“we just didn’t harm reduction hard enough”

A conversation with a colleague yesterday brought to mind the recent study that found no statistically significant impact from an NIH-funded project distributing naloxone, increasing access to MOUD, and providing overdose education.

These findings seem like they would have been big news. These interventions have been the centerpieces of the national response to the opioid overdose crisis.

However, this news has been met with little more than a disappointed yawn. No one seems surprised and it’s not being disputed.

This colleague has been involved in their community’s overdose post-mortem review. They commented that every case had been on MOUD at some point, many tested positive for MOUD at the time of their death, almost all had previous naloxone overdose reversals, and many had naloxone and fentanyl test strips with/near them at the time of death.

This isn’t surprising. These are first-aid or acute-care responses to a chronic illness (in cases of addiction). Even MOUD fits this description in most implementations as a low-threshold intervention.

Studies of buprenorphine prescribing programs often find disappointing retention at intervals like 4, 12, and 24 weeks. It makes sense that MOUD dispensed in an ED or from an outreach program would have lower retention rates.

We know that naloxone is highly effective at rescuing someone experiencing an overdose. However, there are questions about the population-level impact of naloxone distribution on OD rates, and we know that mortality rates are high following a successful rescue.

There’s no doubt these interventions prevent death at a point in time for an individual. However, because that individual’s risk is ongoing it makes sense that there might be a ceiling effect.

My colleague has been frustrated with the unwavering faith in naloxone and MOUD in each post-mortem, despite each case’s access to these medications and their knowledge about how to reduce OD risk.

They said that the review panel’s response to every death amounts to “we just didn’t harm reduction hard enough.”

I get my colleague’s frustration AND I get the committee members’ faith in their toolkit.

I spent years preaching that treatment of adequate quality, duration, and intensity was THE answer to nearly all problems related to addiction. As the overdose crisis emerged, we took it upon ourselves to do post-mortems on fatal and nonfatal overdoses for anyone who had contact with us in the last 30 days. This forced us to confront the moral safety issues involved for clients, staff, community members, and families, and acknowledge that treatment wasn’t the solution to all problems at all times.

Lots of responses are essential and incomplete: