What does “Harm Reduction” mean in medical practice? Miriam Komaromy, MD Medical Director,...
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What does “Harm Reduction” mean in medical practice? Miriam Komaromy, MD Medical Director, Albuquerque Health Care for the Homeless
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Transcript of What does “Harm Reduction” mean in medical practice? Miriam Komaromy, MD Medical Director,...
What does “Harm Reduction” mean in medical practice?
Miriam Komaromy, MDMedical Director, Albuquerque Health Care for the Homeless
Essential underlying philosophy for medical practice
Only the patient can choose change
Respectful communication is key
My goal ≠ patient’s goal
Can we “mandate” change?
Goal: help patient move toward more healthy behaviors
This is harm reduction!
Examples: Patient chooses to…
Decrease the amount of alcohol she drinks on a binge so she can make better decisions about not drivingDecrease his daily cigarette smoking from 2 packs to 1Start to address her diabetes by walking to her daughter’s house rather than driving 2 days out of the week
Essential for addiction treatment
A disease characterized by relapse
Would you refuse to treat an asthmatic patient whose peak flow is low?
Treatment goal: decrease frequency and severity of relapse, acquire sobriety skills
MAT
“classic” HR techniques are also important (syringe exchange, naloxone)
“chronic disease management” model
Disease Management Model
When is disease-management approach indicated?
Moderate-to-heavy dependence
“pre-contemplative”
Unwilling to aim for abstinence
Medical co-morbidities drive need for change
How to implement disease management
Identify patient’s concerns and goalsSet mutually agreed-upon goals, e.g.:
Decrease drinking days/monthDecrease drinks/drinking dayIncrease social contacts/weekImprove housing, finances, social svcs
Engage family/social support members (e.g., Al-Anon, decrease co-dependent behaviors)
Study of Disease Management in Alcoholism
Disease Mgmt Group
Usual Care Group
P value
Drinking days/30 3.7 7.0 .03
Drinks/drinking day
1.8 3 .05
Days since last drink (Median)
139 16.5 .08
Abstinence # (%) 28 (74%) 18 (48%) .02
Clinical Indicators after 2 Years in Disease Management & Control Groups
Willenbring ML, Arch Int Med 1999
HR essential for negotiating all behavior change
Even if the “best” treatment from a medical standpoint is a drug that must be taken 2-3 times per day, if a patient can’t/won’t take it that often, best to change to a once-a-day drug
A homeless client may not take a diuretic because of limited access to bathrooms; explore this from the beginning and you will see less “non-compliance”
Motivational Interviewing techniques = tools for harm reduction
How are you feeling about your smoking? How is that working for you?
Ask permission to discuss
Change readiness scale
Confidence scale
Help your patient move toward “10”
Choose a mutually-agreed upon goal
“Motivational Interviewing in Healthcare” Miller, et al
