“What can we do?” a colleague asked me after learning one of the young people seen in a youth shelter was using heroin. Despite television series readily portraying interventions as an ultimatum-laden confrontation, and even with our own department setting aside a day for buprenorphine waiver training, the question of “What can we do?” remains largely unanswered for the pediatric population.
Based on a 2015 survey, less than 2% of physicians who were waivered to prescribe buprenorphine were pediatricians, despite the fact that between 2001 and 2014 rates of opioid use disorder diagnosis increased approximately six-fold in people between the ages of 13-25. Even with opioid related deaths tripling among young people, substance use disorders (SUDs) are often not seen as a pediatric problem. But one of the more effective strategies does not involve medication or specialized fellowships in addiction medicine: harm reduction.
As a medical student, I can count on one hand the number of lectures I received about SUDs (all given in the context of “adult” medicine), despite training during the opioid epidemic. As a pediatric resident, I was frustrated to see that many of our patients with SUDs were directed to family medicine. The sentiment that “You wouldn’t want your kid next to a drug addict” was voiced by an attending to preclude an admission for an unstably housed teen who wanted to start buprenorphine in the hospital. But hesitancy around understanding SUDs — and especially opioid use disorder — as a pediatric problem is caused by more than just stigma. There is fear of not knowing what to do. This is where harm reduction emerges.
Harm reduction, of course, is nothing new. It was first popularized in the 1980s in Europe to address the HIV epidemic, and eventually led to clean needle exchanges and methadone programs. The term encompasses policies and programs that work to minimize negative health, social, and legal impacts of a health behavior, such as drug use, without necessarily working to extinguish the behavior. In 2017, Hawk et al. used in-depth qualitative interviews with patients with HIV to delineate six principles of harm reduction: humanism, pragmatism, individualism, autonomy, incrementalism, and accountability without termination. These tenets create an effective template that pediatricians are already employing in treating other diagnoses such as disordered eating, depression, or self-harm, where they counsel patients on incremental changes. These can also readily apply to treating SUDs among young people.
When it comes to the question, “What can we do?” harm reduction offers clinicians two answers: one for diagnosis, and one for treatment.
First, harm reduction gives clinicians greater comfort around screening for SUDs in the first place by offering more tools for a positive screen. The HEADSS (home environment, education/employment, activities, drugs, sexuality, suicidality) psychosocial screen for adolescents is only useful when it allows a clinician to connect young people with services. Even though the American Academy of Pediatrics recommends universal screening of SUDs for adolescents, pediatricians’ self-reported rates of routine substance use screening vary from less than 50% to 86%, with most pediatricians using clinical impressions over validated tools. These figures may indeed improve if pediatricians felt that screening did not necessitate a goal of abstinence. The highly effective SBIRT model was adapted for pediatric SUDs to encourage stratification of a patient’s substance use and offer targeted behavioral intervention goals.
Although a good tool for a positive SUD screen, clinicians may find it challenging to want to engage in screening when a patient’s goal is not abstinence or when the benefits of maintaining the patient relationship outweigh the risks of breaking confidentiality. It is also difficult to implement in a 15-30 minute pediatric visit. This is where harm reduction can reconfigure the goals of care so that incremental changes in a patient’s behavior and a joint plan of care can supplant abstinence and empower clinicians to have an actionable plan with a positive screen. An initial disclosure of a SUD may simply mean encouraging a different mode of use rather than cutting down or abstaining. As a resident, one of my primary patients proudly told me she remembered to wrap methamphetamine in tissue paper and swallow it instead of injecting based on a conversation we had. It was the first time she did not feel ashamed of telling me about her use.
The second is that harm reduction changes treatment goals to focus on the patient-clinician relationship over a particular diagnosis of SUD. The difference between diagnosing and treating an SUD and an ear infection is stark: pediatricians are often trained to enjoy the benefits of working with a young, relatively healthy population which responds quickly to treatment. Managing SUDs is slow medicine, not the fast medicine of a dipped urine revealing a UTI. It involves relationship building and understanding where a patient is, making it more akin to counseling an adolescent patient repeatedly admitted for diabetic ketoacidosis. The question is not what to do for diabetic ketoacidosis (a protocol readily available in any binder) but what the barriers are to a young person administering their insulin appropriately.
By shifting the balance of the pediatrician-patient relationship from paternalism to autonomy, pediatricians can leverage their longitudinal role with young patients and first assess why their patient may use substances and what they are hoping to achieve from using. Even obtaining that information alone as a pediatrician may be the first time a young person is asked those questions. There may be reasons for cannabis use that have more effective treatments (anxiety, insomnia) or ways to encourage use of THC to be safer (not using dab pens or oils, using medical grade products when possible, not mixing with tobacco or alcohol).
Harm reduction sees pediatric patients as fully adult; they are capable of making a spectrum of choices rather than dichotomous “good” or “bad” ones at a time in their lives when much of their behavior is characterized as such: don’t smoke, don’t have sex, stay in school. In the case of my colleague’s patient, she was concerned that the young person had no desire to stop or change their heroin use, and did not know what to do to counsel the patient. My colleague and I discussed safer injection sites for heroin (avoiding the groin/neck areas), obtaining HIV/hepatitis C testing, ensuring she had naloxone, and connecting with a clean needle exchange program until she was willing to make an appointment with our clinic. Before pediatric patients transition into adulthood, our goal is to set them up for success: we have guidelines for developmental milestones, nutrition, vaccines, growth charts, and dental care. But adolescence posits more of a gray space where we as clinicians must understand our patient’s goals as something they — and not us — define.
What's your experience with harm reduction? Share in the comments.
Megana Dwarakanath is a third-year adolescent medicine fellow in Pittsburgh where she lives with her husband, Rahul, their young daughter, Meera, and their dog, Milo. When she is not spending time with friends and family, she likes to run, swim, and bike as well as read for as long as she can in one go. Dr. Dwarakanath is a 2022–2023 Doximity Op-Med Fellow.
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