Episode 132: Harm Reduction and Reproductive Health - a podcast by Rio Bravo Family Medicine Residency Program

from 2023-03-17T12:00

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Episode 132: Harm Reduction and Reproductive Health

Meghana explains how to implement harm reduction strategies in at-risk populations such as unhoused patients and injected drug users. Dr. Arreaza adds comments about PrEP for HIV and Expedited Partner Therapy (EPT)  

Written by Meghana Munnangi, MPH, third-year osteopathic medical student, College of Osteopathic Medicine of the Pacific Western University of Health Sciences. Comments by Hector Arreaza, MD.

You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.

Arreaza: It can be frustrating for physicians trying to change “risky” behaviors in their patients and turn those behaviors into “healthy” behaviors. Doctors deal with this issue every day, but after reading more about the principle of harm reduction, I’m feeling more prepared to help our patients reduce their risks.

What is harm reduction?

Meghana: Harm reduction is a set of evidence-based interventions that arose within the public health community to reduce the harms associated with risky health behaviors. Most commonly, harm reduction refers to the policies and programs that aim to minimize the negative impacts associated with substance use disorder. The goal is to “meet people where they are” and to provide compassionate, judgment-free interventions and resources to at-risk populations.

Examples of people who are part of the “at-risk population.”

Some examples are injection-drug users and sex workers. With America experiencing the largest substance use and overdose epidemic we have ever faced, it is exceedingly important we provide services such as clean needle exchange, overdose reversal training, safer sex kits, and more to prevent unnecessary injury, disease, and death. 

Arreaza: In some countries where prostitution is legal, women are required to have regular check-ups to continue work. I see that as a harm-reduction strategy. I disagree with having sexual workers, but if we are unable to eliminate them, then harm reduction may be the way to go. 

Why is harm reduction important in medicine?

Meghana: Healthcare providers have a unique opportunity to improve the quality of life and limit the negative outcomes associated with risky health behaviors by incorporating harm reduction strategies into their practice. Harm reduction interventions not only decrease health risks in an individual but also in the community. 

Examples of harm reduction strategies. 

Meghana: Studies have shown that areas that have introduced clean needle exchange interventions have lower HIV seroprevalence compared to areas that do not have similar interventions [1]. It is critical  as health care providers to respect our patient’s choices and provide supportive care that will not deter patients from accessing care in the future. Patients who engage in risky activities often face stigma and are treated poorly by the medical system making behavioral changes even more difficult [2]. Understanding that many patients may not be willing to change their behaviors and using a practical approach to medical counseling can strengthen physician-patient relationships. 

Arreaza: I can think of another example. Pre-exposure prophylaxis for HIV in patients who have multiple sex partners. You wish those patients would have more insight into the risks associated with having multiple sexual partners, but if you cannot change them, you can still reduce the risk.

What is harm reduction in the context of the reproductive health field?

Meghana: Within Harm Reduction programs, there are many important strategies targeted toward improving sexual and reproductive health. Individuals who inject drugs and sex workers have limited access to family planning services and HIV testing. Studies have shown that individuals with substance use disorder have higher rates of unintended pregnancies, pregnancy-related mortality and morbidity, and lower rates of contraceptive use compared to the general population [3,4]. 

Harm reduction within the reproductive health field must include expanding access to condoms, contraceptive methods, STI and HIV testing, and prenatal care. Reproductive health harm reduction strategies can reduce rates of STIs, HIV, and unintended pregnancies. In addition to expanding access to condoms, STI screening, treatment, and partner therapy must be offered and encouraged to all patients. 

Arreaza: As a reminder to our listeners, Expedited Partner Therapy (EPT) consists in treating the partner(s) of a patient with chlamydia or gonorrhea. You, as a physician, treat a patient with STI, but you also give a prescription or medication to that patient, and he/she takes the prescription or medication to his/her partner(s) without me (the doctor) seeing the partner in the clinic or hospital. This is a harm-reduction strategy. It is permissible in 46 states in the US and potentially allowable in Alabama, Kansas, Oklahoma, and South Dakota. It is prohibited in 0 states. 

Meghana: Regarding birth control, a recent study by Dr. Frank and Dr. Morrison from the University of Michigan suggests that long-acting reversible contraceptives (LARCs) such as the Intrauterine Device (IUD) or the “Implant” should be offered and easily accessible to women with substance use disorder [5].  In America, around 45% of all pregnancies are unintended, and among women with substance use disorders, this number is doubled [6,7]. More so, women with substance use disorders are 25% less likely to use any form of contraception and are more likely to use less effective methods [5]. 

Patient autonomy is important.

Meghana: Autonomy is one of the fundamental principles of ethics in medicine, so it is important that all contraceptive decisions are made without any form of coercion. Also, all discussions must take into consideration previous trauma, such as intimate partner violence. Contraceptive counseling should be comprehensive, and patients should be educated on all methods, including emergency contraception and barrier methods.  Patients should not be coerced into choosing a LARC simply because they engage in risky health behaviors and should be offered the same methods as the general population [8]. 

Arreaza: Let’s remember to offer Nexplanon to unhoused patients. On the topic of emergency contraception, you can listen to episode 129. Now, please give us a conclusion.

“If you can't fly then run, if you can't run then walk, if you can't walk then crawl, but whatever you do you have to keep moving forward.”― Martin Luther King Jr.

Meghana: Overall, family physicians are in a unique position to incorporate harm reduction strategies into their practice to improve the quality of life of their patients and to improve health outcomes in their community. Reproductive health harm reduction strategies should be considered and offered to all patients who engage in risky health behaviors. Individuals with substance use disorder and sex workers should be routinely tested for STIs, including HIV and Hepatitis C, as well as offered pregnancy testing and prenatal care if needed. Comprehensive contraceptive counseling, including condom use and emergency contraception, should be discussed with all patients, and conversations should be stigma-free and collaborative. Incorporating reproductive health interventions into already existing harm reduction programs is key to improving the overall health and well-being of our most vulnerable communities. 

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Conclusion: Now we conclude episode number 132, “Harm Reduction and Reproductive Health.” Meghana gave us an excellent introduction to the principles of harm reduction in medicine. Applied to reproductive health, we can reduce risk by improving access to condoms, HIV and STI tests, and birth control methods, especially IUD and subdermal implants. Dr. Arreaza also reminded us of strategies such as pre-exposure prophylaxis for HIV (PrEP) and Expedited Partner Therapy for STIs. 

This week we thank Hector Arreaza and Meghana Munnangi. Audio editing by Adrianne Silva.

Even without trying, every night, you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you. Send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! 

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References:

  1. Amundsen EJ. Measuring effectiveness of needle and syringe exchange programmes for prevention of HIV among injecting drug users. Addiction. 2006;101:911–2. Available at: https://onlinelibrary.wiley.com/doi/full/10.1111/j.1360-0443.2006.01519.x?sid=nlm%3Apubmed
  2. Nyblade L, Stockton MA, Giger K, et al.; Stigma in health facilities: why it matters and how we can change it. BMC Med. 2019;17(1):25. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6376713/.
  3. Woodhams E. Partners in contraceptive choice and knowledge. November 18, 2021. Available at https://picck.org/enduring-sud/.
  4. Patel P. Forced sterilization of women as discrimination. Public Health Rev. 2017;38:15. Available at https://publichealthreviews.biomedcentral.com/articles/10.1186/s40985-017-0060-9
  5. Frank CJ, Morrison L. Harm reduction for patients with substance use disorders. Am Fam Physician. 2022;105(1):90-92. Preview available at https://www.aafp.org/pubs/afp/issues/2022/0100/p90.html.
  6. Heil SH, Jones HE, Arria A, et al.; Unintended pregnancy in opioid-abusing women. J Subst Abuse Treat. 2011;40(2):199-202. Preview available at https://pubmed.ncbi.nlm.nih.gov/21036512/.
  7. Terplan M, Hand DJ, Hutchinson M, et al.; Contraceptive use and method choice among women with opioid and other substance use disorders: a systematic review. Prev Med. 2015;80:23-31. Preview available at https://www.sciencedirect.com/science/article/abs/pii/S0091743515001140?via%3Dihub
  8. Baca-Atlas MH, Nimalendran R, Baca-Atlas SN. Applying Harm Reduction Principles to Reproductive Health. Am Fam Physician. 2023 Jan;107(1):Online. PMID: 36689956. Available at https://www.aafp.org/pubs/afp/issues/2023/0100/letter-reproductive-health.html.
  9. Royalty-free music used for this episode: “Gushito - Burn Flow." Downloaded on October 13, 2022, from https://www.videvo.net/

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