Kimberly Sue, MD, PhD
Medical Director of the Harm Reduction Coalition (www.harmreduction.org). Attending physician at Rikers Island Correctional Health Services, NY.
Dr. Sue has disclosed that she has no relevant financial or other interests in any commercial companies pertaining to this educational activity.
CATR: You came out with a book last September called Getting Wrecked: Women, Incarceration, and the American Opioid Crisis (University of California Press). What lessons from your book might be relevant to the practicing clinician? Dr. Sue: The book is based on my PhD work in sociocultural and medical anthropology. I spent a lot of time in Massachusetts at the local Boston jail, in the women’s prison, and the state prison in Framingham, and then a local buprenorphine clinic at the state public health hospital. And I followed women through these different places who had opioid use disorder to understand what happens to them when they get incarcerated and how these systems make them feel. How do they make it? Who doesn’t make it? How can we do better?
CATR: What drew you to this topic? Dr. Sue: I was in medical school when I was doing most of this research, and I began to think about the limits of the clinic. There are basic needs that people leaving prison and jail and people with substance use disorders don’t have met, and we need to figure out how we can fulfill those needs. For example, I brought someone with chaotic heroin use to the clinic for primary care after she’d had a bout of necrotizing fasciitis, and I was hoping for buprenorphine. The attending said, “Let’s get all of these labs; let’s do blood work.” The person I was working with had just experienced someone overdosing and dying. She had come home from breakfast and he was dead. And the attending meant well, but he really wasn’t able to meet the woman where she was at and prioritize what she needed. Securing blood work for someone who’s got chaotic IV heroin use is painful, difficult, and sometimes impossible. Getting 6 to 10 tubes on the first visit was alienating—it led to lack of engagement.
CATR: Some say harm reduction is about “meeting people where they’re at.” Can you define harm reduction? Dr. Sue: There’s no one simple definition. At the Harm Reduction Coalition, we’ve been talking about harm reduction in a couple of ways. It is part of a broader movement based on political liberatory frameworks that shift power and resources to people vulnerable to structural violence (Farmer P et al, PLoS Med 2006;3(10):e449). And then we have “lowercase” harm reduction, which is a broad range of strategies that are practical in nature, aimed at reducing the negative consequences associated with drug use. Sometimes I meet people who are working out of one or both of those frameworks, and they are practicing harm reduction without knowing it. They just believe in meeting people where they are at and accepting people’s use, not making judgments or moralizing, not trying to force people to do any one particular thing.
CATR: So harm reduction is an approach that can be used by different kinds of people and professionals. Dr. Sue: Correct. You don’t need any special training to practice harm reduction. A lot of people practice it within their own families: for example, having naloxone in the house and knowing how to use it if their son or daughter is struggling with substance use.
CATR: Some would say that harm reduction may increase risk-taking behavior. In your opinion, how should practicing clinicians weigh the benefits of harm reduction versus the potential risks? Dr. Sue: I actually see the number of ways in which people start using more safely as a means into a steadier form of engagement and retention—whether that’s in drug treatment or in primary care or just generally engaging with health care. So many people have walked into a syringe service program, accessed sterile supplies, and learned sterile injection techniques. When they are treated with respect and dignity, they feel like they are worthy, and they are then more willing and able to access treatment or additional care.
CATR: Let’s unpack this a bit. How might this look for an individual patient? Dr. Sue: Say a patient is a heroin user and is going to inject because of the onset of withdrawal symptoms upon waking up in the morning. That patient is going to use one way or another. It might happen locked away in a convenience store bathroom, where the patient has no light, is struggling to find a vein, and isn’t following sterile practices. The patient might be using a previously used syringe, miss a vein, or accept the risk of an abscess. And it’s chaotic. There’s no space, time, or light. Contrast this with using in a place that is sterile and well lit; a place where there are people who have naloxone who could reverse an overdose if needed; a place where the patient has time and doesn’t have to rush and cut corners.
CATR: How can clinicians begin to discuss harm reduction with patients? Dr. Sue: First of all, I think it’s critical to understand people’s practices. If they are injecting, we can say, “Walk me through how you’re injecting.” If people are sharing equipment, are they using one syringe per injection, or are they reusing syringes? Are they sharing cookers and other paraphernalia? Are they using sterile water or are they injecting with water from puddles under the bridge? Obviously, the latter can lead to infection. There are other harm reduction strategies that involve choosing a safer way to use.
CATR: Can clinicians help patients identify ways of using drugs that may be safer than others? Dr. Sue: Yes. Sniffing rather than injecting is one. Intranasal instead of intravenous use decreases a person’s risk of HIV and hepatitis C. I’ll give you a couple of examples for methamphetamine use, too. We encourage people who are using methamphetamine to set a time limit or dollar amount on their use (per day or per week). We try to keep people hydrated and make sure they have condoms, since we know that a lot of people use methamphetamine to enhance sexual activity. For each substance, you can go through different harm reduction strategies. And a lot of it entails having some compassion and curiosity and respect about how people actually use drugs and then doing some research about how people can use more safely.
CATR: How should clinicians educate themselves about what harm reduction modalities are available to them and their patients? Dr. Sue: It’s a varied landscape. I would recommend first familiarizing yourself with the laws. Are syringe exchanges or syringe access programs legal in your state? You can look that up in the LawAtlas (www.lawatlas.org). Sometimes they are legal but only for people that have a certain kind of card. Those people that have the card might still get arrested for having a syringe, or they might get arrested for having a cooker but not a syringe because only syringes are part of the legislation—even though we know that cookers transmit and hold HIV and hepatitis C for days as well.
CATR: Where does naloxone fit in? Dr. Sue: In a primary care clinic in Massachusetts General Hospital Charlestown where I trained, we figured out ways of making harm reduction kits. These included naloxone and different sterile injection supplies. Being able to hand naloxone to people who are at incredibly high risk is so important, and it’s vital that we lower the barriers to these life-saving harm reduction measures.
CATR: Why might this be better than simply writing a prescription for naloxone or referring to an outside organization? Dr. Sue: Taking that approach can work sometimes, but it also involves enormous barriers for the patient. If you write a prescription for naloxone, have you gone to the pharmacy to see how that actually shakes out? What’s the copay? Is the process stigmatizing? How are you treated? Unfortunately, these experiences can be logistically complicated, discriminatory, and shameful for patients—enough so that they might be driven away from care.
CATR: What are some emerging topics in harm reduction that clinicians might see in the future? Dr. Sue: It’s important to know about safe consumption spaces and the concept of a safe supply. Safe consumption spaces are important for all substances and routes of administration, not just opioids and not just intravenous use. It’s important to think about people who smoke crack and/or meth. An argument in favor of safe consumption spaces is that they protect people from police. The criminalization of people who use drugs has terrible consequences. And if someone is using meth and is having a paranoid delusion, having a safe space where the delusion can pass without the patient possibly being persecuted, prosecuted, hurt, injured, or killed by police is a safer alternative.
CATR: Do safe consumption sites exist in the US? Dr. Sue: There’s an organization in Philadelphia called Safe House that is vying to be the first above-board legal site (Burris S et al, N Engl J Med 2020;382(1):4–5). It would be a place where people can bring and consume illicit substances that they’ve purchased, with the benefit of doing so in a facility that has harm reduction services and the ability to reverse overdoses. There are over a hundred of these sites around the world, and there have been no fatalities in them. So we do know that having places for people to use drugs more safely does not increase the risk of people using drugs.
CATR: You also mentioned safe supply. Dr. Sue: Yes. There was a famous paper, the SALOME trial, that compared diacetylmorphine (heroin) to hydromorphone (Dilaudid) in the treatment of opioid use disorder and found that both had great retention and engagement (Oviedo-Joekes E et al, JAMA Psychiatry 2016;73(5):447–455). The idea of safe supply means access to IV diacetylmorphine; in this case it was made by the Canadian government—it was pharmaceutical grade. They also learned in that study that when they ran out of IV diacetylmorphine, they used IV hydromorphone for everyone, and generally people couldn’t tell the difference. The idea now is that IV hydromorphone can be used for the treatment of opioid use disorder—at least in Vancouver and many other places. Medical use of diacetylmorphine is still illegal in the US.
CATR: In addition to reading your book, where can we learn more about harm reduction? Dr. Sue: There is some great information and booklets on the Harm Reduction Coalition website (www.harmreduction.org). We have a publication called Getting Off Right that goes through things that I never knew how to do—for example, how to do a safer injection. This is not something I’d learned how to counsel about in medical school.
CATR: Anything else you’d like to add? Dr. Sue: I feel strongly that practicing clinicians often disregard the dignity, autonomy, and well-being of people who use drugs—to the point that what clinicians say and do can actually increase harm and increase death. Whether you’re a generalist or whether you’re taking care of people with substance use, be nice to people who use drugs and understand that they come with long histories of trauma and disrespect at the hands of health care providers. That’s something that I’ve learned being in the trenches with people who use drugs, who are cast into the shadows and the alleys. I don’t think that you need to know all the answers, but I think that respecting patients as experts in their own bodies and in their own lives has really opened and changed my relationship with my patients. When you talk to people with respect and you stop trying to force a square peg into a round hole, your life as a provider changes. You change the dynamic between you and your patients so that it is much more level and comes from a place of mutual respect and mutual learning.