Taylor A. Nichols, PharmD, BCPP
Clinical Pharmacy Specialist - Mental Health
Phoenix VA Health Care System
Phoenix, AZ

Dr. Taylor Nichols is a Psychiatric Clinical Pharmacy Provider at the Phoenix VA Health Care System in Phoenix, AZ. She currently works in the Substance Abuse Residential Rehabilitation Treatment Program (SARRTP) and outpatient Substance Use Disorder Treatment Program (SUDTP) clinic where she specializes in substance use disorders and psychiatric care. She also serves as the Residency Program Coordinator for the Phoenix VA PGY2 Psychiatric Pharmacy residency program. Dr. Nichols received her PharmD from the University of the Incarnate Word and completed her PGY1 and PGY2 residencies at the Medical University of South Carolina. She is Board Certified in Psychiatric Pharmacy and is an active member of the College of Psychiatric and Neurologic Pharmacists (CPNP).

As pharmacists, we are dedicated to assess for potential risk, reduce harm, and improve outcomes based on individualized goals. We consider foundational pharmacy principles such as dosing, dosage form, route of administration, pharmacokinetics, side effects, etc. to thoughtfully guide and educate our patients on therapeutic choices. While this practice is often restricted to drugs used for medical purposes, pharmacists already possess the necessary training to apply this same basic knowledge to drugs not being used for medical purposes. One might argue that, as psychiatric and neurologic pharmacists, we are better suited than most to understand how these principles apply to addictive substances. Most of the battle is demystifying these addictive substances and envisioning ways to incorporate harm reduction into our everyday practice. 

Harm reduction is a treatment approach that seeks to reduce the negative effects of substance use, prevent overdose, and limit the spread of infectious diseases. It does not seek to encourage or discourage the use of substances but is rather accepting of each individual’s specific goals. Numerous harm reduction interventions exist— some that may be particularly simple for a psychiatric pharmacist to implement are highlighted in Table 1. These various interventions can be facilitated through patient education, referral to resources, and provision of medications.

Table 1. Potential Harm Reduction Interventions

  • Discuss safer routes of administration (e.g., smoking rather than injection)
  • Educate on overdose prevention and management
  • Educate on potential health consequences of alcohol/drug use
  • Educate on safer injection practices
  • Encourage drug checking (i.e., fentanyl test strips)
  • Offer medications to lessen alcohol use/frequency (i.e., naltrexone, topiramate, gabapentin)*
  • Offer naloxone
  • Reduce transmission of infections through education on safer injection practices and safer sex practices

*If changing use pattern is patient’s goal

Of note, it is important to be aware of state-specific legal restrictions prior to discussing test strips for drug checking and syringe services programs. Some states still classify these items as drug paraphernalia and use may carry legal consequences.

An important step to incorporating harm reduction into your practice is identifying appropriate patients to target. Any patient with problematic substance use or a substance use disorder can be a candidate. If your facility provides population health analytics tools, you can utilize these for outreach regarding overdose education or medications to reduce heavy use if desired. For those in inpatient settings, discharge counseling may be an opportune time to offer overdose education and strategies to mitigate risk if they return to use. Patient education groups can also be a forum to introduce harm reduction on a larger scale. One can capitalize on the expertise of group participants and take the opportunity to dispel “street myths.” It may be helpful to have this group include only people with similar substance use goals, as the discussion might be triggering for those in early stages of abstinence. Additionally, a closed or cohorted group may be more successful as trust in the facilitator incrementally increases and leads to more robust discussion about a highly stigmatized topic. Finally, consider engaging other disciplines in your harm reduction practice. Encourage nurses, social workers, and psychologists to refer patients that have indicated they are not interested in an abstinence goal. These may be prime patients to target for education on drug checking, and safer injection practices, and the health consequences of use.

Now that you’re ready to build harm reduction focus into your practice, what challenges might you face? This topic still garners concern and not all organizations may be immediately receptive to incorporating it. Start small— consider targeting the use of prescription medications to reduce alcohol use or overdose management with naloxone. These agents are already readily prescribed and it could be an easier transition to broadening their use before tackling potentially more controversial subjects like drug checking and safer injection practices. Another challenge can be uncertainty in how to approach harm reduction conversations with patients. Tips for having harm reduction discussions are described in Table 2.

Table 2. Harm Reduction Discussion Tips

  • Use nonjudgmental communication
  • Consistently check your own bias (we all bring bias to the conversation)
  • Speak the language: Take time to learn slang terms so that you can engage your audience
  • Provide practical suggestions, considering environmental constraints
  • Respect the expertise and experience of the person that uses
  • Acknowledge damage that prior healthcare providers may have done
 

Lastly, finding resources to educate ourselves as evidence-based clinicians can be one of the most daunting challenges. It can be difficult to know if the available information is reputable or evidence-based. Much of the information that exists regarding how to prepare and inject drugs is collated and presented without scholarly references. This inherently makes us feel less confident in trusting such materials, considering our training to critically evaluate drug literature. Reminding ourselves that while the information may not be perfect, the overall intervention is likely reducing harm. Working to educate ourselves to the best of our abilities is our responsibility and can increase comfort in incorporating harm reduction practices. Resources that may be helpful include:

Resources will likely grow given harm reduction is a constantly evolving practice. It broadens with our changing perspective on how we can engage patients and make meaningful impacts on their quality of life. Evaluate all of the ways you currently reduce harm in your practice and consider expanding further to addictive drugs. Who better to be the expert on these substances than the drug expert?

25 Years!