Substance Use Harm Reduction 101 for the Emergency Clinician

Harm reduction for substance use is an evidence-based approach to engaging with people who take mind-altering substances with the goal of meeting them where they're at.

It aims to be non-judgmental and patient-driven, to lead with respect, and to focus on improving quality of life rather than abstinence. Importantly, the aim of harm reduction is not to get patients to quit taking drugs (which as you probably know from your high school health class doesn't actually work), it's to help them find ways to interact with drugs safely. Most people with whom we talk about substance use in the emergency department won’t stop taking drugs just because a clinician has advised them to, and an abstinence-based approach implies that we know better than our patients do regarding their own relationship with substance use. Quitting cold turkey is also extremely difficult and often unrealistic. Instead, we can encourage and facilitate taking incremental behavioral steps to move our patients' relationships with mind-altering substances closer to where they want it to be. That being said, there are times when it’s important to emphasize the necessity of complete cessation, for example, in later-stage liver failure or COPD.

What counts as a "mind-altering" substance?

We typically think of alcohol and "drugs" (marijuana, cocaine, MDMA, meth...) but I personally include tobacco and caffeine in this category. Your pre-shift Cherry Limeade Celsius makes you feel alert, maybe even anxious; nicotine can make people feel more focused or calm. I also make sure to include non-street medications under this umbrella (prescription or OTC), as people can take things like benzodiazepines, antihistamines, antipsychotics, cough medication, etc., in order to change how they feel, be that formally sanctioned by a clinician or not.

Doesn't a harm reduction approach encourage people to use mind-altering substances?

No; this has been demonstrated in many different settings over the last several decades, but perhaps nowhere more convincingly than in Vancouver, Canada. The city was a national epicenter for HIV and intravenous drug use-associated overdose in the late 1990s, which prompted the establishment of a large-scale public health effort, including syringe distribution, community programming, methadone therapy centers, and creation of the first sanctioned Supervised Injection Facility in North America. Rates of HIV, HCV, and drug-related harm—including overdose—have since plummeted.¹ In July 2021, Rhode Island opened the United States' first legal supervised consumption site, and later that year, two sites opened in New York City.²

An approach to taking a substance use history

This certainly isn't the "right" way to do this; it's just a system I've found works for me and is aligned with my values and practice. 

1. What do you take? I prefer this language over "What do you use?" as that can sometimes sound pejorative, and discounts the fact that many people take mind-altering substances in a way that borders on or is medicinal. If you've ever come home after a long shift and thought "I could use a glass of wine," then you've thought about alcohol medicinally. Many people take more than one thing, so be sure to ask about co-ingestion to evaluate risk of interaction. The free harm reduction website Tripsit has a useful interactive tool that describes the effects of combining many popular substances.
2. How do you take it? Most people will know what you mean, but when a patient asks for clarification, I'll give examples. This means drug delivery method: ingestion (like taking a drink or having a gummy), smoking (including bongs), vaping, injecting (into vasculature or subdermally, called "skin popping"), or insufflating. Substances can be insufflated intranasally (snorting or sniffing) as well as rectally or vaginally —"boofing" aka "plugging" or "booty bumping" — is when a substance is placed into a body cavity so that it gets distributed to the rest of the body via mucosal blood vessels. People can also use drugs transdermally (like nicotine patches) or sublingually (like buprenorphine). Note that asking a patient if they take a substance in a way people don't or can't use it—for example, asking a patient if they smoke LSD, which is pretty much only taken sublingually—may expose your lack of knowledge about that substance. However, I empower you to ask patients to educate you whenever appropriate. Regardless of the method, be sure to react non-judgmentally. If they endorse injecting, ask where they inject so you know where to look for signs of infection.
3. Ask safety-related questions related to the method. If the patient is injecting, ask if they use clean needles, if they clean their skin with alcohol swabs before injecting, if they ever share equipment like needles or spoons. If they take edibles, ask if they take store-bought or homemade. For almost all drug delivery methods, I ask if patients measure out their dose. For injection drugs, this might mean using a graduated syringe, like we use for giving medications. For edibles, this might mean checking the package of store-bought material for the milligrams of THC or psilocybin, for instance, in one serving. For powders or crystals, I suggest investing in a small and sensitive scale such as a jeweler’s scale to measure out individual doses. Not only does this help to prevent overdose, but it may help people find out how much of a substance makes them feel good compared to how much makes them feel uncomfortable. Some drugs, like pressed pills, are harder to know the dosage—I encourage people to ask whoever they're getting the drug from for dosing information whenever possible. I also ask if they take drugs alone. As you might imagine, this is a safety issue when it comes to adverse drug reactions including overdose, but it also helps give me an idea of the relationship with the substance. While taking drugs alone isn't always indicative of an unhealthy relationship with that drug, solo use might point toward a relationship with that drug that may feel out of that person's control—think of the patient with alcohol use disorder who has an eye-opener or drinks secretly, versus someone who has a beer while hanging out with their friends. I ask about test strips and naloxone with every substance (including marijuana) other than alcohol and nicotine. I encourage you to take the time to learn how to use both, both for patient education and for civilian safety (including your own) outside of the hospital. Many city and state websites have succinct instructional guides—as a New Yorker, I give the following printable materials to my patients with their discharge paperwork: here's the one on test strips, and here's the one on naloxone.
4. Ask how they feel about their relationship with what they're taking. Sometimes, when patients end up in the ED related to their substance use, it can be a bit of a wake-up call for them to change or reduce their use. However, some people end up in the ED for reasons unrelated to their substance use, or have been brought in involuntarily, or have been in the ED several times related to drugs and/or alcohol. You've likely practiced motivational interviewing before, and it's been well-studied to be effective in encouraging change regarding substance use. However, not all substance use is dangerous, and not all substance use needs to be changed or stopped. (For example: do you have the occasional drink at brunch with your friends, and feel like you have a healthy relationship with alcohol? Great! You probably don't need motivational interviewing on your alcohol consumption.) If a patient endorses a challenging relationship with their substance use, I recommend meeting them where they are and providing resources according to what they're looking for, or maybe just a step past that. This might mean individual or group therapy, support groups, detox centers, methadone clinics... My rule of thumb is: it's not a disorder unless it's causing distress. For example, you might experience anxiety, but it's not Generalized Anxiety Disorder until it's making it difficult for you to live your life—this is built into the diagnostic criteria of many mental illnesses.
5. Ask about community and loneliness. Unhealthy relationships with drugs and alcohol have been noted to be related to a lack of supportive community. That's why programs like Alcoholics Anonymous focus so much on coming to meetings and spending time with sponsors. AA's Big Book (a worthwhile read and available for free in its entirety on the AA website) has a chapter dedicated to the importance of developing community, and professionals working in substance use recovery will often emphasize forming meaningful relationships outside of the substance. This is because an unhealthy relationship with a substance is thought to be standing in as a surrogate for relationships with people. 

This is by no means meant to be an exhaustive resource and certainly isn't the only correct way to approach talking about substance use in the ED. My hope is that this paper may help reframe substance use as something familiar rather than foreign, so we can better understand our patients.

As physicians who work at the front door of the health care system, it's essential that we take the time to figure out how each of us wants to interact with this crucial topic in contemporary public health, and to let our approach evolve and grow as we continue to practice.

References

1. Urban Health Research Initiative of the British Columbia Centre for Excellence in HIV/AIDS. Drug Situation in Vancouver. 2013.
2. National Harm Reduction Coalition. Supervised Consumption Services. National Harm Reduction Coalition. Published 2024.