Primary care for people who use drugs

HARM REDUCTION FOR PEOPLE WHO USE DRUGS Daniel Warren, MD Assistant Professor, Department of Family and Community Medicine University of Kansas School of Medicine-Wichita DISCLOSURE Medical director, Wichita Treatment Center

(methadone clinic) Buprenorphine clinic prescriber, HealthCore Clinic (federally-qualified health center) Board member, Substance Abuse Center of Kansas OBJECTIVES Counsel patients on three strategies to reduce the

health risks associated with intravenous drug use Effectively understand and use the language of people who inject drugs Identify at least one potentially helpful harm reduction strategy not currently being utilized in your community TO BEGIN: SCOTT COUNTY, INDIANA

HOW DO PEOPLE LEARN TO USE DRUGS? HOW DO PEOPLE LEARN TO USE DRUGS? Simple question: why do people use drugs? And why do some people inject drugs? And why do some inject in muscles or skin instead of veins?

HOW DO PEOPLE LEARN to prepare a powder to be injected? Snorted? Inhaled? to draw up the right amount? where on the body to inject? to inject, into a vein, without missing? what kind of needle to use?

to get the effect of the drug without overdoing it? SHOULD PEOPLE LEARN HOW TO USE DRUGS? And if so, who should teach them? GETTING OFF RIGHT (HARM REDUCTION COALITION)

One of the results of the United States zero tolerance approach to drug policy is a serious lack of accurate information about drugs and drug use. REDDIT I'm not sure if it is okay to shoot up in the spot where they normally draw blood from. You know right in the

part where your arm bends opposite of your elbow. Is that a vein or an artery? Can you shoot there? It's not the only spot i used but i used to hit there quite often. Not sure if i was dumb for doing that but the first time i used iv somebody else shot me up and used that spot so i thought it was ok. I just wanted to clear this up. GETTING OFF RIGHT

(HARM REDUCTION COALITION) Most of us taught ourselves how to inject through a process of trial-and-error that undoubtedly included lost shots, painful misses, swollen limbs, and a great deal of frustration. BECAUSE A LOT CAN GO WRONG Abscess

Tetanus Bacteremia Anthrax Endocarditis

HBV, HCV, HIV Osteomyelitis Blood clot Overdose Missed shot

Arterial injection Scarring ASSUMPTIONS People are going to do risky and harmful stuff, on purpose,

which is a rational decision most of the time, and some ways of doing stuff are safer than others (not all consequences are guaranteed or necessary). ASSUMPTIONS People are going to use drugs and alcohol which is a rational decision for most people who use

and some ways of using are safer than others. OPTIONS FOR REDUCING ILLICIT DRUG USE Demand reduction Supply reduction Legalization HARM REDUCTION

A third reduction paradigmmeeting people where they are, without precondition I care about you, even while youre using. If you make that choice, I dont want you to get hurt, and I will help. Pushing people who use drugs away reinforces one of the root problemsthere is no place for me in society, and love is contingent on behavior

HOW DOES INJECTION DRUG USE WORK? INJECTION PROCESS Buy substance Buy paraphernalia Find safe place to use, with water source

Dissolve in water, usually using heat on a cooking surface like bottle cap or spoon Draw up through cotton Arm is tied off, vein identified Alcohol swab to clean the surface Inject INJECTION PROCESS

Buy substancebut what if its got fentanyl? Buy paraphernalia Find safe place to use, with water source Dissolve in water, usually using heat on a cooking surface like bottle cap or spoon Draw up through cotton Arm is tied off, vein identified Alcohol swab to clean the surface Inject

INJECTION PROCESS Buy substance Buy paraphernaliado I have access to clean works? Find safe place to use, with water source Dissolve in water, usually using heat on a cooking surface like bottle cap or spoon Draw up through cotton

Arm is tied off, vein identified Alcohol swab to clean the surface Inject INJECTION PROCESS Buy substance Buy paraphernalia Find safe place to use, with water sourcewhat if the waters not clean? What if

strangers are around? Dissolve in water, usually using heat on a cooking surface like bottle cap or spoon Draw up through cotton Arm is tied off, vein identified Alcohol swab to clean the surface Inject INJECTION PROCESS

Buy substance Buy paraphernalia Find safe place to use, with water source Dissolve in water, usually using heat on a cooking surface like bottle cap or spoon Draw up through cotton Arm is tied off, vein identified Alcohol swab to clean the surface Inject

what if someone else used the cooker? INJECTION PROCESS Buy substance

Buy paraphernalia Find safe place to use, with water source Dissolve in water, usually using heat on a cooking surface like bottle cap or spoon Draw up through cottonwhat if no filter is available? Arm is tied off, vein identified Alcohol swab to clean the surface Inject

INJECTION PROCESS Buy substance Buy paraphernalia Find safe place to use, with water source Dissolve in water, usually using heat on a cooking surface like bottle cap or spoon Draw up through cotton Arm is tied off, vein identifiedwhat if I dont have a vein to hit?

Alcohol swab to clean the surface Inject INJECTION PROCESS Buy substance Buy paraphernalia Find safe place to use, with water source Dissolve in water, usually using heat on a cooking surface like

bottle cap or spoon. Draw up through cotton Arm is tied off, vein identified Alcohol swab to clean the surfacewhat if I cant clean? Inject INJECTION PROCESS Buy substance

Buy paraphernalia Find safe place to use, with water source Dissolve in water, usually using heat on a cooking surface like bottle cap or spoon. Draw up through cotton Arm is tied off, vein identified Alcohol swab to clean the surface Injectis anyone around to help if its too much? Test dose? Vein, muscle, skin?

HARM REDUCTION APPLICATION HARM REDUCTION DEAT HARM REDUCTION H Overdose education and naloxone distribution

Good Samaritan Law Medication-assisted treatment (methadone, buprenorphine) Fentanyl test strips OVERDOSE EDUCATION Overdose risk factors

Tolerance Reverse tolerance Mixing drugs Test dose Health changes OVERDOSE EDUCATION Responding to

overdose Dont leave Do put them in recovery position Dont do ice water Do CPR/rescue

Dont inject with Do use naloxone rescue bath stimulants breathing

kit NALOXONE DISTRIBUTION Required training: Overdose education and naloxone distribution Kansas House Bill 2217

since July, 2017 1. Risk factors of opioid overdose; 2. Strategies to prevent opioid overdose; 3. Signs of opioid overdose; 4. Steps in responding to an overdose; 5. Information on naloxone, including possible adverse reactions;

6. Procedures for administering naloxone; 7. Proper storage, disposal, and expiration of the naloxone product dispensed; and 8. Information on where to obtain a referral for substance use disorder treatment.

NALOXONE DISTRIBUTION Naloxone distribution What about fentanyl reversal? How effective/efficient? For non-opioid users? http://pdaps.org/datasets/laws-regulating-administration-of-naloxone-15016

GOOD SAMARITAN LAW Good Samaritan Law (AKA overdose immunity law) Should it cover Probation/parole violations? Paraphernalia? Protective orders?

http://pdaps.org/datasets/good-samaritan-overdose-laws-150169 MEDICATION-ASSISTED TREATMENT Medication-Assisted Treatment (methadone, buprenorphine) Methadone: 11.3 vs 36 deaths per 1000 person years Buprenorphine: 4.3 vs 9.5 deaths per 1000 person

years FENTANYL TEST STRIPS Drugs must be dissolved in water to be tested Not all analogs tested $20 for 10 strips O

I T C INFE HARM REDUCTION N

Syringe and needle exchange Supervised injection facility Safe injection education Inhalation and other alternative routes O I T C

INFE HARM REDUCTION N Syringe and needle exchange Legality: KSA 21-5710 subsections (c) and (d) Evidence: HIV, HCV, cost efficacy, crime,

treatment rates Availability https://www.cdc.gov/ssp/ determination-of-need-for-ssp.html RESOURCES RESOURCES

Harm Reduction Coalition: Getting Off Right DanceSafe.org (fentanyl test strip information) www.CATIE.ca CDC

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