What About This?: Convincing Opioid Users to Avoid Injecting Is the Best Harm Reduction Strategy : Emergency Medicine News

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What About This?

What About This?

Convincing Opioid Users to Avoid Injecting Is the Best Harm Reduction Strategy

Bivens, Matt MD

doi: 10.1097/01.EEM.0000898220.41146.a0
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    injection, overdose, opioids
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    A young man in his 20s was brought in recently after an opioid overdose. He had snorted something he said was fentanyl (although who knows exactly what's in a potpourri of white powder?) and had stopped breathing.

    A friend called 911. EMS found him with a respiratory rate of 4 bpm and an oxygen saturation of 70%. They gave him intranasal naloxone, he recovered, and now he was sitting in a hallway bed, playing with his phone. Because, as the nurse had told him: “You can't leave until the doctor sees you.”

    This is not a new scene for EPs. Millions of opioid overdoses come to emergency departments every year.

    Before COVID-19 hit in early 2020, the annual U.S. overdose death toll had risen to about 70,000 and was considered a national crisis. (National Institute on Drug Abuse. https://bityl.co/E3yG.) But drug and alcohol use soared during the pandemic, and the overdose death toll passed 100,000 last year. (CDC. May 11, 2022; https://bityl.co/E3yP.) COVID-19, for perspective, has a U.S. death toll of more than one million.

    But even 100,000 deaths don't capture the scope of tragedy. You don't have to die to have your life wrecked. Every physician knows patients who have become paraplegic from a spinal abscess or cognitively impaired from an anoxic brain injury.

    This young man's overdose was interesting to me because of our interaction. We quickly established that he occasionally snorted but never injected opioids; he did not think he had a problem and was not interested in addiction services; he felt fine medically and psychiatrically; and he had a job he had to get to. He listened respectfully to my customary spiel: “This was a life-threatening event. Your brain was not getting oxygen. If the paramedics had not given you naloxone, you probably would have died or suffered permanent brain damage.”

    The Dangers of Injecting

    We talked more and revisited the question of injecting. He insisted he had never done so. “Good,” I said, and then launched into a spontaneous second spiel about the dangers of injecting.

    You can still overdose if you inhale drugs, whether snorting them intranasally or by “chasing the dragon,” the practice of cooking heroin on a piece of foil and inhaling the smoke with a straw. Inhalation routes avoid other dangers of injecting, including viral infections like HIV and bacterial processes like bacteremia, spinal abscess, and endocarditis. “If you're going to continue to use drugs, at least promise me you will only snort or inhale and never inject,” I said.

    The patient seemed impressed, so I told him street drugs are usually mixed with something to stretch the supply, from the dog tranquilizer xylazine to the veterinary dewormer levamisole, which is found in most of the cocaine tested in this country and known to cause vasculitis that attacks and deforms the ear lobes. (Arch Pathol Lab Med. 2015;139[8]:1058; https://bityl.co/E3ym; Inj Prev. 2021;27[4]:395; https://bityl.co/E3yx.) The late James Roberts, MD, reviewed some of this for EMN last year. (EMN. 2021;43[9]:16; https://bityl.co/E42N.)

    Sometimes drug dealers go even cheaper and stretch white powder with other white powders. I offered the patient a lurid account of specks of talc, sugar, and other particulates coursing through his blood, scraping tiny gashes into the smooth surfaces of heart valves and blood vessels and allowing bacteria to come along and seed that plowed surface. “Think of what would happen if you put sugar into your car's gas tank. That's sort of what happens when you inject tiny bits of grit into a vein,” I said.

    The patient seemed genuinely surprised and impressed by things like endocarditis. It's easy to forget that not all opioid users are worldly or well informed. He seemed sincere in volunteering he would never inject drugs thanks to this information.

    Harm Reduction

    I found myself exploring the same question with other opioid overdose patients over the following weeks. All seemed sobered to learn or be reminded of the dangers of injections. Importantly, many seemed indifferent about whether they took opioids by mouth, inhalation, or injection.

    I began to ponder the harm reduction potential of a brief intervention by just telling a patient, “Don't misuse opioids, of course, because you can die or end up brain dead. But if you are going to use them, at least avoid injecting a bunch of sugar and talc and dewormer and ending up with a brain abscess or needing heart surgery.”

    Harm reduction helps people mitigate the damage of a substance use disorder. It's often focused on encouraging safer injection practices, whether by providing education, free clean needles, or sites where people can inject while being observed by naloxone-armed volunteers. But when it comes to safe injections, what could be safer than not injecting at all?

    ‘Chasing the Dragon’

    Can doctors convince opioid users to avoid injecting? I found few studies to support the idea. Researchers in London in the 1990s interviewed 400 heroin users, and found 44.5 percent identified inhaling as their favored route of heroin use versus 55.5 percent who preferred injections. (Am J Addict. 1999;8[2]:148.) The researchers added that inhalation was now the most widely used method of heroin use worldwide.

    This surprised me—the opioid overdose patients I see inject or snort—until it occurred to me that inhalation probably makes it harder to overdose and end up in the ED. Unlike snorting or injecting, where a bolus goes in and there's no taking it back, those actively trying to inhale smoke will quickly become bad at that as they get oversedated. They may set the couch on fire, but they are a lot less likely to have a respiratory arrest.

    (As an aside, I find it off-putting that the substance misuse literature so often uses a fun-sounding street term to describe inhaling opioid fumes. Our literature does not describe those who are intoxicated as “wasted,” so why are we normalizing a term as loaded as chasing the dragon? It's so flagrantly boosterish, with an entire second meaning of chasing the ultimate high.)

    The London researchers drilled down to whether and why heroin users changed their route of administration. (Am J Addict. 1999;8[2]:148.) They found that about 20 percent had first used by snorting. Many would transition to injecting or inhaling fumes, and once they did, transitioning back to snorting was extremely rare. The longer a person misused opioids, the more likely he would end up injecting. “However, transition to injection was not inevitable,” the researchers reported. “The majority of ‘chasers’ had never moved to regular injecting despite often using at high doses for many years ... [and] many chasers give up heroin without moving to injecting.”

    So, maybe this brief intervention is worth a try? The public health benefit could be massive if emergency physicians could convince even five percent of opioid misusers never to inject.

    Dr. Bivensworks at emergency departments in Massachusetts, including St. Luke's in New Bedford and Beth Israel Deaconess Medical Center in Boston. He is double-boarded in emergency and addiction medicine. Follow him on Twitter@matt_bivens.

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