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The Effectiveness of Harm Reduction Model Treatments for Individuals Addicted to

Heroin

Emily Brown

University of Lynchburg: Health Promotion

HP 300A223 Drugs & Behavior Management

Dr. Judith K. Muir

March 15th, 2022

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The Effectiveness of Harm Reduction Model Treatments for Individuals Addicted to

Heroin

Introduction

Illicit opioid and heroin use is a growing worry for nations across the world due to the

harmful and possibly deadly side effects that come from becoming addicted. Heroin is classified

as an opioid and individuals who have often been prescribed opioids for pain management find

themselves reliant on the drug and move into heroin use due to the cheaper cost. In a study done

by Compton et al. (2016), they find that reports of increased heroin usage (including both

injection and non-injection modes of intake) and deaths from heroin overdose have coincided

with institutional attempts to prevent non-medical prescription-opioid use and overdose.

According to national surveillance statistics, 914,000 individuals reported using heroin in 2014,

up 145 percent from 2007, and heroin overdose mortality has more than quintupled, from 1842

fatalities in 2000 to 10,574 deaths in 2014. (Compton et al., 2016) This high level of addiction

combined with the increased use of opioids in the U.S. creates a huge influx of individuals

suffering from addiction into treatment centers that may or may not be helpful. According to the

National Institute on Drug Abuse (NIDA, 2021), Heroin is a highly addictive Schedule I drug

made from morphine, a naturally occurring chemical found in the seed of pods of some poppy

plants. Heroin also stimulates and binds to mu-opioid receptors in the brain (MORs), and the

neurotransmitters in one’s body that are naturally occurring molecules attach to these receptors

in the brain and body to control pain, hormone release, and emotions of well-being. (NIDA,

2021) When MORs in the brain’s reward region are engaged, they cause the neurotransmitter

dopamine to be released, reinforcing drug-taking behavior and causing one to become dependent

on it. (NIDA, 2021) While heroin itself is an extremely harmful opioid, it is growing increasingly
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more dangerous with the addition of fentanyl. American Society of Addiction Medicine (ASAM,

2021) states that the number of drug overdose deaths over a 12-month period ending in May

2020 was the highest ever reported and that the major cause of the rise in overdose mortality is

synthetic opioids, most likely illicitly made fentanyl entering the drug supply. This leads to a

relatively new treatment option for individuals who are suffering from heroin addiction, which is

the Harm Reduction Model. According to the Canadian Pediatric Society (2008), the Harm

Reduction Model was born in the 1980s in response to adults who were suffering from substance

abuse disorder (SUD). Harm reduction is a method aimed at people or communities to reduce the

negative consequences of particular behaviors. When it comes to substance misuse, harm

reduction recognizes that a continued degree of drug use (both licit and illegal) is unavoidable in

society and sets goals to reduce negative outcomes. (Canadian Pediatric Society, 2008) In

addition, the harm reduction model argues that if the individual is allowed to gradually wean

themselves off of the addictive substance, in this case, heroin, then it will be long-lasting and

more efficient than simply quitting the use of heroin “cold-turkey” like traditional rehabilitation

methods may suggest (Canadian Pediatric Society, 2008) According to the National Harm

Reduction Coalition (2021), there are three growing programs that fall under the umbrella of

harm reduction, which include needle-exchange, overdose prevention sites, and medication-

assisted treatment. Needle exchange is a program that which an individual may swap out used

needles for a sterilized one, and is aimed at reducing the rates of blood born-illnesses, such as

HIV. (NHRC, 2021) ASAM (2021) describes overdose prevention sites as locations where

individuals may use previously purchased opioids in a sanitary, well-monitored setting without

the worry of being arrested and with direct care from healthcare professionals if they accidentally

overdose. Medication-assisted treatment (MAT) is a type of recovery that allows the individual
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who is using drugs to either wean themselves off or take medication that subsides cravings for

heroin itself. (NHRC, 2021) These three harm reduction programs- needle exchange, overdose

prevention sites, and MAT- are efficient in preventing accidental overdoses and blood-borne

illnesses because they encourage community engagement to fight the opioid epidemic, educate

the surrounding community on the dangers of drug use and how to stop a potential overdose, and

give the addicted individual seeking care a non-judgment environment that promotes safety and

cleanliness.

Literature Review

Needle-exchange programs have been argued for and against for many years now

because they provide an individual with a safe way to inject heroin, which can be argued that

encourages more people to use. In an article written by Kerley et al. (2019), researchers write

that the method of administration has an impact on risk issues and outcomes, and when

compared to alternative ways, using needles increases the risk of certain health risks (e.g.,

developing HIV or Hepatitis C). Kerley et al. (2019) also expand on the importance of the needle

to the user, and many do not have the patience to make sure their needle is clean and sterile,

which brings up the issue of the likely connected withdrawal symptoms that force them to inject

without knowing their injection device is clean and without the potential of disease. Needles are

also considered one of the quickest routes of administration to get the fastest effects due to the

drug going directly into the blood supply, but it does come with many other health concerns.

According to the Centers for Disease Control and Prevention (CDC, n.d.), there are three main

goals that needle-exchange programs aim for which include preventing blood-borne illnesses,

preventing substance abuse, and supporting public safety. An example the CDC (n.d.) gives as a

blood-born illness is HIV, and needle-exchange programs are known for a 50% reduction in
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reported cases once introduced into a community. In a supporting study done by Strathdee et al.

(2015), they researched the effects of harm reduction of needle-exchange programs on an HIV

outbreak in rural Indiana due to the sharing of used drug needles. Researchers discovered a

dramatic decrease in cases once they began introducing clean needles into the public and given

to users (Strathdee et al., 2015). Not only are they important in the decrease of harmful needle-

sharing illnesses, but they also decrease overall rates of suspected heroin use in an area (CDC,

n.d.). In fact, needle-exchange sites sometimes give out recommendations for MAT, and they

reduce overdose fatalities by teaching individuals who inject drugs how to avoid overdose and

how to respond to a drug overdose by offering training on how to administer naloxone, a

medicine that reverses an overdose. (CDC, n.d.) This education is important to give out to users

because if they were taught how to administer heroin in a risky way in an unsafe environment,

this education allows them to potentially seek treatment and put a harmful behavior, such as

heroin use, in their past. Needle-exchange programs engage the surrounding community by

supporting public safety through partnering with local first responders and law enforcement with

education on dirty needles and disposing of them in a safe, effective way (CDC, n.d.). This is

important reasoning because it teaches the community who are against this program that dirty

needles are staying off the streets, and there is less chance of someone coming into contact with a

potentially harmful and disease-ridden needle by accident. It keeps the local community safer

and it gives heroin users their human right to stay safe, even when engaging in risky behavior

like heroin use. One downside to this program is that there have been no findings of decreased

crime rates with the introduction of a needle-exchange site, which is a huge factor that comes

into play when cities are thinking of putting one in their community. (CDC, n.d.) Overall,
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needle-exchange programs give heroin users the education on potential treatment options and

build a bridge for local law enforcement to safely engage with heroin users.

While needle exchange programs target individuals for preventing illness and educating

users about the dangers of overdoses, overdose prevention sites (OPSs) focus more on

intervening rapidly on a potential overdose rather than attempting to solve the root of the

addiction. The ASAM (2021) describe OPSs as locations where people may use sterile

equipment to inject previously obtained illicit substances in settings where they can be monitored

and healthcare professionals can rapidly act in the case of an overdose. In a study done by Pauly

et al. (2020), they researched the implementation of OPSs in Canada and were lucky enough to

stop any death from occurring, but on top of that, discovered that the more open they allow the

users to be with their drugs, the more open they were to discuss their substance abuse, which

allows relationships to form between health professionals and users and work to destigmatize

heroin abuse. Pauly et al. (2020) also mentioned the fact that users would come to these sites just

to spend time with the experienced staff instead of the worse off living conditions they were

staying in. While this factor does not directly relate to someone injecting heroin, it opens up a

discussion of what users are seeking, which is trusting relationships with a non-judgmental staff

member that can refer them to treatment centers if they are willing to commit. Another very

important aspect is the rates of violence between individuals who are habitual drug users. In a

supporting study done by Boyd et al. (2018), they discovered the following- “Women commonly

positioned OPS as ‘safe havens’: regulated settings where they could consume drugs safely

without fear of death and minimize exposure to extreme forms of gendered and racialized

violence characterizing some drug scene settings and situations.” Not only are these women

being monitored for a potential heroin overdose, but they are also being allowed to be away from
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some of the potential violent factors that come into play when one is in a typical drug-using

environment. OPSs not only impact their mortality rate, but it improves their quality of life by

being in an environment that is sterile and safe with health providers standing by in case of an

emergency. Some researchers argue that this strategy is harmful to the user because it allows

them to use drugs more often without fear of retaliation from police or other governmental

agencies, which could increase the overall use of heroin. In addition, opponents of OPSs believe

that their existence in a community signals a tacit approval of drug use by public officials and

that they do nothing to address the non-medical repercussions of drug use, such as family and

work-related issues (ASAM, 2021). Furthermore, in the United States, OPSs confront a number

of legal and regulatory hurdles at the federal, state, and municipal level (ASAM, 2021).

Lastly, there is the medication-assisted treatment (MAT) harm reduction strategy. Spas et

al. (2020) writes that- “in 2014, 6 out of 10 overdose deaths in the USA were due to opioids and

4 out of 5 new heroin users developed their substance use problems by first misusing

prescription pills, whether prescribed to them personally or to someone else.” These high rates of

new users and opioid deaths require changing and updating ways to combat it. According to the

NHRC (2021), examples of prescriptions that are given to heroin users include methadone and

buprenorphine. Methadone is a “synthetic opioid agonist that binds to opioid receptors that

eliminate opioid withdrawal symptoms and relieve cravings” (NHRC, 2021). Methadone is an

important drug that allows users who are going through withdrawal to avoid the intense and

sometimes deadly side effects that can occur. NIDA (2021) explains that methadone is an oral

tablet that is taken daily and is a good option for individuals who have a difficult time with other

medications. Buprenorphine is similar to Methadone in that it reduces cravings without the

intense elation and is given out through outpatient treatment programs, yet it is a “partial opioid
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agonist that binds to the same receptors heroin would, but activates them less intensely” (NHRC,

2021). These two medications have a great impact on one’s ability to quit heroin and remain

sober. In a study done by Deyo-Svendsen et al. (2020), there is a case report about a patient who

is a regular heroin user and one-day overdoses and goes into moderate withdrawal. After 6

months of MAT, the patient was eager to tell others about his great experience and referred two

persons for MAT, he was still taking his withdrawal medication daily a year after starting MAT

and felt ready to start tapering to a lesser dose. (Deyo-Svendsen et al., 2020) In another

supportive study written by Jones et al., (2015), they write that the most effective therapy for

opioid use disorder is opioid agonist medication-assisted treatment with methadone or

buprenorphine, which has been found to improve treatment adherence and decrease opioid usage,

as well as risk behaviors that spread HIV and hepatitis and death. One downside of MAT is that

at times it can take months on end to be truly effective in ending one’s addiction, but studies are

showing that although it may take months, it is effective in treating and preventing future

relapses in those who were addicted. In an article by Oesterle et al. (2019), researchers write

“Despite broad recognition of the importance of MAT, it is estimated that only 11% of patients

with an opioid use disorder are prescribed Food and Drug Administration (FDA)-approved

medications for the disorder.” This disparity in patients who are using this useful resource shows

that there is work to be done in providing access to people who are suffering from heroin

addiction. MAT is the only harm reduction strategy that is aimed at completely dissolving one’s

reliance on heroin and related opioids, and the above studies show that it is making a difference

in users’ lives. MAT allows heroin users to be prescribed medication that can truly make a

difference in their treatment and allows them to live a relatively normal life without the effects of

harmful withdrawal and cravings. MAT also encourages community engagement by supportive
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healthcare workers who prescribe the medication and give individuals seeking care a judgment-

free facility to receive their daily prescription and regain independence back into society

following an addiction.

Summary & Conclusion

All in all, harm reduction is a topic that is up for heavy debate in this day and age. But the

research is showing that it does have important health implications for habitual heroin users who

are suffering from addiction. Based on the above findings, the three harm reduction programs-

needle exchange, overdose prevention sites, and MAT- are efficient in preventing accidental

overdoses and blood-borne illnesses because they encourage community engagement to fight the

opioid epidemic, educate the surrounding community on the dangers of drug use and how to stop

a potential overdose, and give the addicted individual seeking care a non-judgment environment

that promotes safety and cleanliness. I chose to research this topic because I believe addiction is

a disease and there is no one reason one becomes addicted. Whether it be environmental factors,

a simple prescription from your doctor, genetics, or just daily life stressors- everyone deserves

the right to be treated fairly and humanely, no matter what risky behavior they act on. I think the

portion of the U.S. population who are addicted to heroin are being forgotten about and do not

have many supporters in their corner fighting for their rights, and I wish to be that person who

advocates for their safety and treatment. Overall, I was surprised by the findings, especially

related to MAT. The fact that MAT has been proven as a reliable treatment for the addiction to

heroin and other opioids, yet only 11% of patients with a diagnosed substance use disorder are

undergoing the treatment (Oesterle et al.,2019) shows that the government has not fully grasped

the idea of it just yet, and there is work to be done in continuing to advocate for its efficacy. An

example of simple safety advocacy is Needle exchange programs that give clean needles to users
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who have a higher risk of contracting HIV or other blood-borne illnesses. OPSs are sites that are

free of opinion and are simply there to listen and save lives in the event of an overdose and give

addicts a sense of peace in a world that may be full of crime, instability, and violence. MAT is a

treatment option for individuals who have tried or are not interested in the “cold-turkey” method,

and wish to try prescriptions that are proving to be reliable. Harm Reduction is an incredible new

method to combat the growing opioid crisis that is hurting the U.S. and nations around the world,

and I believe treats addicts in a humane way that encourages them to be more open about their

addiction, for example, the study was done by Pauly et al. (2020), which saw an abundance of

individuals who at times came to the sites not to inject heroin, but instead sit with a healthcare

professional and gain a new relationship and trusted friend. Harm reduction is a great resource

for heroin users because it reduces their risk of infections, can give them opportunities for

treatment and less of a chance of accidentally overdosing, and a better quality of life.

Recommendations

As for recommendations that could be beneficial towards the efficiency of harm

reduction strategies, the number one recommendation would be to add government funding for

this type of rehabilitation for drug users in all areas of the country. In addition to funding,

increasing the access to these programs in rural areas of the country instead of inner-city areas

closes the gap between heroin users who live far away from healthcare providers. Another

recommendation to be more efficient would be to provide these types of services at incarceration

sites to prevent addicts from continuing their use or relapsing once they are released from prison.

A specific recommendation for needle-exchange programs is to expand on exchanging dirty

needles for clean ones, but growing it into a community development that encourages public

safety measures and education on properly disposing of a used needle. A specific

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recommendation for OPSs would be to work with community leaders because once they have

their support, local citizens should follow and be more open-minded to the idea of overdose

prevention sites. And lastly, a specific recommendation for MAT would be to expand coverage

and encourage more primary care physicians to become certified in giving out methadone to

patients who are suffering from opioid addiction.

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