Notes From the Field: Reducing Harm Among Injection Drug Users During and After the Emergency Department Visit
Harm reduction is a public health approach that aims to reduce the harms associated with a health risk behavior, short of eliminating the behavior itself. [1]
The COVID-19 pandemic has increased the urgency of maintaining and expanding healthcare and harm reduction services for persons who inject drugs (PWID). Rates of morbidity and mortality associated with drug use in Florida were already alarming pre-COVID. Now, we are experiencing one of the highest rates of overdose increase (50%), which is roughly twice the national increase (28.5%). [2] A variety of factors have played a role in this increase, including high rates of synthetic opioids and anxiety brought on by the pandemic (see sidebar), which has caused many to cope by either beginning or increasing illicit drug use. The pandemic has also triggered a collapse of social support structures and critical access to essential healthcare services that normally help prevent or treat overdoses, blood-borne infections, skin infections, and chronic conditions. These factors have culminated in a substantial increase in emergency department (ED) visits for PWID. Further, PWID—much like the general population—avoided hospitals and restricted their social networks during the pandemic, further cutting themselves off from available resources and support. This places them at a higher vulnerability for poor health outcomes and high morbidity from advancement of disease.
While there has been significant recent efforts to address expanded ED-based treatment access for PWID by focusing on expanding capacity for buprenorphine induction for opioid use disorder treatment, we must also consider specific strategies needed in the management of health risks related to injection drug use for patients who decline substance use treatment. [3] We require strategies that address common risks such as wound care and medication adherence, but also risks associated with structural vulnerability, safe injection practices and harm reduction education to reduce injection-related complications and prevent the spread of infectious disease. Examples of strategic implementation include integrating infectious disease screening into routine ED care, availability of medication for opioid use disorder, broad access to the overdose prevention drug naloxone, and community-based harm reduction strategies for PWID who decline substance use treatment during the ED encounter. A timeline of our implementation efforts around these strategies at Tampa General Hospital (TGH) are below:
2016 — Our team initiated an ED-based Hepatitis C virus (HCV) screening program at TGH. We have tested over 75,000 patients, identifying over 3,000 people with Hepatitis C antibody and, of those, over 1,000 individuals with active HCV infection. The proportion of patients born after 1980 with new Hepatitis C virus now represents 90% of all HCV diagnoses, almost exclusively from intravenous drug use (IVDU). Patients with active HCV and IVDU can transmit HCV, and ultimately develop liver failure and liver cancer.
2018 — The literature for ED-based treatment utilizing medications for opioid use disorder (MOUD) was overwhelmingly favorable, suggesting potential mortality reductions and retainment in care that was much higher than programs that did not utilize medication stabilization therapy in the ED. [4] Understanding that the HCV epidemic is linked to the rise in opioid use, we initiated an ED MOUD program. To offer MOUD in the ED, we established a close relationship with community substance use treatment facilities and employed two full-time peers who ensure linkage to services after medical stabilization. To date, over 800 patients have been stabilized and our linkage rate is 74%, which is well above the national average and similar to the prospective study that led to implementation of our program.
2020 — We established a program for take-home naloxone that is free to all patients with opioid use disorder as part of a more robust harm reduction strategy. To date, we have distributed over 1200 boxes of no-cost naloxone, with 863 reported overdose reversals.
2021 — We greatly expanded our harm reduction efforts by becoming the second approved syringe services program (SSP) in the state of Florida. We operate a daily exchange program that also offers naloxone, HIV/HCV testing, wound management, and hospital avoidance. Since February 2021, we have enrolled over 550 participants; completed over 1,300 daily visits, resulting in over 100,000 syringes exchanged; resolved 18 serious wounds on-site, negating the necessity of an ED visit; and performed nearly 200 HIV/HCV tests, linking 68% of all positives to care.
Our strategy over these last 5 years has been finding innovative ways to curb the opioid epidemic with novel ED treatment strategies, increased community engagement, and moving towards a continuum of care that encompasses flexible approaches to PWID care. The next steps in our implementation plan include rapid pre-exposure prophylaxis (PrEP) for HIV negative PWID, offering telehealth-based MOUD, low-barrier MOUD induction and HIV treatment at our mobile syringe exchange site, and a formalized training practicum for residents in internal medicine, emergency medicine, and psychiatry to increase access to formal addiction medicine training. Please scan our QR code for a more comprehensive example of the resources we have built for patients, including structural support, harm reduction education, and additional linkage to community-based care. ■
Download Tampa General Hospital’s Behavioral Health & Community Resource Guide here.
Synthetic Opioid Trends Among our Patient Population since February 2021:
Three main trends appear in substance-use patterns for IDEA participants. First, and most dramatically, is the rise of fentanyl and its impact on overdose rates. Rates of self-reported fentanyl use among participants are high and steadily increased every quarter in 2021: 11.9% in Q1; 23.1% in Q2; and 37.2% in Q3. Fentanyl overdoses have also risen precipitously, overtaking self-reported heroin overdoses. In Q1, 72.1% of enrolled participants reported having an overdose from heroin use and 18.6% from fentanyl. In the most recent quarter, 54.5% of participants reported having overdosed from heroin use, but 68.2% reported having overdosed from fentanyl use.
Second, participants report high rates of methamphetamine use for both non-injection and injection. 7.1% of participants report having overdosed on methamphetamines.
Third, most participants at IDEA report prescription opioid use as a prelude to injection drug use: 69% of participants report entering substance use through prescription opioids, and of these, 71.3% started taking opioids to manage pain and/or following a medical procedure.
Overall State & National Trends:
100,306 Americans died from a fatal overdose between April 2020 and April 2021, which equals 275 deaths per day. [5]
14,708 people in Florida died from a drug overdose in 2020. [6]
Of those deaths, 6,089 were directly caused by an opioid, a 42% increase from 2019. [6]
5,302 of those deaths were directly caused by fentanyl, and 95% had at least one other drug present in their system. [6]
References
- Harm Reduction International. 2021. hri.global/what-is-harm-reduction Accessed 12/17/21
- CDC/National Center for Health Statistics. Drug Overdose Deaths in the U.S. Top 100,000 Annually. November 17, 2021. cdc.gov/nchs/pressroom/nchs_press_releases/2021/20211117.htm
- Macias-Konstantopoulos W, Heins A, Sachs CJ, Whiteman PJ, Wingkun NG, Riviello RJ. Between Emergency Department Visits: The Role of Harm Reduction Programs in Mitigating the Harms Associated With Injection Drug Use. Ann Emerg Med. 2021 May;77(5):479-492.
- D’Onofrio G, O’Connor PG, Pantalon MV, et al. Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. JAMA. 2015;313(16):1636-1644. doi:10.1001/jama.2015.3474
- CDC. “Provisional Drug Overdose Death Counts.” Vital Statistics Rapid Release. cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm
- “Drugs Identified in Deceased Persons by Florida Medical Examiners: 2020 Annual Report.” Florida Department of Law Enforcement. Nov. 2021.
This article is part of the following sections:
Heather Henderson, PhD, CAS
