Syringe Exchange Programs. IDU accounts for up to 15% of all new HIV infections and is the primary risk factor for the transmission of HCV.5 These infections occur when people inject using equipment contaminated with blood that contains HIV and/or HCV. Given this, if people who inject drugs could access and consistently use sterile syringes and other injection paraphernalia, the risk of transmitting blood-borne infections would be dramatically reduced. This is the concept behind syringe exchange programs (also known as needle exchange programs), which serve to increase access to sterile syringes while removing contaminated or used syringes from the community.
There is compelling evidence that syringe exchange programs decrease the rate of HIV transmission and likely reduce the rate of HCV transmission as well.6 In addition, syringe exchange programs often provide other beneficial services, such as counseling, testing, and prevention efforts for HIV, HCV, and sexually transmitted infections; distribution of condoms; and referrals to treatment services for substance use disorder.5
Unfortunately, in the U.S., restrictive state laws and lack of funding limit the number of established syringe exchange programs. According to the North American Syringe Exchange Network, there are only 226 programs in 33 states and the District of Columbia. Hospitalists and social workers should be aware of available local resources, including syringe exchange programs, and distribute this information to hospitalized individuals who inject drugs.
Opioid Overdose Education and Naloxone Distribution. Syringe exchange programs and safe injection education aim to reduce harm by decreasing the transmission of infections; however, they do not address the problem of deaths related to opioid overdose. The primary harm-reduction strategy used to address deaths related to opioid overdose in the U.S is opioid overdose education and naloxone distribution (OEND). Naloxone is an opioid antagonist that reverses the respiratory depression and decreased consciousness caused by opioids. The OEND strategy involves educating first responders— including individuals and friends and family of individuals who use opioids—to recognize the signs of an opioid overdose, seek help, provide rescue breathing, administer naloxone, and stay with the individual until emergency medical services arrive.7 This strategy has been observed to decrease rates of death related to opioid overdose.7
Given the evolving opioid epidemic and effectiveness of the OEND strategy, it is not surprising that the number of local opioid overdose prevention programs adopting OEND has risen dramatically. As of 2014, there were 140 organizations, with 644 local sites providing naloxone in 29 states and the District of Columbia. These organizations have distributed 152,000 naloxone kits and have reported more than 26,000 reversals.8 Certainly, OEND has prevented morbidity and mortality in some of these patients.
The adoption of OEND can be performed by individual prescribers as well. Naloxone is U.S. FDA-approved for the treatment of opioid overdose, and thus the liability to prescribers is similar to that of other FDA-approved drugs. However, the distribution of naloxone to third parties, such as friends and family of individuals with opioid misuse, is more complex and regulated by state laws. Many states have created liability protection for naloxone prescription to third parties. Individual state laws and additional information can be found at prescribetoprevent.org.
Hospitalists should provide opioid overdose education to all individuals with opioid misuse and friends and family of individuals with opioid misuse. In addition, hospitalists should prescribe naloxone to individuals with opioid misuse and, in states where the law allows, distribute naloxone to friends and family of individuals with opioid misuse as well.
Controversies. In general, opioid use disorder treatment providers; public health officials; and local, state, and federal government agencies have increasingly embraced harm-reduction strategies. However, some feel that harm-reduction strategies are misguided or even detrimental due to concern that they implicitly condone or enable the use of illicit substances. There have been a number of studies to evaluate the potential unintended consequences of harm-reduction strategies, and overwhelmingly, these have been either neutral or have shown the benefit of harm-reduction interventions. At this point, there is no good evidence to prevent the widespread adoption of harm-reduction strategies for hospitalists.