Evidence-Based Practice, Drug Policy, and the Promotion of Harm Reduction in Nursing and Society

Along with significant morbidity and mortality, the drug epidemic and drug war have brought widespread incarceration, hospitalization, and numerous other individual, family, and social harms.  Drug overdose kills more Americans than gun violence, car crashes, or suicide, and injection drug use puts users and the public at risk for HIV, viral hepatitis, and other infections (CDC, 2014).  In the researchers’ mid-size population home state, over 15,230 were hospitalized at a cost of $16-29 thousand each (Jenkins & Toevs, 2014).  With the drug epidemic worsening, the United States and other countries are in the midst of a shift in drug policy from criminal justice to public health approaches, engaging harm reduction practices like syringe exchange, community distribution of naloxone, and housing first approaches to housing the homeless.  While many harm reduction practices have become the standard of care in public health departments, others like supervised injection facilities (SIFs) are under debate in cities across the United States, Canada, and elsewhere.   SIFs are nurse-driven facilities with a 40 year history in Europe that offer clean supplies, safer use education, nurse supervision, wound assessment, rapid overdose response, health screenings, referrals to detox resources, and numerous preventative health resources.  To assess the public health value of SIFs, the student researchers utilized an evidence based practice model to investigate their effects on rates of overdose, overdose mortality, and other outcomes.

After a thorough search of CINAHL, Medline, Cochrane, and Academic Premier databases, we chose a selection of mixed methods systematic reviews, case-control studies, and descriptive studies to assess SIF effectiveness.  Key findings across all studies included fewer overdoses, more rapid treatment, and zero deaths reported at any facility.  Secondary findings included fewer risk behaviors, costs, and public nuisances (discarded syringes, public use), as well as increased referrals to treatment (Potier, et al., 2014; Stoltz, et al., 2007).  With regards to Insite, the only facility currently located in North America, researchers calculated a ten-year savings of $14 million, 920 years of life, avoidance of 1191 HIV and 54 Hepatitis C infections (Potier, et al., 2014).  Another study examined coroner’s records and found a 35% decrease in deaths/person-years in the immediate vicinity of Insite, versus a 9.3% decrease in other parts of Vancouver’s Downtown East Side (Marshall, et al., 2011).  In Sydney, Australia, Salmon, et al. (2010) found an 80% decrease in ambulance calls for opiate-related overdose in the immediate vicinity compared with 45% in adjacent parts of the district.  Descriptive survey and qualitative interview studies demonstrated that frequent SIF users adopted safer injection practices, including cleaning injection sites, using sterile syringes and supplies, injecting more slowly, and testing doses as well as under medical supervision, which yielded shorter response times and fewer hospitalizations (Kerr et al., 2007; Stoltz et al., 2007).

Given that the United States currently lacks protections for provider-supervised drug use, and that many health professionals and members of the public lack familiarity with evidence-based harm reduction practice, the student researchers sought to enact a practice change through professional advocacy in the state’s nurses union and professional organization. 

The proposed addition of harm reduction language to the health policy platform passed, as did a public affirmation of harm reduction’s efficacy and the nurse’s responsibility to advocate for humane evidence based drug policy.  However, additional language in support of the viability of employment in SIFs was removed, given concerns about the legality of such a position (XXXX, 2016).  Further discussion with both supporters and opponents of the draft language suggested that further dialogue and exposure to harm reduction theory, practice, and evidence among nurses and public health officials could sway positions in the future.

The implications for other nurses, students, and nurse researchers appear ambiguous though encouraging.  Nurses, like other health professionals and sectors of society, are in the process of reevaluating our positions on drug use and non-abstinence-only drug treatment, as well as how nursing principles such as non-judgmental care, non-maleficence, and human rights impact our role in drug policy and in caring for patients who engage in risky behaviors.  Further research and policy development are necessary to increase health knowledge, access, and outcomes for drug users and other marginalized communities.