“Do no harm.”
This is a key phrase in the Hippocratic Oath; one that I announced with conviction at my medical school graduation. I swear to do no harm. What would Hippocrates, the Father of Modern Medicine, think about the concept of harm reduction?
Canada has a drug problem. We are one of the world’s largest per-capita opioid consumers. The country is facing what has become known in the media as the “opioid epidemic.” The government of British Columbia declared a public health emergency in response to the increasing number of overdoses from opioids. A total of 914 people died from illicit substance overdose in 2016 in the province, representing an 80 percent increase from the previous year.
While recently traveling in Vancouver, I rode my bicycle through the Downtown Eastside. Users were injecting on the street in broad daylight; drug deals were being done openly. The crisis is alive and well where I work as a family physician on the East Coast, too.
The traditional approach in treating drug addiction was sending users to rehab for detoxification, the goal being to get “clean” while providing strategies to prevent relapse. Often, such programming was based on abstinence (cutting drug use out completely). However, the most recent literature shows that when it comes to treating opioid addiction, harm reduction is a superior method.
In Canada, the CAMH (Centre for Addiction and Mental Health) defines harm reduction as “any policy or program designed to reduce drug-related harm without requiring the cessation of drug use.” One example of harm reduction is opioid substitution therapy (OST), using drugs like methadone and buprenorphine to treat opioid dependence.
Normally, opioids like heroin or fentanyl work by binding to receptors in the brain that cause intense feelings of euphoria and pain relief. Drugs like methadone and buprenorphine bind to those same receptors but don’t produce euphoria. They help to prevent withdrawal without making the person high.
The research in support of opioid substitution therapy is clear: it works, and it’s more effective than abstinence-based programming. Patients taking OST are more likely to stay in their treatment programs and are less likely to use illicit drugs. OST reduces the chances of contracting diseases like Hepatitis C and HIV. Most importantly, OST patients are less likely to overdose.
With abstinence-based programming, patients are at higher risk for overdose upon getting out of rehab. This is because their tolerance is typically much lower than when they were first admitted. If they relapse once discharged, they may try to consume the same amount of the drug as they had in the past. The consequences are often lethal.
In addition to saving lives, opioid substitution therapy has financial benefits. Reducing the rates of HIV, for example, decreases the costs associated with treating the disease. Some studies have also shown that OST helps reduce criminal activity, another way to save the system money.
In other words, harm reduction works. Yet, it is still questioned by government officials, members of the public and even health care professionals. With such strong evidence in favor of harm reduction, why is there still so much resistance?
So much of what we do in medicine is harm reduction. I do not expect my diabetic patients to eliminate all unhealthy foods. Instead, the goal is to reduce their risk of complications from having high sugars. If the sugars come down, it is a cause for celebration. But when a person who has recently enrolled in a methadone program has two overdoses per year instead of four, success is not the obvious deduction. We don’t blame a person for succumbing to the temptation of a pastry in the same way an addict is judged for shooting up.
Addiction needs to be seen as the life-threatening, chronic, relapsing disease that it is. To stigmatize those living with it is to cause harm. To dispute evidence-based medicine is to cause harm. If Hippocrates were alive today, I think he would agree with a slight modification to his long-lasting oath.
Let’s do less harm.
Sarah Fraser is a general practitioner who blogs at Sinus Rhythm.
Image credit: Shutterstock.com
