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Harm Reduction as a Public Health Strategy
Elsewhere around the world, Comprehensive User Engagement
Sites (CUES) are known as "supervised consumption facilities" or
"supervised injection facilities." What these spaces have in common
is that they allow individuals to consume pre-obtained drugs under
medical supervision, and provide access to sterile drug paraphernalia
and medical care if needed. Should an overdose occur, it can be
recognized and treated, averting a fatal overdose. These facilities
often also provide social services and referrals to drug treatment.
There are no CUES operating in the United States, owing in
part to potentially prohibitive state and federal laws. But there are
over one hundred of these facilities around the world, many of which
have been exhaustively studied. The evidence in support of them is
significant. Despite the millions of injections that have occurred in
these facilities worldwide over the last decade, no one has died in
a CUES.3 They have averted cases of HIV and hepatitis C.4,5 They
have reduced public drug use and discarded syringes, without an
increase in neighborhood crime.6,7,8 And they have served as an entry
into drug treatment for drug users who are ready.9
Underlying CUES, in Philadelphia and around the world, is
the theory of harm reduction. This approach acknowledges that for
many and often personal reasons, not all people who use drugs are
interested in or ready for treatment at the same time. Understanding
that these individuals will continue to consume drugs until they
are ready, the goal of harm reduction is to mitigate the harmful
consequences of their use, such as an overdose or infection. CUES
exist on the harm reduction continuum with syringe exchange, an
intervention that has been widely credited as reducing HIV spread
among people who use drugs.

44 Philadelphia Medicine : Spring 2018

Although the name may only now be gaining traction in the
lay press, "harm reduction" is a concept that should be familiar to
physicians. We strive to prevent diseases in our patients by encouraging
them to live a healthy lifestyle, being screened for cancer and getting
vaccinated. But despite our efforts, illnesses - such as hypertension
or diabetes - may still occur. Our responsibility to our patients
then shifts towards managing those diseases and preventing their
complications, regardless of the behaviors that contributed to them.
As we strive to lessen the long-term harms that result from chronic
medical conditions such as these, we too are harm reductionists.

A Chronic Disease, not a Moral Failing
The medical care provided to people who use drugs should be
no different. And yet for many people, including some health care
professionals, mitigating the risks associated with drug use through
CUES feels different. But this is where the comparison of treating
a patient with diabetes is apt. Wouldn't we treat our patient with
diabetes even if he or she engages in a behavior - such as consuming
sugar-rich foods - that increases the risk of negative outcomes? We
may encourage them to eat fewer sweets, but we would not abandon
our responsibility to prescribe insulin. In fact, we may even redouble
our efforts and work with the individual, wherever he or she is in
their illness and their readiness for change.
The difference between a patient with diabetes and a patient with
a substance use disorder is one of stigma. Substance use continues to
be seen as a moral failing rather than a chronic medical condition.
Individuals affected by substance use - and their families, too - often
describe the shame associated with the disease, a feeling reinforced
by their interactions with health care professionals who use words
such as "clean" and "dirty" to describe urine test results.
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