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Making the case for harm reduction programs for injection drug users

Kulikowski, Julie, BSN, RN; Linder, Erika, BSN, RN

doi: 10.1097/01.NURSE.0000532745.80506.17
Feature: ISSUES IN NURSING

Review the evidence supporting needle-exchange programs and supervised injection sites.

Julie Kulikowski is an RN at Mayo Clinic in Rochester, Minn. Erika Linder is an RN at Brigham and Women's Hospital in Boston, Mass.

The authors have disclosed no financial relationships related to this article.

With Issues in Nursing, our purpose is to lay the groundwork for further discussion about current controversies in the nursing profession. To succeed, we need to hear from you. E-mail us at Andrew.Parent@wolterskluwer.com; place “Issues” in the subject line. Be sure to include your full name, credentials, city, state, and daytime phone number.

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IN MANY AREAS of the United States, incidence rates for HIV/AIDS have declined in recent years.1 Despite this success, the evidence suggests that about 50,000 people become infected with HIV every year in the United States alone.2 The current opioid crisis sweeping the country is threatening to further propel HIV into epidemic proportions: Although HIV is commonly transmitted through sexual behaviors, it's also spread via shared needle use.

Unfortunately, the practice of sharing needles, syringes, and other injection supplies is common among users of illicit or recreational injection drugs. One large-scale study of this population found that 40% of injection drug users (IDUs) admitted sharing syringes.3 This puts IDUs at a higher risk of contracting HIV and other communicable diseases transmitted via blood exposure and transmitting disease to the wider community.4

This article discusses evidence supporting harm reduction strategies such as needle exchange programs and supervised injection sites, and argues for expanding use of these strategies in the United States.

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Injection drug use spreads HIV infection

In 2014, an estimated 774,434 adults and adolescents in the United States injected illicit drugs.5 These IDUs comprise only 3% of the population but they disproportionately account for 22% of all people living with HIV infection. IDUs also place their noninjecting sexual partners at risk for contracting HIV. Estimates suggest that without intervention, each infected IDU transmits HIV to an average of 10 other individuals, with half of the transmissions occurring within the first month of infection.6

Injection drug use is currently increasing at a faster rate than prevention programs are put into place.6 If current rates of injection drug use continue, the CDC projects that 1 in 23 women who inject drugs and 1 in 36 men who inject drugs will be diagnosed with HIV in their lifetime (see HIV survival: Sobering statistics).7

Clearly, injection drug use and the subsequent transmission of HIV is a current and serious public health concern. What's controversial is the best way to approach this crisis.

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Competing policies

Two policy approaches dominate the debate about reducing the harms of injection drug use.8 The first approach utilizes law enforcement to prohibit and criminalize the possession and use of illegal substances. The second option, known as the harm reduction approach, strives for the safer use of injection drugs. This public health strategy consists of policies, programs, and practices to reduce the adverse health, social, and economic consequences of injection drug use without necessarily reducing rates of use. Examples include needle exchange programs (NEP) and supervised (or safe) injection sites.

Harm reduction aims not only to improve the health and safety of IDUs, but also to protect their families and the larger community. This approach doesn't replace prevention or treatment strategies; rather, it complements those efforts as part of a comprehensive public health response.8

Harm reduction programming has already had a major impact on decreasing HIV prevalence among IDUs.4 The strategy has been embraced by the World Health Organization, the Joint United Nations Programme on HIV/AIDS, and the CDC.7-9 Currently in the United States, however, injection drug use is treated largely as a criminal activity rather than a public health concern. The criminalization and stigma still surrounding injection drug use today remains a barrier to programs aimed at assisting this population.

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Needle exchange programs (NEPs)

Eliminating needle sharing is essential to reduce long-term morbidity due to HIV and other blood-borne infections among IDUs.10 Harm reduction programs can help to eliminate needle sharing via education and provision of sterile supplies.

NEPs provide access to sterile needles and syringes free of cost and facilitate the safe disposal of used needles and syringes.3 These community-based programs have been linked to decreased reporting of needle and syringe sharing, as well as other injection equipment.11 This trend holds true even when controlling for demographic and behavioral variables such as age, race/ethnicity, gender, education level, area of residence, injection frequency, and drug injected. In fact, it's been shown that each increase of sterile needles supplied by local NEPs is associated with a subsequent decline in reported HIV infections among IDUs.11 This inverse relationship is exemplified in a comprehensive review of data throughout Europe, Asia, and North America that found HIV prevalence in cities without NEPs to increase by 5.9% per year, while the prevalence decreased by 5.8% per year in cities hosting NEPs.12

Unfortunately, NEPs remain widely underused in the United States compared with Australia, Canada, and many countries in Western Europe. Increasing use of NEPs by only 5% could initiate noticeable decreases in the incidence of HIV infection. By some estimates, this decline in HIV incidence could reach nearly 35% by 2040 and over 60% if combined with substance abuse treatment programs.13

Despite the evidence supporting the effectiveness and safety of NEPs, these services often face opposition that limits, or in worse cases discontinues, the delivery of services.14 Currently 41 states host syringe exchange programs, up from only 33 states just 3 years ago (see Find an NEP near you).15 However, the supply of syringes often falls substantially short of the demand. In a recent 5-year span, the number of syringes distributed by NEPs in the United States declined from 22 syringes/year/IDU to 15 syringes/year/IDU.14

Social and political forces play a critical role in the acceptance or rejection of NEPS in each community.14 Some argue that the programs will only perpetuate or exacerbate drug addiction. However, NEPs haven't been found to increase drug use or initiation into drug use, nor have they been found to increase rates of crime or improperly discarded needles.14 In fact, the CDC reports that NEPs actually reduce drug usage because IDUs are five times more likely to enter treatment programs when accessing NEPs. Further, NEPs reduce needle-stick injuries among first responders—a hazard that one in three officers will face in his or her career.7 NEPs even decrease taxpayer healthcare costs and preserve resources by preventing infections. The average lifetime cost of treating an HIV-infected individual is over $400,000.7

Because NEPs have been consistently found to be an effective way to combat the transmission of HIV among IDUs, many researchers suggest that the immediate expansion of prevention programs in communities of IDUs is required to markedly reduce the drug-related transmission of HIV in the United States.11,13,14,16,17 The CDC has even added access to sterile needles and syringes to their list of evidence-based HIV prevention interventions.11 Now that a substantial body of research supports the safety and effectiveness of NEPs, efforts to implement these programs on a larger scale are warranted.

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Next step: Supervised injection sites

New evidence-based research on harm reduction programs points to supervised injection sites as the next crucial step in increasing safety for IDUs.16 Supervised injection sites allow the clean and legal use of previously obtained drugs under professional supervision in a nonjudgmental environment.8 The operation of individual sites varies, but many run similarly to other medical clinics with a centralized nursing station where medical personnel keep the sterilized needles and injection equipment such as tourniquets and bandages.16 IDUs check in at a reception desk, where they're questioned about their usage and provided with education about safety and treatment options. They're then provided access either to a private room where they can inject, or to a large common-space injection room. The professional staff—typically nurses—provides constant supervision and emergency care if necessary. With each encounter, nursing staff gives appropriate guidance in the form of both evidence-based practice for user safety and education about treatment options and disease screenings.16

In early 2016, approximately 100 supervised injection sites were operating in at least 66 cities in 9 countries across the globe.18 The first North American supervised injection site opened in Vancouver, Canada, 15 years ago.18

Despite over a decade of private efforts and political lobbying, currently no supervised injection sites have been established in the United States, although programs are under consideration in several cities. In February 2018, the San Francisco Department of Public Health unanimously approved recommendations for the nation's first supervised injection site. Two facilities are set to open in July 2018 using private funding. Similarly, Philadelphia, Seattle, and Baltimore are in conversation to follow suit.19

The main mechanism by which supervised injection sites reduce HIV transmission is through modification of risk behaviors.3 In researching perceptions of IDUs regarding supervised injection sites, Petrar et al. found that 75% of users reported changes in their injecting behaviors as a direct result of access to a facility.20 These changes included fewer rushed injections, fewer injections in public places, less unsafe needle/syringe disposal, and a greater likelihood of using clean supplies on a clean injection site. The most frequent requests were for longer operating hours and shorter wait times—both indicative of the popularity of the program among IDUs. More recent research has also shown that access to a facility positively changes injecting behavior, leading to cleaner and safer communities.21

Most supervised injection sites offer services above and beyond nursing supervision. Education is provided on safer injection practices, overdose prevention, wound care, and safer sex practices.8 At many sites, clinicians also provide screening for HIV, hepatitis C, and other sexually transmitted diseases; tuberculosis screening; vaccinations; and HIV pre-/postexposure prophylaxis.7

The secondary benefits of supervised injection sites have been tremendous. These sites connect IDUs to resources such as healthcare follow-up, substance use treatment, and social services.14 Because many people who use NEPs or supervised injection sites otherwise lack access to healthcare services, these benefits are particularly important.8 Supervised injection sites may be the first point of engagement for many IDUs, linking an often hard-to-reach population to much-needed healthcare services.14

Many challenges remain. For example, few injection sites are open 24 hours, sometimes leaving IDUs with no choice but public injection. Additionally, lines to gain access to sites can be long, which is particularly problematic for users experiencing withdrawal. Some IDUs report a hesitance to utilize supervised injection sites for fear of disappointing staff members with whom they've built a positive relationship.22

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Potential benefits in the United States

Researchers suggest that if supervised injection sites were widely used in the United States, the positive effects would be felt not only among IDUs but also by the surrounding community.16 Researchers recently investigated the frequency of HIV testing among high-risk individuals to determine not only how well the public is following testing guidelines, but also to gain insight into the success of HIV prevention programs in promoting testing.22 They found that the timing between two consecutive HIV tests among IDUs has decreased over the past decade. It can be extrapolated that increasing the availability of HIV testing via harm reduction programs plays a role in the increased frequency of HIV testing among IDUs.22 Therefore, one can reasonably infer that harm reduction programs can help reduce the window in which HIV-positive IDUs are unknowingly transmitting the virus to others.

In addition, supervised injection sites are associated with cost savings for taxpayers due to less demand for ambulance and medical services provided for those who overdose or have complications related to their injection drug use, such as HIV infection. Irwin et al. suggest that placing a single supervised injection site in an American city could result in a net savings of three and a half million dollars per year.23 HIV prevention programs associated with continuous care and aimed at helping those already infected to reduce their transmission risk can be cost effective and even cost saving.2

The need for harm reduction public health initiatives such as supervised injection sites is apparent. In many areas of the country, even in states where public health initiatives are well funded, the number of drug users, HIV incidence, and drug overdoses are increasing.16 Researchers agree that opposition to preventive programs must be overcome with increased education about, advocacy for, and implementation of harm reduction programs.16

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Implications for nursing practice

The importance of expansion of harm reduction programs in the reduction of HIV prevalence is a common theme in current research.6 Nursing advocacy and education is imperative to continue to improve harm reduction awareness among IDUs while also helping nursing colleagues in their communities to increase success of NEPs.4 An increased presence of public health leadership is essential in the implementation of NEPs and other harm reduction programs.13 This leadership can come from public health and community health nurses or any nurse motivated to get involved.

Of all healthcare professionals, nurses often spend the most time with patients. This gives them time to form deep and trusting bonds with the patient and family members. Because injection drug use is taboo and criminalized, this trusting relationship is required to break down communication barriers between IDUs and healthcare professionals and create an opportunity for education on clean needle use. The more knowledgeable nurses are about HIV prevention resources in their community, the more comfortable they'll be promoting them.

Currently, a large disparity in HIV incidence rates exists among Black and Hispanic IDUs compared with White IDUs.5 Education and outreach to underserved populations utilizing culturally competent care is one aspect of addressing these disparities that a nurse can effectively initiate. Current programming must be evaluated and designed to ensure a culturally holistic approach so all IDUs receive effective care.5 The nurse can translate specialized training in culturally competent care into initiating programming that reaches all cultures affected by injection drug use.

Specific objectives for the nurse within these public health initiatives include data collection to help with planning and implementation of programs that serve IDUs who are at risk for HIV infection. Such data include an accurate census of IDUs, the rates of HIV infection among them, and demographic information on those affected.5 This could be accomplished through public health or community health nursing.

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Legal and ethical concerns

Inherent in harm reduction programs is the association with illegal substance use. This leads to legal and ethical concerns for nurses at both the state and the federal level. One area that comes into question is the legality of possessing and distributing syringes and other paraphernalia that are being actively used for illicit drug use at supervised injection sites. The Canadian Nurses Association's position is that in this context, the equipment obtained at the supervised injection sites should be considered instruments for preventing disease transmission and fostering safer use practices.8

In Canada, governmental policies have been put into place through agreements, exemptions, and amendments to substance laws in support of supervised injection sites. This frees healthcare workers from criminal liability while involved in these harm reduction programs.8

RNs at a harm reduction center in Vancouver had major concerns about overdoses on site as well as preventable soft-tissue infections associated with injection drug use.8 Questioning whether providing clients with education on evidence-based practice in safe I.V. injections would be considered within the scope of practice, they brought this concern to the Registered Nurses Association of British Columbia (RNABC). The RNABC ruled that this was in fact within the scope of nursing practice as this promotion of evidence-based knowledge would help promote health and decrease illness in this high-risk population.8

In the United States, where no supervised injection sites currently operate, this is largely uncharted territory. Little data are available on the legal and ethical ramifications for an RN's involvement in harm reduction programs in the United States. In San Francisco, where the nation's potential first supervised injection site certainly contradicts California and federal law, state legislators are working on a bill that would protect people associated with the injection site from arrest—including property owners, medical personnel, and the IDUs.19

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Going forward

Canada has made significant progress in harm reduction practices. This success can be used as a template for progress in the United States, especially with the help of nurses' mitigating efforts in advocacy and education, which are imperative to continue to improve NEP awareness among IDUs.4 Collecting accurate data, providing reliable education, and encouraging community involvement will further support these programs and lead to the creation of more robust harm reduction programs. Through nursing research, these programs have gained traction, and ongoing nursing research supports their continued expansion.

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HIV survival: Sobering statistics

Users of injection drugs are not only at an increased risk of contracting HIV, but also at increased risk of morbidity and mortality due to HIV. Mitsch, Hall, and Babu report that among all individuals diagnosed with HIV, those who contracted the disease via injection drug use have a shorter life expectancy than those who contracted HIV differently.17 The CDC reiterates that across all ages and regardless of gender, survival after a diagnosis of HIV is lowest among those using injection drugs compared with those in all other categories of transmission.7

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Find a NEP near you

The North American Syringe Exchange Network provides a directory of NEPs in the United States. Visit www.nasen.org/directory and enter your location into the search box or browse by state.

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REFERENCES

1. U.S. Department of Health and Human Services. CDC fact sheet. Today's HIV/AIDS epidemic. 2016. http://www.cdc.gov/nchhstp/newsroom/docs/factsheets/todaysepidemic-508.pdf.

2. Lin F, Farnham PG, Shrestha RK, Mermin J, Sansom SL. Cost effectiveness of HIV prevention interventions in the U.S. Am J Prev Med. 2016;50(6):699–708.

3. Centers for Disease Control and Prevention. National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. HIV and injection drug use. 2016. http://www.cdc.gov/hiv/pdf/risk/cdc-hiv-idu-fact-sheet.pdf.

4. Wejnert C, Hess KL, Hall HI, et al Vital signs: trends in HIV diagnoses, risk behaviors, and prevention among persons who inject drugs—United States. MMWR Morb Mortal Wkly Rep. 2016;65(47):1336–1342.

5. Lansky A, Finlayson T, Johnson C, et al Estimating the number of persons who inject drugs in the United States by meta-analysis to calculate national rates of HIV and hepatitis C virus infections. PLoS One. 2014;9(5):e97596.

6. Vasylyeva TI, Friedman SR, Lourenco J, et al Reducing HIV infection in people who inject drugs is impossible without targeting recently-infected subjects. AIDS. 2016;30(18):2885–2890.

7. Centers for Disease Control and Prevention. National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. Reducing harms from injection drug use & opioid use disorder with syringe services programs. 2017. http://www.cdc.gov/hiv/pdf/risk/cdchiv-fs-syringe-services.pdf.

8. Canadian Nurses Association. Harm reduction and illicit substance use: implications for nursing. 2017. http://www.cna-aiic.ca/en/policy-advocacy/harm-reduction.

9. United Nations. UNAIDS. http://www.unaids.org/en/whoweare/about.

10. MacArthur GJ, van Velzen E, Palmateer N, et al Interventions to prevent HIV and hepatitis C in people who inject drugs: a review of reviews to assess evidence of effectiveness. Int J Drug Policy. 2014;25(1):34–52.

11. Burt RD, Thiede H. Reduction in needle sharing among Seattle-area injection drug users across 4 surveys, 1994-2013. Am J Public Health. 2016;106(2):301–307.

12. Wilson DP, Donald B, Shattock AJ, Wilson D, Fraser-Hurt N. The cost-effectiveness of harm reduction. Int J Drug Policy. 2015;26(suppl 1):S5–S11.

13. Marshall BD, Friedman SR, Monteiro JF, et al Prevention and treatment produced large decreases in HIV incidence in a model of people who inject drugs. Health Aff (Millwood). 2014;33(3):401–409.

14. Deren S, Naegle M, Hagan H, Ompad DC. Continuing links between substance use and HIV highlight the importance of nursing roles. J Assoc Nurses AIDS Care. 2017;28(4):622–632.

15. North American Syringe Exchange Network. Directory of Syringe Exchange Programs. https://nasen.org/directory.

16. Kral AH, Davidson PJ. Addressing the nation's opioid epidemic: lessons from an unsanctioned supervised injection site in the U.S. Am J Prev Med. 2017;53(6):919–922.

17. Mitsch AJ, Hall HI, Babu AS. Trends in HIV infection among persons who inject drugs: United States and Puerto Rico, 2008-2013. Am J Public Health. 2016;106(12):2194–2201.

18. Drug Policy Alliance. Supervised injection facilities. 2016. http://www.drugpolicy.org/sites/default/files/DPA%20Fact%20Sheet_Supervised%20Injection%20Facilities%20%28Feb.%202016%29.pdf.

19. Lieber M. Safe injection sites in San Francisco could be first in the U.S. CNN news report. 2018. http://www.cnn.com/2018/02/07/health/safe-injection-sites-san-francisco-opioid-epidemic-bn/index.html.

20. Petrar S, Kerr T, Tyndall MW, Zhang R, Montaner JS, Wood E. Injection drug users' perceptions regarding use of a medically supervised safer injecting facility. Addict Behav. 2007;32(5):1088–1093.

21. Ontario HIV Treatment Network. Rapid response. What is the effectiveness of supervised injection services? 2014. http://www.ohtn.on.ca/Pages/Knowledge-Exchange/Rapid-Responses/Documents/RR83-Supervised-Injection-Effectiveness.pdf.

22. An Q, Song R, Finlayson TJ, Wejnert C, Paz-Bailey G. Estimated HIV inter-test interval among people at high risk for HIV infection in the U.S. Am J Prev Med. 2017;53(3):355–362.

23. Irwin A, Jozaghi E, Bluthenthal RN, Kral AH. A cost-benefit analysis of a potential supervised injection facility in San Francisco, California, USA. J Drug Issues. 2017;47(2):164–184.

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RESOURCES

American Foundation for AIDS Research. A clear case for supporting syringe services programs: new study shows relationship between public funding and lower HIV incidence. 2015. http://www.amfar.org/uploadedFiles/_amfarorg/On_the_Hill/BIMC%20SEP2%20052215%20rev0106.pdf.

Bonacci RA, Holtgrave DR. U.S. HIV incidence and transmission goals, 2020 and 2025. Am J Prev Med. 2017;53(3):275–281.

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