for Narcotic Addiction:?Not Without Risks.”

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Category: Letters to the Editor, Past Articles

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