_________________________________________________________________________ Opioid Use Disorder
Needle-Exchange Programs Needle-exchange programs, also referred to as syringe ser- vices programs, have been shown to be effective in reducing drug-related health problems, reducing injection frequency, and increasing entry and retention in drug treatment [77]. According to one review, there is sufficient evidence of efficacy, effectiveness, and financial benefit to recommend needle- exchange and outreach programs [127]. It is important to note that information regarding infection prevention strategies be provided to all participants in needle-exchange programs, as increased incidences of HIV and other bloodborne pathogens have been noted in this population [129]. The Consolidated Appropriations Act of 2016 gives states and local communities, under limited circumstances, the opportunity to use federal funds to support certain components of needle-exchange programs. Although federal funds cannot be used to purchase sterile needles or syringes for illegal drug injection, these funds can be used to support a comprehensive set of services as part of a needle-exchange program [130]. Injection Rooms Medically supervised injecting rooms, or overdose prevention centers (OPCs), are officially designated areas where injecting opioid users, often persons who use heroin, can inject with- out fear of arrest and with knowledge that medical assistance is available if overdose occurs. Such facilities have existed in Switzerland since 1986, in Germany since 1994, and in the Netherlands since 1996. The goal of OPCs is to promote health and reduce risk behaviors and public nuisance, with a specific focus on overdose reduction and hygiene [131]. Several descrip- tive studies have shown significant effects on harm reduction and reduction of public nuisance [77]. Heroin Maintenance Heroin maintenance, also referred to as heroin-assisted treat- ment, is the implementation of heroin prescriptions under medical supervision. This option may improve health and reduce heroin overdoses, illicit opioid use, and crime. How- ever, formidable barriers to heroin maintenance exist in the United States [99]. One systematic review compared heroin maintenance to metha- done or other substitution treatments of opioid dependence for efficacy and acceptability; retaining patients in treatment; reducing the use of illicit substances; and improving health and social functioning [132]. Eight studies involving 2,007 patients met the inclusion criteria. Five studies compared supervised injected heroin plus flexible dosages of methadone to oral methadone alone. Results suggest an added value of heroin prescribed alongside flexible doses of methadone for long-term, treatment-refractory, opioid users to reduce use of illicit substances and sustain treatment [132]. DETOXIFICATION AND WITHDRAWAL The process of tapering opioid-dependent patients from agonist therapy is often referred to as detoxification, or more accurately, medically supervised withdrawal [56; 133; 134]. Its
According to the World Health Organization, people likely to witness an opioid overdose should have access to naloxone and be instructed in its administration to enable them to use it for the emergency management of suspected
opioid overdose. (https://www.who.int/publications/i/
item/9789241548816. Last accessed March 21, 2024.) Strength of Recommendation/Level of Evidence : Strong/very low
HARM REDUCTION Harm reduction measures are primarily employed to mini- mize the morbidity and mortality from opioid abuse and to reduce public nuisance [99]. As a part of this effort, measures to prevent and minimize the frequency and severity of over- doses have been identified. Enrollment in opioid substitution therapy, with agents such as methadone and buprenorphine, substantially reduces the risk of overdose as well as the risk for infection and other sequelae of illicit opioid use [99]. Education Reducing the risk for harm involves education on polydrug use and needle-exchange programs [99]. The authors of one review noted that there was positive evidence, though lim- ited, to support education regarding noninjecting routes of administration, brief interventions, and supervised injecting facilities [127]. Given that a harm-reduction approach can address risk behaviors that may occur alongside drug use, the authors of one paper suggest that risk-reduction education be based on harm reduction philosophy as a whole rather than on the specific harms of drug use and harm reduction strategies (e.g., needle-exchange programs) [128]. The authors defined six principles—humanism, pragmatism, individualism, autonomy, incrementalism, and accountability without termination—and generalized them for use in healthcare settings with patients beyond those who use illicit substances. Each principle was defined and providers were given descriptions of how to deliver interventions informed by the principles as well as examples of how to apply each principle in the healthcare setting [128]. To improve response to overdoses, opioid abusers and their friends and families should be taught simple cardiopulmonary resuscitation skills to keep comatose users alive until emergency medical personnel arrive. Associates of users should be encour- aged to call an ambulance when overdose occurs. The provision of naloxone to opioid users should be tested and evaluated; naloxone could be distributed through existing outlets, such as needle and syringe exchanges, pharmacies, urgent care facilities, or treatment agencies. Heroin users should also be encouraged to switch to noninjecting routes of administration to reduce related morbidity and mortality [99].
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MDRI2026
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