1. What does “Harm Reduction” mean in medical practice? Miriam Komaromy, MD Medical Director, Albuquerque Health Care for the Homeless

2. Miriam Komaromy, MD Internal Medicine and Addiction miriamkomaromy@gmail.com 505-715-0394

3. 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!

4. Examples: Patient chooses to… Decrease the amount of alcohol she drinks on a binge so she can make better decisions about not driving Decrease his daily cigarette smoking from 2 packs to 1 Start to address her diabetes by walking to her daughter’s house rather than driving 2 days out of the week

5. 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

6. 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

7. How to implement disease management Identify patient’s concerns and goals Set mutually agreed-upon goals, e.g.: Decrease drinking days/month Decrease drinks/drinking day Increase social contacts/week Improve housing, finances, social svcs Engage family/social support members (e.g., Al-Anon, decrease co- dependent behaviors)

8. Study of Disease Management in Alcoholism Disease Mgmt Group Usual Care Group P value Drinking days/303.77.0.03 Drinks/drinking day 1.83.05 Days since last drink ( Median ) 13916.5.08 Abstinence # (%)28 (74%)18 (48%).02 Clinical Indicators after 2 Years in Disease Management & Control Groups Willenbring ML, Arch Int Med 1999

9. 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”

10. 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

11. “Motivational Interviewing in Healthcare” Miller, et al