The 25th International Harm Reduction Conference (HR17) took place in Montréal, Canada, last week. NAM is the official scientific reporter for the conference.

Harm reduction means reducing the harms associated with using drugs. This includes providing services such as needle and syringe exchange, opioid substitution therapy (such as methadone or buprenorphine), and overdose prevention. Harm reduction also refers to policies that aim to reduce negative consequences of drug use. It is an approach which is informed by good public health practice and focused on individual human rights.

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Health Minister Jane Philpott and protestors at the HR17 opening ceremony © Charles Mackay / HRI

The 25th International Harm Reduction Conference (HR17) in Montréal, Canada, kicked off with a dramatic opening session last week, featuring Jane Philpott, Canadian Minister of Health, along with a group of angry protesters chanting ‘They talk, we die’.   

The minister’s speech and the protest focused on the soaring rate of overdose deaths dominating the work of harm reduction organisations across Canada.

Dramatic increases in heroin and fentanyl-based overdoses in Canada and the US have been compared to the worst of the days of the AIDS crisis. Last year, an estimated 2300 people died of heroin and fentanyl-related overdoses in Canada. It looks likely that this figure will increase in 2017.

Across North America, widespread use of synthetic opioids such as the painkiller fentanyl, and heroin contaminated with illicitly manufactured fentanyl, is leading to dramatic numbers of overdose deaths. 

Fentanyl is 50 to 100 times more potent than heroin and is used by illicit manufacturers to intensify the euphoric effects of heroin. For users of street heroin, it is impossible to tell by looking whether their heroin is contaminated with fentanyl.

Dan Ciccarone at HR17. Photo by Liz Highleyman, hivandhepatitis.com

Data on fentanyl seizures presented at the conference show a strong correlation between higher rates of fentanyl seizure and higher rates of overdose in the United States. Fentanyl seizures increased by 134% between 2009 and 2014, with the biggest increases taking place in the Midwest and Northeast. Along with Kentucky, Tennessee, Alabama and Mississippi, these regions also saw the largest increases in heroin overdose during the same period.

Professor Dan Ciccarone of University of California San Francisco said that more could be done with drugs seized by law enforcement officials to inform a public health response to the overdose crisis.

“Currently in the US seized drugs most often end up in a county crime lab and are not tested. Information is power, we need to get creative and promote drug testing and dissemination of the data, ensuring law enforcement and public health authorities are working together,” said Ciccarone.

Ciccarone argued that the opioid epidemic should be treated less as a drug epidemic and more as a poisoning epidemic, warranting more proactive surveillance and testing of drugs themselves – not just people who use drugs. He also urged faster response to overdose by making naloxone widely available to people who use drugs and their loved ones, more harm reduction services and more evidence-based treatment for drug addiction.

“If synthetic opioids are in fact becoming the new norm in terms of distribution and consumption then drug checking and supervised injection sites ought to become the new public health norms too,” said Rick Lines, Executive Director of Harm Reduction International, convenors of HR17.

Mark Lysyshyn at HR17. Photo by Liz Highleyman, hivandhepatitis.com

A pilot project to check the purity of drugs at Vancouver's Insite safe injection facility found that around 80% of tested samples contained fentanyl, and people who learned their drugs were contaminated were more likely to reduce their drug doses and less likely to overdose, researchers reported at the conference.

Like the United States, Canada is experiencing a sharp increase in deaths due to overdose. In British Columbia alone, 922 overdose deaths were recorded by the province’s Coroner’s Service in 2016. Fentanyl was detected in 61% of all drug overdose deaths in the province, the Coroner’s Service reported.

Users at the supervised injecting facility were offered the option to have their drugs tested for fentanyl before or after injecting.

A total of 1138 drug checks were performed between July 2016 and March 2017, about 40% before consumption and about 60% afterwards.

The researchers found that, overall, 79% of all drug samples contained fentanyl. Contamination was more common in heroin and crystal methamphetamine samples (83 and 82%, respectively), and less so in samples of cocaine (40%) or other drugs (48%).

Thirteen per cent of people with fentanyl-positive drug samples experienced overdose, compared to just 2% of those with negative samples – more than a sixfold higher risk. Similarly, 10% of clients with fentanyl-positive samples required naloxone, compared to 2% of those with negative samples.

During the conference a new law came into effect in Canada that will speed up the opening of supervised injecting facilities. Insite, Canada’s first public supervised injecting facility, opened in 2003 and remains the only public facility (Montréal will open a facility soon).

Robin Pollini at HR17. Photo by Liz Highleyman, hivandhepatitis.com

Another overdose risk – overdosing of methamphetamine or other stimulants – is an under-recognised problem in a harm reduction community that more often focuses on opioid overdose, the conference heard.

The health effects of ‘overamping’ are much more varied than opioid overdose. They may include severe physical health events such as heart attack, stroke, seizure or intense overheating, or severe mental health events such as extreme panic, paranoia, anxiety or agitation, hallucinations, or psychosis.

A survey of 494 people who inject drugs in Fresno, California, found that a third of participants had experienced overamping or stimulant overdose. Ten per cent had done so in the previous three months. The most common symptoms were racing heartbeat, overheating, severe anxiety and panic, and shortness of breath or irregular breathing. Currently there is no known way to reverse a stimulant overdose, as naloxone does for an opioid overdose. One in four who experienced an episode had gone to an emergency room for help.

Of those who had experienced overamping, 41% said that they had also used heroin in the days before the episode.

Another study, carried out in Australia, showed that people using heroin and methamphetamine together were often using heroin to moderate the effects of methamphetamine, as a form of harm reduction.

The researchers of the overamping study suggest that combining education on stimulant and opioid overdose may be appropriate, especially where stimulant use is frequent.

UK-based NGO Harm Reduction International (HRI) warns in a new report that if the roll back of funding harm reduction services such as needle and syringe programmes and methadone provision in the European Union remains unchecked, renewed spikes in HIV and hepatitis C infections amongst people who use drugs are inevitable.

The report – Harm Reduction investment in the European Union – current spending, challenges and successes – was released ahead of the 25th International Harm Reduction Conference (HR17).

Harm Reduction International also presented further findings from its 2016 Global State of Harm Reduction report, highlighting the lack of new needle and syringe programme provision. Of the 90 countries that report provision of needle and syringe programmes, only 17 countries are expanding these services, whilst 20 countries report a decrease of needle and syringe programmes.

Katie Stone of Harm Reduction International said:

“This is the first time that there has been no increase since we started monitoring coverage of harm reduction services in 2008. Access to one of the most important HIV prevention and harm reduction services is stagnating, while rates of injecting drug use are increasing.”

A UN target to halve HIV transmission among people who inject drugs by 2015 was not only missed, but HIV rates amongst people who inject drugs increased by a third between 2011 and 2015 according to UNAIDS.

“The Sustainable Development Goals pledge to end AIDS by 2030, but there is no way we’ll ever achieve this goal in the current climate given the lack of leadership and funding for harm reduction for people who inject drugs,” said Stone.

Harm Reduction International says that a shift away from a failed ‘war on drugs’ approach to policing of drug use, including a massive reduction in imprisonment of people who use drugs, could save up to $100 billion a year. A change in approach would allow reinvestment of money saved in harm reduction – $10 billion a year would finance all global efforts to reach the prevention and care targets for people who use drugs, says Harm Reduction International.

David Marsh at HR17. Photo by Liz Highleyman, hivandhepatitis.com

Prescribing an alternative to street drugs may help some people who inject drugs to stabilise their drug use, stop sharing injecting equipment and improve their health.

Methadone and buprenorphine are the standard medications used for opioid substitution therapy, but they do not work for everyone. Around 15 to 25% of people who inject heroin will not respond well to methadone and need other options, such as prescription of heroin.

But, use of medical heroin (diacetylmorphine) on prescription remains illegal for this purpose in most countries (although Canada recently legalised its prescription for people who do not respond to opioid substitution therapy). Hydromorphone (brand name Dilaudid) is a semi-synthetic morphine derivative that works similarly to heroin, but it is an approved painkiller and is widely legally available for medical use.

The phase 3 SALOME (Study to Assess Long-term Opioid Medication Effectiveness) trial, conducted at the Providence Health Crosstown Clinic in Vancouver's Downtown Eastside, evaluated whether hydromorphone is as effective as diacetylmorphine for the treatment of long-term opioid addiction.

The study found that hydromorphone was just as effective as diacetylmorphine in reducing illicit use of heroin. The researchers recommend that hydromorphone should be available as an alternative to diacetylmorphine, in order to expand the range of options available to help people who have not responded to opioid substitution therapy.

Magdalena Harris at HR17. Photo by Liz Highleyman, hivandhepatitis.com

AA amyloidosis, a condition resulting from skin and soft tissue infections that can lead to kidney failure, may be more common than previously recognised among people who inject drugs, according to the findings of a systematic review presented at HR17.

Amyloidosis occurs when abnormal proteins known as amyloid fibrils build up in body tissues. The AA type of amyloidosis is caused by chronic inflammation. Untreated skin and soft tissue infections in people who inject drugs cause chronic inflammation, which encourages the build-up of abnormal proteins in body tissues in a minority of people.

The kidneys are usually affected first. Symptoms of AA amyloidosis kidney disease include proteinuria (protein in the urine) and swelling of the extremities. Over time it can lead to renal failure, the need for dialysis, kidney transplantation or death.

AA amyloidosis was first reported among injection drug users in the 1970s. Later that decade the condition was linked to skin and soft tissue infections, and informally dubbed 'skin popper's disease'. The first cases in Europe were reported in the late 1980s.

In the UK, up to 60% of people who inject drugs report recent skin and soft tissue infections, and about 10% – or 20,000 individuals – are hospitalised for this reason each year. UK drug treatment services have seen a growing number of clients with AA amyloidosis or on kidney dialysis in recent years, said Magdalena Harris of the London School of Hygiene and Tropical Medicine.

She is working with colleagues in the UK to investigate the care and prevention of soft tissue infections in drug users, and find out what people who inject drugs need. Her research will also investigate the prevalence of AA amyloidosis among a sample of people who inject drugs in the UK.

Hepatitis C virus reinfection is uncommon after being cured with DAAs

Jason Grebely at HR17. Photo by Liz Highleyman, hivandhepatitis.com

Most people on opiate substitution therapy were successfully treated for hepatitis C with an interferon-free regimen of grazoprevir/elbasvir (Zepatier), and only a small number became reinfected during three years of follow-up, researchers reported at the conference. Read more >>

Indonesian buyers club helps people obtain generic hepatitis C treatment

Sindi Putri at HR17. Photo by Liz Highleyman, hivandhepatitis.com

A community-led buyers club in Indonesia has helped more than 100 people get generic direct-acting antiviral (DAA) drugs to treat hepatitis C and is seeing a high cure rate, according to a presentation at the conference. Read more >>

Combining drug addiction treatment and perinatal HIV prevention leads to good outcomes in Kenya

Benjamin Kirimo at HR17. Photo by Liz Highleyman, hivandhepatitis.com

An integrated programme offering medication-assisted drug addiction treatment and services aimed at preventing mother-to-child HIV transmission led to improved outcomes for opioid-dependent HIV-positive mothers and their babies, according to a presentation at the conference. Read more >>

Use of psychedelic drugs may reduce the risk of suicide in female sex workers

Elena Argento at HR17. Photo by Liz Highleyman, hivandhepatitis.com

Women sex workers who used psychedelic drugs such as LSD were less likely to think about or attempt suicide, while some other drugs increased the risk, according to study results presented at the conference. Read more >>

Pet care can connect people to health and harm reduction services

Providing free veterinary care can be a good way to bring homeless and marginally housed people into contact with health care, harm reduction and other services, according to a presentation at the conference. Read more >>