Integrating Responses at the Intersection of Opioid Use Disorder and Infectious Disease Epidemics Proceedings of a Workshop (2018) / Chapter Skim
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3 Exploring Opportunities for, and Barriers to, Treatment and Prevention in Public Health, Hospitals, and Rural America
3 Exploring Opportunities for, and Barriers to, Treatment and Prevention in Public Health, Hospitals, and Rural America
Pages 53-94
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From page 53... ...
ROLE OF PUBLIC HEALTH DEPARTMENTS Harm Reduction Programs Matthew La Rocco, community liaison with the Louisville Metro Syringe Exchange Program in Kentucky, explored the role of harm reduction in reducing the transmission of infectious diseases. He drew on his experience as a certified drug and alcohol counselor who is also in long 53
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From page 54... ...
Political Boons and Barriers to Syringe Services Programs in Kentucky Kentucky Senate Bill 192 was introduced on February 13, 2015, representing a momentous state-level response to the opioid epidemic with respect to both syringe exchange and treatment funding, said La Rocco. On February 25, the health department in nearby Scott County, Indiana, announced that within the past 2 months, they had confirmation of 26 new human immunodeficiency virus (HIV)
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From page 55... ...
Democrats introduced House Bill 160 to lay out the specifics of needle disposal by health departments, with no reference BOX 3-1 Misperceptions Around One-to-One Needle Exchange Policy makers may lobby to require one-to-one needle exchange in syringe services programs based on arguments about the potential for accidental needle sticks to transmit HIV or HCV infection. In fact, La Rocco explained, the likelihood of contracting HIV or HCV in such circumstances is incredibly low, even from a fresh needle stick; a needle that has been sitting in a park's sandbox for 5 days is even less likely to transmit HIV or HCV.
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From page 56... ...
These delays in diagnosis and treatment for conditions such as abscesses and endocarditis significantly increase the cost of treating the patients. It also compounds the impact that these infectious diseases have on the individuals and their quality of life.
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From page 57... ...
Drug-related stigma and internalized shame put these women at significant risk for contracting infectious diseases and delaying treatment for those diseases. A key challenge, he said, is that these women are less likely to access annual reproductive health care, which provides opportunities for infectious disease screening, education, and referral for treatment as needed.
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From page 58... ...
Women who cannot access services or escape their domestic situation can end up feeling hopeless, he explained, which has the potential to increase their drug use and thus their risk of infectious diseases. Women in relationships are often tasked with the domestic responsibilities as well as the responsibilities for acquiring drugs, earning money to buy drugs, and getting a better deal on drugs, noted La Rocco.
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From page 59... ...
Additionally, they are exploring a partnership with physicians at the University of Louisville Hospital to increase early treatment of soft tissue infections and endocarditis to help reduce the number of ED visits, among other benefits. The partnership would ensure that people who are concerned they have an infection related to their injection drug use have access to trained, polite, and respectful physicians.
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From page 60... ...
Health departments cannot always deliver programming, La Rocco said, but they can certainly support and work collaboratively with smaller agencies. Overdose, Hepatitis C Virus, and Drug User Health Katie Burk described the response of the San Francisco Department of Public Health (SFDPH)
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From page 61... ...
For example, many people are not currently engaged in primary care. If they are engaged in syringe exchange programs they should, if needed, be able to receive HCV treatment and/or be induced to begin methadone or buprenorphine treatment in that setting.
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From page 62... ...
project, which is housed at the Harm Reduction Coalition, which is funded by SFDPH. Burk explained that the NOSE project was launched in response to the problem of opioid analgesic deaths in the city, which exceeded 100 each year between 2000 and 2012, and were continuing to persist despite significant reductions in heroin-related overdose deaths.
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From page 63... ...
. SOURCES: As presented by Katie Burk at the workshop Integrating Infectious Disease Considerations with Response to the Opioid Epidemic on March 12, 2018; Phillip Coffin, San Francisco Department of Public Health.
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From page 64... ...
For example, if advocates successfully increase funding into the system to address HCV, then health departments can fund crucial HCV services. The staff of drug treatment programs and SSPs can in turn focus on outreach, education, testing, and linkage to providers for treatment and cure.
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From page 65... ...
Community providers, supported by SFDPH, added HCV testing in settings where naloxone was being distributed and drug users were already successfully engaged in interventions: syringe access programs, homeless shelters, the county jail, single-room occupancy hotels, methadone programs, residential drug treatment programs, transgender wellness groups, and STD clinics. She reported that since the End Hep C initiative started in January 2016, there have been increases in the number of HCV tests while the 15 percent rate of reactive antibody tests has been maintained throughout the scaled-up testing.
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From page 66... ...
To improve access to treatment outside of primary care, SFDPH is working to scale up smaller programs and pilots to treat HCV at the county jail, a syringe exchange, a gay men's sexual health clinic, homeless shelters, through street medicine teams, and the opiate treatment outpatient program at the University of California, San Francisco. She said, "We are doing some incredible life-changing work with these populations by embodying the experience of harm reduction and meeting them where they are, literally." Burk highlighted the national Patient-Centered Outcomes Research Institute (PCORI)
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From page 67... ...
She observed that many people receive HCV treatment before they have addressed all their other issues and stabilized in every possible way, but once they have been cured of HCV, they feel empowered to the extent that they become more adherent to their HIV medications, reduce their substance use, get housing, go back to work, and enact other positive changes. To del Rio's question about linking health departments to local-level service providers, Burk said that the End Hep C SF initiative has demon
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From page 68... ...
Benjamin Linas, associate professor of medicine at Boston University, commented that the 15 percent seropositivity rate for HCV in San Francisco was interpreted as indicating that right spots are being reached, but he suggested that public health departments take such rates as indicating that not enough is being done and approaches need to be broader. Although the "right" positivity rate is unclear, the rate of 15 percent suggests overspecificity and not enough sensitivity about who is being screened.
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From page 69... ...
Hospitalization often addresses patients' acute medical illnesses but not the underlying cause of SUD, which leads to significant waste and very poor patient outcomes. Effective treatments exist but they are underused; despite such frequent interactions with hospitals, most people with SUD are not engaged in SUD treatment.
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From page 70... ...
The outcome was quite tragic. But her story, though exemplary, is not at all unique." SOURCE: As presented by Honora Englander at the workshop Integrating Infectious Disease Considerations with Response to the Opioid Epidemic on March 12, 2018.
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From page 71... ...
SOURCES: As presented by Honora Englander at the workshop Integrating Infectious Disease Considerations with Response to the Opioid Epidemic on March 12, 2018; adapted from AHRQ, 2017. Designing a Hospital-Based Addiction Medicine Intervention Englander explained they designed the IMPACT intervention by mapping the findings from the needs assessment onto the intervention's key components.
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From page 72... ...
line, which goes from the outside of their body directly into the patient's heart. To address the prolonged length of hospital stays for such patients and to increase community treatment options, IMPACT evolved a new care model called a Medically Enhanced Residential Treatment Model (MERT)
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From page 73... ...
. Englander said that they are also carrying out work to understand the role of peers who have lived experience in recovery and are working as part of the IMPACT interprofessional team.
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From page 74... ...
Medically Enhanced Residential Treatment Model Outcomes Englander noted the experience in implementing the part of the intervention called MERT that integrated IV antibiotics into residential treatment. To implement MERT, OHSU hospital partnered with a residential addiction treatment setting.
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From page 75... ...
Other implications include the need for flexible postacute care models that can engage patients across the precontemplative stage to the action stage of change, as well as the importance of integrating pain management, physical health care, and SUD treatment. While the experience with IMPACT demonstrates that hospitalization is a reachable moment, residential treatment represents a higher bar.
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From page 76... ...
Additional implications for policy makers are the need to establish treatment pathways spanning the hospital and community SUD treatment and the need to develop new care models that integrate IV antibiotics and SUD care. She also reminded the group that treating SUD in the hospital can and should be the standard of care.
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From page 77... ...
. The top figure illustrates rising trends in the numbers of HIV diagnoses in rural West Virginia that warrant serious concern (Evans et al., 2018)
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From page 78... ...
SOURCES: As presented by Nickolas Zaller at the workshop Integrating Infectious Disease Considerations with Response to the Opioid Epidemic on March 12, 2018; Evans et al., 2018; Zibbell et al., 2015.
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From page 79... ...
According to data from CDC on the age-adjusted deaths per 100,000 population from heroin in 2014 and 2015 by region, the South has an increasing number of heroin overdose deaths, but the rate is not increasing at the same magnitude as it is in the Midwest and the Northeast.6 He attributed this to lower rates of people who inject heroin and lower levels of fentanyl in the drug supply compared with the Northeast. Treatment admissions for opioid use are on the rise across Kentucky, Tennessee, Virginia, and West Virginia, said Zaller.
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From page 80... ...
Zaller explained that this "tidal wave" of opioid use and its infectious disease consequences can be tracked spreading from the northeast of the country into Kentucky, North Carolina, West Virginia, and southern parts of Indiana and Ohio. Primary prevention is urgently needed in rural communities with extremely limited access to harm reduction resources and drug treatment, he cautioned.
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From page 81... ...
SOURCES: As presented by Nickolas Zaller at the workshop Integrating Infectious Disease Considerations with Response to the Opioid Epidemic on March 12, 2018; Rosenblatt et al., 2015. Copyright 2018 by the Annals of Family Medicine, Inc.
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From page 82... ...
He described efforts to carry out ongoing surveillance of nonmedical use of prescription opioids at the county jail in Little Rock, Arkansas. They began by screening people who enter the jail for opioid use disorder and of almost 1,000 people screened, around 10 percent were identified as opioid dependent (Wickersham et al., 2015)
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From page 83... ...
Discussion del Rio commented that Zaller carried out work in the Republic of Georgia years ago, which found that prescription opioids were also the most commonly injected drug and people who injected prescription opioids were less likely to be infected with HBV and HIV than people who injected street drugs. He asked whether safe injection sites have been considered as an intervention in Arkansas.
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From page 84... ...
If the ACA is repealed, he warned, it will be critical to find alternative ways to cover addiction treatment. Judith Feinberg of West Virginia University reflected on her experience doing research in southern West Virginia, the center of the coal industry and the part of the state that is poorest and hardest hit by the opioid epidemic.
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From page 85... ...
Springer replied that there needs to be a systemic paradigm shift toward the idea that health care providers should treat everyone, including people with opiate addiction. del Rio commented on a related systemic issue -- providers tend to feel like they have done their job just by giving patients a referral for substance abuse treatment and then hoping for the best.
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From page 86... ...
Zaller added that there are no infectious disease physicians in large parts of the country, so prevention will need to be provided by primary care and family medicine physicians who will need training. Ellen Eaton, assistant professor in the University of Alabama at Birmingham School of Medicine's Division of Infectious Diseases, asked Englander if they encountered problems obtaining buy-in from physicians for the IMPACT intervention, given how burdened physicians are by clinical demands and by the challenges they face caring for SUD patients; for example, the challenge of getting patients to actually show up to mental health and SUD services when they are referred.
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From page 87... ...
They have found that in rural areas, the real issue is how the needed therapy will be provided even when physicians are waivered to prescribe the medication (see Box 3-3 for a more detailed description of the multiple epidemics that West Virginia is facing)
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From page 88... ...
This is a powder keg, she warned, that extends beyond West Virginia. SOURCE: As presented by Judith Feinberg at the workshop Integrating Infectious Disease Considerations for Response to the Opioid Epidemic on March 13, 2018.
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From page 89... ...
Counseling is likely to help benefit people in this respect, but the first step should be to address the neurobiology of addiction through the use of medications. Springer noted that similar issues are seen in the incarcerated population and in women and men who experience intimate partner violence -- these types of issues start to emerge after their addiction is treated, for which support services are needed.
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From page 90... ...
The onus is on those who understand the guidelines to go out and educate people about how easy it is to start someone on treatment. Burk described a parallel example related to training primary care physicians to treat HCV.
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From page 91... ...
Some doctors see patients who are unable to taper from high-dose prescription opioids for chronic pain to safer dosages recommended by CDC guidelines, and they may prescribe buprenorphine to those patients instead. This is a grey zone, because opioid use disorder can be challenging to diagnose in patients with chronic pain and patients without opioid use disorder may still benefit from sublingual buprenorphine, which is not currently approved for treatment of pain.
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From page 92... ...
An absolute lockdown on all opioids for all patients is not the appropriate strategy, he said. del Rio noted that the United States consumes 90 percent of prescription opioids without having an equivalent amount of the world's pain -- the global inequity in access to opioids for pain treatment is huge.
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From page 93... ...
2018. Notes from the field: HIV infection investigation in a rural area -- West Virginia, 2017.
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From page 94... ...
2015. Increases in hepatitis C virus infection related to injection drug use among persons aged
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