Effective Addiction Strategy Is Often Overlooked

A valuable strategy that can help many addicts is often overlooked by psychiatrists, in part because of the way our profession conceptualizes addiction treatment. Yet this intervention, needle-exchange programs, can go a long way to reducing some of the serious risks that our intravenous drug using patients confront.

As psychiatrists, we think of addiction as “use despite consequences.” DSM defines substance-dependence using criteria that identify individuals who continue to use substances in spite of negative physical, emotional, and social consequences. We know that it typically takes a long time for someone with an addiction to realize that he or she must change and that, even with this realization, the addict will usually suffer multiple consequences before achieving recovery.

Unfortunately, the medical model by which we practice does not include effective methods for treating addicts who are not yet ready to give up their habits. During medical school and residency, we were taught about the stages of change, and recommendations for intervention at the precontemplative stage are few: advise patients to quit using and reassure them that when they are ready to quit, you will help them. During subsequent visits, we continue to inquire about patients' drug-use habits to reassess their readiness to change. Often it is only when a patient is ready to quit using that our psychiatric interventions come into play. However, when we focus our efforts on only patients who are ready and willing to pursue sobriety, we fail many patients.

A population that suffers greatly in this model is intravenous (IV) drug users, who—by nature of the route through which they use their drug of choice—are at high risk for serious, but often preventable, health problems. The injection process carries the inherent risk of infection, and many IV drug users contract cellulitis, endocarditis, hepatitis C, and HIV.

Fortunately for IV drug users, there is a strategy that operates on the principle of meeting addicts where they are, regardless of their motivations about recovery, with the aim of reducing the incidence of injection-related harm. And we psychiatrists can help ensure that this strategy becomes more readily applied.

The best known harm-reduction strategy is needle exchange—the simple intervention of collecting dirty injection equipment from IV drug users and providing sterile equipment in exchange. Needle exchange has been around since the 1980s. Its efficacy in preventing HIV transmission in this population, without increasing the incidence or prevalence of drug-use behavior, has been clearly established in multiple research studies. Needle exchange is endorsed by APA, as well as the AMA, World Health Organization, Centers for Disease Control and Prevention, and National Institutes of Health.

Yet despite this body of expert opinion, needle-exchange programs are not readily available in the United States. Part of the problem is purely legislative; for 20 years the federal government has had a ban on the use of federal dollars to establish and operate needle-exchange programs.

But part of the problem lies with providers. Because of our training, we tend to see just one positive outcome for addicts—sobriety. We receive little to no training in harm reduction, and we are not trained in proper drug-injection techniques ourselves, much less how to teach these techniques to IV drug users. Furthermore, we have an aversion to harm-reduction strategies, which many physicians believe makes them complacent in the face of drug abuse.

I recently had the opportunity to volunteer at the needle-exchange program at Cleveland's Free Clinic. I came to appreciate that a psychiatrist operating under the standard medical model can play only a limited role in the treatment of addicts who are injecting drugs. I was humbled by watching the outreach workers meet with IV drug users in the streets, without judgment or anticipation of their eventual progression to a desired stage of change. I learned firsthand that for many people with drug addictions, it is the development of a relationship with someone in the health care field who cares foremost about keeping them as safe as possible—no matter what type of behavior they are engaging in—that ultimately leads to recovery.

On July 24 the House of Representatives passed HR 3293, which includes a repeal of the funding ban on needle-exchange programs. I hope that psychiatrists will advocate for passage of this bill in the Senate by contacting their senators about its merits. We can also work to transform our profession's approach to patients with addiction by adopting harm-reduction strategies in our treatment of IV drug users.

We know that mounting consequences do not dissuade addicts from using drugs. It is time to abandon the attitude that reducing harm, when possible, would serve as a detriment to recovery. ▪