Reference no: EM133307086

Assignment: What Approaches are Effective in Treating Substance Use?

Substance Use Disorder (SUD) is a complex treatable brain disease that affects behavior and brain function. The definition of SUD presented by psychiatry's Diagnostic and Statistical Manuel can be summarized as a compulsion to use harmful substances despite negative consequences (Mignon 3-6). One pressing negative consequence is the risk of overdose and death. According to the Centers of Disease Control and Prevention, more than 100,000 people died from drug overdoses from 2021 to 2022. Drug overdose deaths are 3.5 times higher in the United States than 17 other western countries (Quigley). So, what can be done to prevent further fatality in people suffering with SUD? In simple terms, providing access to effective treatment can prevent death due to drug overdose. Effective treatment can be measured by eliminating or reducing substance abuse, reduction of problems accompanying substance abuse, as well as a reduction in public safety risk (Mignon 1).

Historically, treatment has not always been the frontline response to substance abuse. Researcher and author of "Opinions Throughout History: Drug Use and Abuse", Micah Issitt, remind us that throughout most of American history, addiction and substance abuse has been approached through a punitive lens with a focus on punishment rather than rehabilitation (ch.28). There was a strong belief that severe punishment would prevent substance abuse, this belief influenced the political response and enactment of the 1914 Harrison Narcotic Act. The Harrison Act of 1914 focused on narcotics policing and increasing severe prison sentences and began what is now known as the War on Drugs. Issitt notes that there has been debate regarding whether or not this approach was successful while offering evidence that this punitive strategy has failed. Issitt points out, "There is significant evidence to suggest that the American anti-drug efforts have failed: the current opioid crisis being defined as the worst drug problem in U.S history" (ch.28). Harm reduction advocate and researcher, Maia Szalavitz, offers insight on the nature of drug addiction and recognizes that a person who is using substances may not have the ability to consider the consequences of their actions. Szalavitz argues that "The compulsive nature of addiction overpowers otherwise rational responses; and many addicts face consequences far deeper and more lasting than those provided by the law, and yet are still unable to resist these impulses." (qtd. in Opinions Throughout History: Drug Use and Abuse, ch.28). In other words, Szalavitz insists that a punitive approach is unsuccessful because an addict must rationally think of the consequences presented by their use, and their compulsions override this rational thinking.

"When a friend taught me to run bleach through my syringe at least twice and then rinse twice with water before injecting, she most likely saved my life," reflected Szalavitz. As a former addict, who now successfully abstains from harmful substances, Szalavitz references her first exposure to harm reduction and attributes this approach to saving her life. Aaron Quigley, a licensed social worker, defines harm reduction as "policies, programs or practices that are aimed at reducing or eliminating negative health, social and legal impacts associated with substance use". Harm reduction concentrates on positive change and doesn't require people to practice abstinence to receive support. This approach focuses on minimizing the impact substance use has on the individual, family, and community while "recognizing the inherent dignity and worth of a human life" (Quigley). Individuals suffering from substance use deserve the opportunity to live happy, healthy, and fulfilling lives. As a society, we must provide access to effective treatment approaches that meet the individual where they are in the recovery process. Harm reduction provides an effective treatment approach and should be accessible for all individuals who encounter substance use.

The concept of harm reduction is not new and was practiced in England as early as the 1920s to treat opiate addiction with prescription heroin and morphine (Mignon 25). Unfortunately, it took the U.S. some time to catch on. Not until the late 1980s, during the HIV/AIDS epidemic, did the U.S. start funding harm reduction through needle exchange programs. Harm reduction strategies can include syringe exchange programs, medication-assisted treatment, safe places where substances can be consumed and harm reduction therapy (Mignon 25-26). Harm reduction is often associated with substance use, however, if you take a deeper look, it is used everywhere. Szalavitz emphasizes the idea that harm reduction should reduce harm first before demanding that people cease all risky behavior. A recent example of harm reduction in everyday life was presented during the coronavirus pandemic. Epidemiologists acknowledged that complete abstinence from socializing was unrealistic, so instead they implemented harm reduction through masking, social distancing, and increased testing. Harm reduction is centered around the idea that you can provide people with accurate risk information and trust the individual to make better choices. Some examples of everyday harm reduction are the use of seatbelts and condoms. Seatbelts reduce harm while driving in a motor vehicle, although people may still be injured while wearing them. Condoms reduce sexually transmitted infections but do not eliminate them (Szalavitz).

Harm reduction therapy (HRT) traditionally happens in a clinical setting with a licensed harm reduction practitioner. HRT addresses one of the top reasons people with substance use disorder do not seek treatment; they are not ready to practice abstinence (Vakharia 66). Abstinence is often defined as no illegal drug use or alcohol, as well as no use of medications that were not prescribed by a doctor (Mignon 22). HRT offers people a low threshold treatment option without requiring individuals to commit to abstinence (Vakharia 66-7). Offering a low threshold treatment option "means offering as many points of entry as possible so that community members can choose how they access services" (Little and Franskoviak 179). Removing barriers to accessing treatment creates a welcoming environment for people who use substances and increases their willingness to engage in self-improvement by practicing harm reduction. Harm reductionists, Sheila P. Vakharia and Jeannie Little, propose that the environment HRT creates will increase the number of substance users accessing treatment, those who may have been deterred from the abstinence only model that many traditional treatments mandate (p.75). Increasing the number of people accessing treatment will reduce death due to drug overdose.

HRT is often combined with other methods of harm reduction, such as medication assisted treatment. An example of this combined harm reduction effort is a community-based medical practice based in Ithaca, New York. Respectful, Equitable Access to Compassionate Healthcare (REACH), provides buprenorphine, primary care and mental health services through a harm reduction informed, low threshold model (Griffin et.al 1898-99). Buprenorphine is a pain medication that is used for people withdrawing from opioids, as well as short- and long-term treatment for opioid addiction. This medication reduces the physical side effects of withdrawal and blocks the effects of opioids, including cravings and the impulses to use (Mignon 95). REACH identifies that stigma prevents people who use substances from engaging in healthcare and disclosing their substance use. This medical practice intends to provide harm reduction treatment while minimizing stigma by "organizing care around non-judgmental interactions with people who use drugs" (Griffin et al 1898-1901). Removing stigma in accessing buprenorphine, or any healthcare, increases a person's probability of receiving medication-assisted therapy and reduces intake of harmful substances. Medication-assisted treatment programs have a 60% success rate in preventing relapse (Issitt). On the other hand, traditional abstinence-based treatments have a 10% success rate and have a much higher overdose rate when people relapse (Issitt). To put it briefly, medication-assisted treatment keeps people alive long enough to find a treatment that works (Quigley).

While harm reduction plays a critical role in reducing death related to drug overdose it also reduces comorbidities associated with substance use, such as human immunodeficiency virus (HIV), hepatitis C virus (HCV) and hepatitis B virus (HBV) (Des Jarlais 1). Blood borne illnesses are one the greatest risks for people who inject drugs and are often contracted through the shared use of syringes (Mignon 24-25). The harm reduction model works to reduce these risks by providing needle exchange programs. These programs provide new sterile syringes in exchange for used ones in addition to other health and social services. Additionally needle exchange programs offer testing and counseling for HIV, HCV and HBV, condoms, referrals for substance abuse treatment, education, and naloxone. Naloxone is a medication that revereses overdoses. The education and distribution of this medication has proven to be lifesaving (Des Jarlais 4). According to the CDC, "people who use syringe services programs are five times as likely to start treatment and three times as likely to stop using drugs" reports Renuka Rayasam, reporter for Kaiser Health News. Don C. Des Jarlais, PhD and director of research at the Baron Edmond de Rothschild Chemical Dependency Institute, reports that syringe exchange programs have been "remarkably effective in reducing HIV transmission" (p.5). Consequently, a study done in New York from 1990 to 2002 examined the impact of syringe exchange programs on the HIV rate and reported a decrease from 50% to 19%. Similarly, the District of Columbia conducted a similar study and reported a 70% decrease

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