Opportunities to Improve Opioid Use Disorder and Infectious Disease Services Integrating Responses to a Dual Epidemic (2020) / Chapter Skim
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Today, infectious diseases related to OUD include HIV; hepatitis A, B, and C viruses; and bacterial, fungal, and other infections (transmitted either via injection drug use or risky sexual behaviors)
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for OUD and infectious diseases in stark relief. There are opportunities to improve the public's health by integrating treatment of OUD in clinics that treat infectious diseases, focusing on screening and treating infectious diseases in SUD care settings, removing policy barriers to treatment, better integrating care at all points where a patient interacts with the health system, and recognizing that preventing and treating OUD improves prevention and treatment outcomes for infectious diseases.
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STUDY PROCESS The National Academies convened an ad hoc, 10-member interdisciplinary committee that included academicians and medical professionals with expertise in the social determinants of health, health equity, family medicine, epidemiology, addiction medicine, infectious diseases, implementation science, nursing, correctional systems, and public health policy. The report's scope addresses both OUD and infectious diseases, primarily through the routes of transmission of injection drug use and high-risk sexual behaviors that are common among people who use drugs.
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Prior authorization policies -- and other associated requirements such as step therapy, lifetime limits, or the requirement for concurrent psychosocial therapy -- imposed by state Medicaid programs and private insurers are one such measure. The committee found that prior authorization policies to prescribe medications for OUD are an administrative burden for providers and prevent medications from reaching patients, thereby both preventing the delivery of holistic, patient-centered care in a timely fashion for patients with concurrent OUD and infectious diseases, as well as increasing the population risk of infectious diseases.
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Lack of Data Integration and Sharing: Due to infrastructural difficulties and federal policies, medical care providers -- including infectious disease providers -- may not be able to access patients' information surrounding substance use and treatment, thereby inhibiting comprehensive care plans. Inadequate Workforce and Training: There are several barriers to integration from a workforce perspective, including the geographic distribution and inadequate training of providers who can treat patients with opioid use disorder and infectious diseases and restrictions about which providers can deliver certain kinds of care in certain settings.
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Drug Addiction Treatment Act Waiver Requirement Despite the urgency of the opioid crisis, there is a shortage and misdistribution of providers who can prescribe buprenorphine and other medications to treat OUD, thereby increasing the population at risk of contracting infectious diseases and reducing access to care for patients with concurrent infectious diseases and OUD. One contributing factor is the Drug Addiction Treatment Act (DATA)
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, it is nonetheless important that providers are well trained in prescribing medications for OUD and feel comfortable doing so (both to treat the disorder and to reduce the population risk of infectious diseases as well as to treat patients with co-occurring diseases more holistically)
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As programs from this study mentioned, the current silos between OUD and infectious disease clinicians and organizations come at the expense of comprehensive, quality care. To this end, the committee recommends that the Health Resources and Services Administration direct additional resources toward workforce development that breaks down such silos and does so for all providers who would interact with patients struggling with OUD, infectious diseases, or both.
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The committee determined that this is a missed opportunity and recommends that efforts should be made to integrate services further by leveraging opioid treatment programs as testing and treatment sites for infectious diseases. Moreover, given that methadone is a proven therapy for treating OUD -- and that it has been historically divorced from primary care settings
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Removing financial barriers to obtain a DEA registration number would serve as an incentive for health professionals to independently treat individuals for OUD instead of relying on the registration number of their supervisor or the training hospital. In turn, a greater number of providers able to treat OUD can diminish the overall burden on the population's health by reducing the risk of infectious diseases (as it has been shown that adherence to treatment for OUD promotes adherence to medication for infectious diseases)
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and infectious diseases in health profes sions training: • The Liaison Committee on Medical Education (LCME) should assure that medical students receive practical, clini cally relevant, harm-reduction-focused, case-management based training on OUD and infectious disease assessment, management, and treatment in response to LCME's curricu lar content standard 7.5 (societal problems)
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The committee identified a need for specific interventions to reduce the stigma surrounding SUDs and infectious diseases, both generally and especially in clinical settings. Provider stigma occurs when providers attribute negative stereotypes to patients with SUDs or infectious diseases, and it can result in different treatment for certain patients.
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Payment and Financing Limitations Syringe service programs are an essential piece of a harm-reduction strategy toward integrating responses to OUD and infectious diseases. Currently, syringe service programs face a barrier in that federal funds cannot be used to purchase syringes.
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Any new services to address the opioid epidemic must therefore be similarly comprehensive, providing wraparound services to support treatment plans and recognizing that OUD and infectious diseases cannot be approached as separate epidemics. Recommendation 3-17: Congress should authorize and appro priate funding for the Health Resources and Services Admin istration to comprehensively address the needs of low-income uninsured or under-insured individuals with co-occurring opi oid use disorder and infectious diseases.
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Recommendation 3-18: State Medicaid administrators should revise their billing policies to allow for more than one service in a given day (e.g., allow for one physical and one behavioral visit per day; allow multiple providers to bill on the same day for the same patient; or allow the same provider to bill on the same day for different diagnoses, such as opioid use disorder and infectious diseases)
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Disconnect Between the Health and Criminal Justice Systems The committee's findings make clear the opportunities to improve care for patients with OUD and/or infectious diseases, both while incarcerated and following release from criminal justice settings. Formerly incarcerated individuals are especially prone to overdose and may lack connections to infectious disease treatment in the weeks after release.
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Recommendation 3-25: Through federal grant funding, state block grants or direct appropriations, states should fund high quality, evidence-based reentry services for prisons and jails, including medications for opioid use disorder and infectious diseases, as well as linkage to care in the community and harm reduction services following release (e.g., naloxone to reduce the risk of fatal overdose)
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