What is Harm Reduction?
Harm reduction is a policy framework that minimizes the negative healthcare outcomes of undesired behaviors by acknowledging that said behaviors are likely to persist. In the context of substance use, this would mean reducing the impact of drug use before reducing the drug use itself. Crucially, harm reduction does not mean drug use is condoned. It simply means withholding condemnation of the behavior while the consequences of behavior are first addressed. One of the most common examples of opioid-related harm reduction is increasing the accessibility of naloxone, the overdose-reversing medication. By increasing ease of access and protecting from civil liability those who administer the medication in good faith, this acknowledges that the drug use is likely to occur but with naloxone at hand a life may be saved. In this way, keeping the person who uses drugs alive increases the chance that they may enter recovery services. As Dr. Stephen Loyd of Cedar Recovery says, “you cannot treat dead people.” This is the key to harm reduction: when the cessation of the behavior is sought, help will be provided, but until the person is ready, the programs will be there to keep them alive and as healthy as possible. In other words, harm reduction is about meeting the individual where they are on their own path to recovery.
Current Harm Reduction Policies in Tennessee
Tennessee already has a number of harm reduction policies in place. Some date back decades, some to the early days of the opioid epidemic, and some were only implemented after the epidemic was declared a national emergency.
Expanded Naloxone Access
Naloxone was first approved by the FDA in 1971, but rose to prominence more recently alongside the opioid epidemic. Currently, Tennessee law allows access to naloxone for anyone with or without a prescription. Naloxone is available in many forms, most commonly as a nasal spray sold under the brand names Narcan and Kloxxado, and in a much less expensive intramuscular injection variety favored by emergency departments (EDs) and clinics. In 2014, Tennessee joined other states in passing a Good Samaritan law, protecting healthcare providers from civil suit when prescribing naloxone to a person at risk of experiencing an opioid overdose, or to a family member or friend in a position to assist a person at risk of an overdose. Furthermore, anyone administering naloxone to someone they reasonably believe is experiencing an overdose is also protected from litigation under this law. In 2022, a new law was passed that permits a healthcare provider to prescribe naloxone to anyone who is or knows someone at risk of overdose of any drug—not just opioids—due to the rising risk of fentanyl contamination. The law also increases the kinds of governmental and nongovernmental agencies that can store and distribute the medication to include schools, homeless shelters, health departments, county jails, and harm reduction organizations. Such programs—such as syringe service programs—often offer naloxone to anyone requesting it for free.
Syringe Services Programs
Syringe services programs (SSPs) are proven and effective community-based prevention programs that provide a range of services, including access to and proper disposal of used syringes and injection equipment, vaccination (including contra hepatitis), screening for hepatitis C, HIV and other similar diseases, and linkage to infectious disease care and substance use treatment. They also distribute fentanyl test strips, which are discussed below. Nearly thirty years of research shows that SSPs are safe, effective, cost-saving, do not increase illegal drug use or crime, and play an important role in reducing the transmission of viral hepatitis, HIV, and other infections. Most SSPs offer resources for recovery, and it has been shown that new clients of these programs are five times more likely to enter drug treatment and three times more likely to stop using drugs altogether. SSPs also often offer naloxone education and distribution. These programs can further reduce overdose deaths by teaching people who inject drugs how to prevent and respond to overdose and provide them with “overdose prevention kits” that contain naloxone.
SSPs were legalized in Tennessee since 2017 in order to “reduce the spread of [HIV], [AIDS], viral hepatitis, and other bloodborne diseases in this state; reduce needle stick injuries to law enforcement officers and other emergency personnel; and encourage individuals who inject drugs to enroll in evidence-based treatment.” The law provides limited immunity to SSP staff, volunteers, and enrolled participants, protecting them from being charged with possession of syringes or other injection supplies when in transit to or from a site and able to present an SSP card. While SSPs are legal, per the Consolidated Appropriations Act of 2022, no state funding may be used to “purchase sterile needles or syringes for the hypodermic injection of any illegal drug,” with the notable exception of a State or local jurisdiction experiencing or being at risk for a “significant increase in hepatitis infections or an HIV outbreak due to injection drug use.” As this shows, harm reduction is already written into Tennessee law.
Fentanyl Test Strips
Fentanyl is a synthetic opioid used medically to treat severe pain, such as with late-stage cancers. It is 50-100 times more potent than morphine yet is inexpensive. As such, illicitly manufactured fentanyl has become widely available on the street. Of particular concern is the contamination by fentanyl of other illicit substances, which is increasingly common. Drug suppliers can lace heroin, meth, or any other drug with fentanyl or use illegal pill presses to manufacture a fentanyl-laced pill that resembles Oxycodone or another prescription, such as counterfeit Xanax and Adderall. People that buy these pills on the street think they know what drug and dose they are about to ingest. However, due to the presence of fentanyl, they unintentionally overdose.
Originally used to detect fentanyl in urine, fentanyl test strips (FTS) have become an inexpensive and easy way to detect if fentanyl is present in an individual supply of nearly any substance. The tester dissolves a small amount of substance in water and then dips the strip into the mixture. The strip will indicate the presence of fentanyl in five minutes. Though not foolproof, as FTS cannot determine the potency or amount of fentanyl present, they can promote increased awareness and lead people to take safety precautions to prevent overdose. FTS were considered illicit drug paraphernalia in Tennessee and could not be used as a sanctioned harm reduction strategy until they were decriminalized in May 2022. Strategies are currently being developed to best distribute FTS to the substance use population. For example, in Delaware and New York, legislation was introduced in the summer of 2022 to include fentanyl test strips in naloxone kits.
Novel Harm Reduction Strategies
Safe Injection Sites/Supervised Injection Facilities
Supervised injection facilities (SIF), also known as overdose prevention centers, are a type of harm reduction program not unlike syringe service programs (SSPs). Whereas SSPs provide a place for people who use drugs to obtain unused hypodermic needles and naloxone, as well as connections to long term recovery services, SIFs also provide a space for people to inject drugs under the supervision of a clinician trained in naloxone administration. SIFs have been associated with a marked decrease in overdose mortality compared to the surrounding areas (35% decrease versus 9%), a significant reduction in infectious disease transmission (such as HIV) as well as overall drug use, and increased access to healthcare and social services. In November 2021, two SIFs opened in New York City and averted 59 overdose deaths in the first three weeks of operation. The first legal SIF in the United States was opened in Rhode Island earlier that year. Though the Department of Justice prevented the opening of a facility in Philadelphia in 2019, the DOJ has not interfered with either the Rhode Island or New York facilities.
Case Study: Choice Health Network
Choice Health Network (CHN) medical clinic was launched in 2018 by Positively Living, Inc., which itself began in 1996 to provide care to those living with HIV and AIDS. CHN still provides services aimed at this population, but has expanded to new services aimed at a wider population base. “In addition to medical care, our services now include food and transportation support, mental health counseling and therapy, HIV and HCV testing and treatment, pharmacy services, peer support and telehealth, and HIV prevention (PrEP and PEP).”
Since the 2017 bill legalizing SSPs passed, CHN has begun offering these services at multiple locations, including Knoxville and Chattanooga. In 2019, they served 4,709 clients, collected and disposed of 450,156 syringes, and delivered over 23,706 doses of naloxone. Their clients reported that using that naloxone, they reversed over 2,500 overdoses. That is more than the number of people that died of fatal overdoses in Tennessee in 2019. In FY2018-19, CHN conducted 494 HIV tests, 305 HCV tests, and started 85 patients on PrEP, the HIV prophylactic medication.
In addition to services directly related to SUD, Choice Health Network has addressed multiple social determinants of health. In FY2018-19, they provided 754 clients with case management services, 353 clients with food assistance and 195 clients with rental assistance, as well as provided 66,700 miles of client transportation assistance.
Policy Brief Authors:
Jeremy Kourvelas, MPH, SMART Initiative
Jennifer Tourville, DNP, Executive Director, SMART Initiative
Johnnie Bower, RN, Graduate Assistant, UT Institute for Public Service, SMART Initiative