Research Report: Harm Reduction in California Addresses the Overdose and Opioid Epidemic

By Brian N. Talleur, M.D., Chief Medical Officer, Aegis Treatment Centers

California is famous for a wide variety of amazing things. Hollywood movies, the music industry, the relaxed lifestyle that created surfing and skate culture, the outdoor lifestyle that created the extreme sports movement, the stunning beauty of the Sierra Mountains, the deserts, the beaches, and much more. California is ground zero for many icultural movements the rest of us adopt after they lead the way. California is also ground zero for something else: its robust response to the national opioid crisis, characterized by widespread implementation of harm reduction strategies.

The overdose and opioid epidemic in the U.S. is a genuine public health crisis. Data from the Centers for Disease Control (CDC) shows this sobering fact:

Since 1999, over a million people in the U.S. have died of drug overdose.

And the number keeps growing, year after year.

Here’s the latest available data on the overdose and opioid crisis, also from the CDC:

Fatal Opioid and Drug Overdose in the U.S.

2019:

• 50,178 opioid overdose fatalities
• 67,697 total drug overdose fatalities

2020:

• 70,029 opioid overdose fatalities
• 93,655 total drug overdose fatalities

2021:

• 80,816 opioid overdose fatalities
• 107,622 total drug overdose fatalities

Those national numbers mirror the numbers in California, which you can access via the California opioid data dashboard below. Overdose fatalities are the initial reason the state of California committed substantial state resources to support people with substance use disorder – and opioid use disorder in particular – with harm reduction strategies. They implemented these strategies early, based on evidence collected in countries like Portugal, where the first harm reduction programs originated.

But harm reduction is not an esoteric, European thing. The Substance Abuse and Mental Health Services Administration (SAMHSA) in the U.S. indicate that harm reduction services can:

• Connect people to education, counseling, and treatment for SUD and OUD
• Provide naloxone – an overdose reversing drug – to first responders and people at risk of overdose
• Reduce the spread of infectious diseases associated with IV drug use
• Reduce fatal overdose
• Facilitate access to care and promote initiation of SUD treatment services in emergency and primary care settings
• Reduce stigma around SUD and mental health disorders that often appear alongside SUD, called co-occurring disorders
• Increase hope and healing by recruiting individuals with real-life recovery experience to help design, implement, and manage harm reduction services
• Make it easier to connect people seeking treatment and support with the types of treatment and support they seek

We share that information from SAMHSA to reassure you that harm reduction is a legitimate approach to SUD and OUD treatment, and that it’s not just some kooky California thing imported from Europe. Harm reduction is real, evidence-based, and may be our best chance of ending the opioid and overdose crisis in the United States.

But we’re ahead of ourselves: let’s define exactly what we mean by harm reduction.

What is Harm Reduction?

The National Harm Reduction Coalition (NHRC) and the World Health Organization (WHO) define harm reduction as follows:

“Harm reduction is a set of practical strategies and ideas aimed at reducing negative physical and social consequences associated with drug use.”

The WHO definition includes the reduction of infectious diseases such as hepatitis and HIV as primary objectives of harm reduction programs, while the NHRC expands the definition of harm reduction to include an additional component that experts around the world are gradually accepting as a necessary conceptual framework for reducing addiction and overdose related harm around the world:

“Harm Reduction is also a movement for social justice built on a belief in, and respect for, the rights of people who use drugs.”

Those two components of harm reduction go hand in hand. As you read this article, you’ll see that harm reduction programs require a revision and re-evaluation of how we approach substance use, substance use disorder, and the ways we prevent substance use and treat substance use disorder.

We observe that a bellicose approach to substance use and substance use disorder treatment – as exemplified in the operative word in The War on Drugs – has failed. In the 1990s, policymakers chose a course: crack down on the criminal aspect of substance use, increase arrests for drug use, increase arrests for drug possession, and increase rates of incarceration and the length of sentences for people arrested on drug charges, whether for possession or distribution.

While those initiatives originated in a need to address the crack cocaine epidemic of the mid- and late-1980s, the philosophies persisted, and when the opioid crisis arrived in the late 1990s, they were still in place. The statistics we opened this article with show that our old approach is largely ineffective in mitigating the harm caused by the 21^st century opioid epidemic.

A growing body of evidence shows that the most effective way to reduce the negative consequences of substance use and substance use disorder is adopting a harm reduction approach. This article will review the current harm reduction efforts in place in the state of California, where we own and operate three treatment centers that offer medication-assisted treatment (MAT) for opioid use disorder (OUD):

1 .Aegis Treatment Centers Bakersfield Truxtun in Bakersfield, CA

2. Aegis Treatment Centers Modesto in Modesto, CA

3. Aegis Treatment Roseville in Roseville, CA

MAT is a core element of harm reduction services in California and around the world. That’s why we offer those links here: we’re part of the harm reduction movement in California through our commitment to offering integrated MAT programs statewide.

Enough about us.

We’ll now share what we learned about the overall harm reduction movement in California.

Spoiler alert: they’re ahead of the curve, nationwide. Local advocates at the community, town, county, and state level lead the way in this new, 21^st century approach to substance use and treatment and support for people with substance use disorder.

Harm Reduction in California: Key Programs

The first thing we’ll note is that the California Department of Public Health created a comprehensive, well-maintained, easy-to-navigate data dashboard to help everyone in California gain access to the latest facts about the opioid crisis. The dashboard helps treatment professionals, community members, and policymakers understand exactly what’s going on, so that they may identify areas of need and help where they can.

This comprehensive dashboard includes data at the state and county level on:

• Prescriptions and prescription monitoring
• Overdose rates
• Treatment services
• Harm reduction services

The dashboard is a tangible example of what can happen when a state acts early and decisively on a pressing public health issue such as the opioid crisis. In 2014, the state convened a Statewide Opioid Safety Workgroup (SOS) that enlisted the input of 40 public and private organizations to formulate a plan to address the situation.

They identified and implemented programs to meet nine priorities across the state:

1. Strengthen Statewide Collaboration
2. Promote Safe Prescribing
3. Build Community Capacity
4. Expand Medication Assisted Treatment (MAT)
5. Increase Access to Naloxone
6. Reduce Access to and Negative Consequences of Illicit Drugs
7. Address Priority Populations in High-Risk Settings
8. Promote Public Education and Awareness
9. Translate Data into Actionable Information

To read a detailed explanation of these strategies and their positive impact for individuals, families, and communities in California, please read this article on our blog:

The Opioid Crisis: California Takes Action

That article contains a thorough examination of the government-led, official response to the opioid crisis in California. The rest of this article will focus on harm reduction efforts of the California Harm Reduction Initiative (CHRI), a 15.2 million dollar program established by the California Budget Act of 2019.

What is the California Harm Reduction Initiative?

The funds allocated by the state allowed harm reduction advocates and policymakers to partner with the National Harm Reduction Coalition to tailor programs designed to meet the specific needs of California communities and residents of California.

All states in the U.S. are diverse, but California is large and diversity is the norm. California has progressive urban neighborhoods in San Francisco, underserved urban neighborhoods in Oakland and Los Angeles, thriving wine country in Napa, underserved rural farm areas in the central valleys, and ultra-conservative former logging communities in northern counties like Shasta.

In other words, California represents the diversity of the U.S. – all in one state.

That’s why tracking harm reduction efforts there can inform harm reduction efforts around the country. California faces similar challenges to other states. The successes or shortcomings of their programs can help the rest of the nation adapt their strategies to meet their specific needs. Think of it this way. If it happens anywhere in the U.S., it probably happens somewhere in California. Therefore, we can learn from what they do, because most of the time – but not always – California goes first.

That leads us to this question:

What has the California Harm Reduction Initiative done?

Answer:

The California Harm Reduction Initiative (CHRI) has enacted programs to:

• Expand harm reduction initiative across the state
• Increase treatment and support capacity
• Reduce the negative consequences of substance use and substance use disorder

We’ll focus on one program implemented by the CHRI that includes the three components above, and has had a significant positive impact on communities across California: CA Bridge. Here’s the stated goal of the CA Bridge Harm Reduction Program:

“To save lives by making it possible for people who use drugs to get treatment at any hospital – whenever and wherever they need it.”

To understand why this innovative program has had – and can have in other states – a significant impact, it’s important to know that when a person with SUD and or OUD has an emergency related to SUD or OUD, such as a non-fatal overdose, the time immediately after surviving that emergency is a window of opportunity to encourage them to initiate treatment. Most often, the hours spent in an emergency room (ER) are transformative. They change the way people think about their current drug use. Most importantly, during that time, many reconsider continuing their drug use in the future.

The CA Bridge Program: A Template for the Nation

Here’s how CA Bridge leverages that window of healing opportunity. Their emergency room based programs:

Increase Addiction Treatment Capacity in Hospitals:

• Between April 2019 and September 2021, CA Bridge programs:
  • Identified and offered SUD care to 52,719 people with OUD
  • Provided medication-assisted treatment (MAT) to people with OUD in 23,849 discrete instances

Coordinate Continued Care After the Emergency Room:

• 67% of people with OUD who received MAT in the ER received ongoing care in outpatient MAT programs after initiating treatment in the ER

Provide Resources for Expansion:

• Successfully lobbied to keep 20 million dollars allocated to MAT in the state budget. Some state policymakers proposed removing this funding – approved during COVID-19 – from the budget. However, CA Bridge advocates convinced enough lawmakers to keep the funding in place.
• The funding provided MAT programs in 155 hospitals in the state
• The success of those programs led to an additional 75 million dollars in funding to expand MAT and SUD treatment programs in California ERs

Two crucial elements of implementing these initiative are the CA Bridge Navigator Program, which guides hospitals and emergency rooms through the process of establishing MAT and SUD support in their facilities, and a Substance Use Navigator Support program, which we’ll describe now.

Substance Use Navigators – in the words of the CA Bridge directors – are “instrumental to the CA Bridge Model.” They understand and believe in the principles of harm reduction. They commit their working days to putting these principles into action. Their goal is to help people with OUD who may benefit from MAT services.

The Bridge Model: Essential Functions

• Connect patients to MAT services immediately
• Connect patients to resources for ongoing SUD treatment and ongoing MAT when appropriate
• Model a culture of harm reduction related to SUD and OUD in the emergency room context
• Engage patients with compassion, respect, and without judgment
• Model a person-first approach to SUD treatment and harm reduction

These navigators serve as a liaison between the individual in need of treatment and the treatment services they need. An individual in an ER after an OUD/SUD related emergency may not have the capacity – at that moment, or even in the days or weeks that follow – to engage the treatment infrastructure and seek the support they need. Their risk of relapse is as real as the window of opportunity to initiate treatment. These substance use treatment navigators who can save lives by pointing individuals toward treatment. They can be instrumental in keeping them from returning to the lifestyle that led to their OUD/SUD emergency.

The Foundation of Harm Reduction: Person First Principles

In the second section of this article, we defined harm reduction and outlined its basic theoretical and practical framework. We’ll close this article by expanding on the theoretical framework with an eight-point summary of the principle of harm reduction as defined by the National Harm Reduction Coalition (NHRC).

The Eight Principles of Harm Reduction

1. Accept that licit and illicit drug use is a reality. Choose to minimize its harmful effects in favor of ignoring or condemning them.
2. Understand drug use is complex. It includes a full continuum of behavior, from excessive use to compete abstinence. Acknowledge that some ways of using drugs are safer than others.
3. Accept that quality of life and wellbeing – for the individual and community – are valid criteria measuring recovery. Total abstinence is not the only meaningful metric for recovery.
4. Prioritize providing SUD treatment in a non-judgmental, non-coercive manner. Offer resources to people where and when they need them.
5. Enable people who use drugs or with a history or drug use to contribute knowledge gained through lived experience to the creation and implementation of programs and policies meant to serve and support them.
6. Affirm that the people who use drugs and need treatment for drug use have a real voice in reducing the drug-related harm they experience. Create situations where they can help other people who use drugs by recommending strategies that they know from experience are practical and actionable.
7. Recognize the social determinants of health, including poverty, socioeconomic status, racial discrimination, social isolation, institutional trauma, and sex/gender-based discrimination increase vulnerability to drug related harm, and impair the capacity to mitigate that harm without external support.
8. Validate, recognize, and understand the level of harm caused by illicit drug use, misuse, and disordered use.

We owe it to everyone in the U.S. – a group that includes our family, friends, and peers – to attempt to implement this approach to the opioid and overdose epidemic.

How to Create Change

We can learn from our national approach in the 80s and 90s – called The War on Drugs – that treating drug use and people who use drugs as enemies to be defeated by force is an incomplete and sometimes counterproductive approach.

Do we need force and a warlike attitude to deal with international drug traffickers and drug cartels that seek to gain profit and power from the suffering of individuals, families, and communities?

Absolutely. Yes.

Do we need to treat people who use drugs and people with substance use disorder with the same warlike attitude?

No.

We don’t.

Evidence shows that integrated treatment and compassionate support are the most effective ways to support people with substance use disorder. That’s the essence of harm reduction – and right now, in the U.S., California leads the way.