Harm Reduction 101 Safe talk about using drugs Scott Steiger, MD, - PDF document

2/28/2019 Harm Reduction 101 Safe talk about using drugs Scott Steiger, MD, FACP , FASAM Associate Clinical Professor of Medicine and Psychiatry - UCSF Deputy Medical Director, Opiate Treatment Outpatient Program – ZSFG Scott.Steiger@ucsf.edu Disclosures  No financial relationships to disclose  Trade names may occasionally be used for clarity 1

2/28/2019 Acknowledgments  Harm Reduction Coalition  Eliza Wheeler  Charles Hawthorne  Einstein/Montefiore  Aaron Fox  University of Washington  Joe Merrill Outline  Language activity  “Practical” or “clinical” harm reduction activity  Resources  Questions, comments, concerns 2

2/28/2019 What is wrong with this clinical picture? What is wrong with this clinical picture? 3

2/28/2019 What is wrong with this clinical picture? Words matter LANGUAGE  BELIEFS  ACTION 4

2/28/2019 Words matter, but they’re not the only thing LANGUAGE  BELIEFS  ACTION “Drug abusers”  “weak-willed” or “bad people”  poor medical care “PSA”  “demanding”  no treatment of OUD, AMA, missed opportunity for reducing harm from ongoing use We do “harm reduction” all the time  Counseling on diet, exercise  Anti-hypertensives  Oral hypoglycemic agents, insulin  anticoagulants  IVF, pressors  Dialysis  AICD 5

2/28/2019 Most people with substance use disorders are not in treatment SAMHSA, NSDUH Data Review, Sept 2016 6

2/28/2019 Wheeler et al., MMWR, 2015 It is the law (in CA)! AB-2760, effecitve 1/1/2019:  Covers all people authorized to prescribe a medication  Naloxone must be offered to all patients who  High dose opioids (morphine>90 mg daily)  Opioids+benzos  h/o OD, Substance use disorder, h/o high dose opioids 7

2/28/2019 In addition to naloxone… 24 yo F presents to establish primary care. No complaints. On Nexplanon for birth control. Dropped out of job training program recently. Accompanied by mother who’s worried about her being “moody.” Screens negative for depression. Screens positive for drug use. “Ballucci” to party, now 7-8x/day. Clinical harm reduction  “Create the space”  Privacy  Ask permission  “Can we talk about ______”  Avoid q’s and use normalizing language  “ tell me more about____”  “when was the last time you _____” THE PATIENT IS THE EXPERT ON THEIR OWN DRUG USE 8

2/28/2019 Case, continued 24 yo F presents to establish primary care. No complaints. On Nexplanon for birth control. Dropped out of job training program recently. Accompanied by mother who’s worried about her being “moody.” Screens negative for depression. Screens positive for drug use. “Ballucci” to party, now 7-8x/day.  “Mom can’t know about this”  Reports single episode injection use  “I’m scared of needles”  Doesn’t like withdrawal, but not ready for tx  “I’ve seen people on methadone and they keep using” WHAT DO YOU DO NOW? 9

2/28/2019 Clinical harm reduction, continued  Anticipatory guidance  “When was the last time you used alone?”  “What would you do if you saw someone have a bad reaction to their drug?”  “Can we talk about your options if you want to cut back some day?”  Learn about subjective drug effects  “What does it feel like when you…” (use/don’t use)  Educate on objective drug risks  “Can we talk about what opioids and stimulants do to your body?”  Prescribe appropriate risk reduction materials  Naloxone, syringes, etc. Resources 10

2/28/2019 https://harmreduction.org/ https://harmreduction.org/wp-content/uploads/2011/12/SAP.pdf 11

2/28/2019 https://harmreduction.org/wp-content/uploads/2011/12/getting-off-right.pdf 12

2/28/2019 www.yestoscscalifornia.org 13

2/28/2019 “Maybe them no like your medicine” 14