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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Integrating Responses at the Intersection of Opioid Use Disorder and Infectious Disease Epidemics: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25153.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Integrating Responses at the Intersection of Opioid Use Disorder and Infectious Disease Epidemics: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25153.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Integrating Responses at the Intersection of Opioid Use Disorder and Infectious Disease Epidemics: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25153.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Integrating Responses at the Intersection of Opioid Use Disorder and Infectious Disease Epidemics: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25153.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Integrating Responses at the Intersection of Opioid Use Disorder and Infectious Disease Epidemics: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25153.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Integrating Responses at the Intersection of Opioid Use Disorder and Infectious Disease Epidemics: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25153.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Integrating Responses at the Intersection of Opioid Use Disorder and Infectious Disease Epidemics: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25153.
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Page viii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Integrating Responses at the Intersection of Opioid Use Disorder and Infectious Disease Epidemics: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25153.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Integrating Responses at the Intersection of Opioid Use Disorder and Infectious Disease Epidemics: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25153.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Integrating Responses at the Intersection of Opioid Use Disorder and Infectious Disease Epidemics: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25153.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Integrating Responses at the Intersection of Opioid Use Disorder and Infectious Disease Epidemics: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25153.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Integrating Responses at the Intersection of Opioid Use Disorder and Infectious Disease Epidemics: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25153.
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Page xiii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Integrating Responses at the Intersection of Opioid Use Disorder and Infectious Disease Epidemics: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25153.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Integrating Responses at the Intersection of Opioid Use Disorder and Infectious Disease Epidemics: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25153.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Integrating Responses at the Intersection of Opioid Use Disorder and Infectious Disease Epidemics: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25153.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Integrating Responses at the Intersection of Opioid Use Disorder and Infectious Disease Epidemics: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25153.
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Anna Nicholson, Rapporteur Board on Population Health and Public Health Practice Health and Medicine Division PREPUBLICATION COPY—Uncorrected Proofs

THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001 This activity was supported by Contract No. 10003842 between the National Academy of Sciences and the Department of Health and Human Services. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project. International Standard Book Number-13:  International Standard Book Number-10:  Digital Object Identifier:  https://doi.org/10.17226/25153 Additional copies of this publication are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. Copyright 2018 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2018. Integrating responses at the intersection of opioid use disorder and infectious dis- ease epidemics: Proceedings of a workshop. Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/25153. PREPUBLICATION COPY—Uncorrected Proofs

The National Academy of Sciences was established in 1863 by an Act of ­ ongress, C signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president. The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to ad- vising the nation. Members are elected by their peers for extraordinary contribu- tions to engineering. Dr. C. D. Mote, Jr., is president. The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president. The three Academies work together as the National Academies of Sciences, ­Engi­neering, and Medicine to provide independent, objective analysis and ­ dvice a to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine. Learn more about the National Academies of Sciences, Engineering, and ­ edicine M at www.nationalacademies.org. PREPUBLICATION COPY—Uncorrected Proofs

Consensus Study Reports published by the National Academies of Sciences, E ­ngineering, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typi- cally include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task. Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The statements and ­ pinions o contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies. For information about other products and activities of the National Academies, please visit www.nationalacademies.org/about/whatwedo. PREPUBLICATION COPY—Uncorrected Proofs

WORKSHOP PLANNING COMMITTEE ON INTEGRATING INFECTIOUS DISEASE CONSIDERATIONS WITH RESPONSE TO THE OPIOID EPIDEMIC1 CARLOS M. DEL RIO (Chair), Hubert Professor and Chair, Rollins School of Public Health, Emory University JOHN DREYZEHNER, Commissioner, Tennessee Department of Health TRACI G. GREEN, Adjunct Associate Professor of Emergency Medicine, Adjunct Associate Professor of Epidemiology, Boston Medical Center VAN INGRAM, Executive Director, Kentucky Office of Drug Control Policy P. TODD KORTHUIS, Associate Professor of Medicine, Program Director, Addiction Medicine Fellowship, and Chief, Addiction Medicine Section, Oregon Health & Science University NATASHA K. MARTIN, Associate Professor, University of California, San Diego SANDRA ANN SPRINGER, Associate Professor of Medicine, Associate Clinical Professor of Nursing; Director, Infectious Disease Outpatient Clinic, Veterans Administration Healthcare Services, Newington, Yale School of Medicine DACE SVIKIS, Deputy Director, Virginia Commonwealth University CHUCK WEXLER, Executive Director, Police Executive Research Forum Health and Medicine Division Staff ROSE MARIE MARTINEZ, Senior Director, Board on Population Health and Public Health Practice KATHLEEN STRATTON, Scholar, Study Director HOPE HARE, Administrative Assistant ALEXIS WOJTOWICZ, Senior Program Assistant 1 The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speak- ers. The responsibility for the published Proceedings of a Workshop rests with the workshop rapporteur and the institution. v PREPUBLICATION COPY—Uncorrected Proofs

Reviewers T his Proceedings of a Workshop was reviewed in draft form by indi- viduals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engi- neering, and Medicine in making each published proceedings as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the charge. The review com- ments and draft manuscript remain confidential to protect the integrity of the process. We thank the following individuals for their review of this proceedings: JUDITH FEINBERG, West Virginia University JAMES HUGHES, Emory University P. TODD KORTHUIS, Oregon Health & Science University CHARLES P. O’BRIEN, University of Pennsylvania SANDRA SPRINGER, Yale University Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the content of the proceedings nor did they see the final draft before its release. The review of this proceedings was overseen by HUGH H. TILSON, University of North Carolina. He was responsible for making certain that an independent examination of this proceedings was carried out in accordance with standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the rapporteur and the National Academies. vii PREPUBLICATION COPY—Uncorrected Proofs

Contents ACRONYMS AND ABBREVIATIONS xiii MEDICATIONS xv 1 INTRODUCTION 1 Workshop Objectives, 2 Charge to the Workshop Attendees, 3 Organization of the Proceedings, 7 2 THE SCOPE OF THE PROBLEM 9 Geography of Infectious Diseases Related to the Opioid Epidemic, 9 Modeling the Prevention of Infectious Diseases Among People Who Inject Drugs, 25 Economic Implications of Treatment Programs, 36 Perspectives of Patients and Providers, 42 References, 49 3 EXPLORING OPPORTUNITIES FOR, AND BARRIERS TO, TREATMENT AND PREVENTION IN PUBLIC HEALTH, HOSPITALS, AND RURAL AMERICA 53 Role of Public Health Departments, 53 Improving Care for Hospitalized Adults with Substance Use Disorder, 69 ix PREPUBLICATION COPY—Uncorrected Proofs

x CONTENTS Exploring Challenges and Opportunities in Rural America, 77 Panel Discussion, 84 References, 93 4 EXPLORING OPPORTUNITIES IN CORRECTIONAL HEALTH, LAW, AND LAW ENFORCEMENT 95 Correctional Health and the Opioid Epidemic, 95 Using Law to Address Addiction and Its Consequences, 101 Opportunities for Law Enforcement and First Responders, 107 Panel Discussion on Law and Law Enforcement, 112 References, 116 5 RESEARCH DIRECTIONS, POLICY INITIATIVES, AND POTENTIAL WAYS FORWARD 121 Research Directions and Policy Initiatives, 121 Roundtable Discussion, 128 Presentations by Session Rapporteurs, 131 Potential Ways Forward, 133 Final Remarks, 137 APPENDIXES A Workshop Agenda 139 B Speaker and Planning Committee Member Biosketches 143 C Statement of Task 157 PREPUBLICATION COPY—Uncorrected Proofs

Boxes and Figures BOXES 1-1 Impact of the Opioid Epidemic on Women, 6 2-1 Network Effects in Hepatitis C Treatment Targeting Specific People Who Inject Drugs, 30 2-2 Incremental Cost-Effectiveness Ratio, 37 2-3 Veda Moore’s Story, 45 3-1 Misperceptions Around One-to-One Needle Exchange, 55 3-2 Case Example of a Patient with Opioid Use Disorder, 70 3-3 Multiple Epidemics in West Virginia, 88 4-1 Ensuring the Safety of Responding Police Officers, 109 4-2 Personal Stories of “Not My Child” Panelists, 111 5-1 Highlights from Session Rapporteur Presentations, 131 5-2 What Is This All About?, 136 FIGURES 2-1 Number of persons living with diagnosed HIV attributed to injection drug use (2014), 13 2-2 Incidence of reported acute hepatitis C in the United States (1982– 2008), 16 xi PREPUBLICATION COPY—Uncorrected Proofs

xii BOXES AND FIGURES 2-3 Incidence of acute hepatitis C by age group in the United States (2000–2015), 17 2-4 Estimated hepatitis C antibody prevalence rate per 100,000 persons (2010), 18 2-5 Age-adjusted drug overdose death rates by opioid category, United States (1999–2016), 20 2-6 Rebound in chronic HCV prevalence if HCV treatment is halted after achieving a 90 percent decrease in prevalence or incidence in 2030, 29 2-7 Estimated number of transmissions among individuals in U.S. care cascade (2009), 31 2-8 Effect of HCV screening and treatment on new HCV infections in the community, 34 2-9 Efficiency frontier of HIV prevention packages, 40 2-10  Effect of substance disorders on medical and behavioral health expenditures by age group, 41 3-1 Overdose deaths by opioids in San Francisco (2006–2016), 63 3-2 Opioid-related hospitalizations in the United States (2005–2014), 71 3-3 Increasing rates of infectious diseases in the rural South, 78 3-4 U.S. counties with physicians with waivers to prescribe buprenorphine, 81 4-1 Opioid euphoria and withdrawal, 98 4-2 Opioid effect versus log dose for opioid agonist, partial agonist, and antagonist, 99 4-3 Distribution of Kentucky counties with needle exchange programs and high infectious disease risks, 104 4-4 Cycle of implementation science, 106 5-1 The Patient-Centered Outcomes Research Institute’s complementary role, 125 PREPUBLICATION COPY—Uncorrected Proofs

Acronyms and Abbreviations ACA Patient Protection and Affordable Care Act ACO accountable care organization AHRQ Agency for Healthcare Research and Quality ART antiretroviral therapy ASAM American Society of Addiction Medicine CDC Centers for Disease Control and Prevention CER clinical effectiveness research CMS Centers for Medicare & Medicaid Services CROI Conference on Retroviruses and Opportunistic Infections DOPE Drug Overdose Prevention and Education DUHI Drug User Health Initiative ED emergency department HBV hepatitis B virus HCUP Healthcare Cost and Utilization Project HCV hepatitis C virus HHS Department of Health and Human Services HIV human immunodeficiency virus HRSA Health Resources and Services Administration xiii PREPUBLICATION COPY—Uncorrected Proofs

xiv ACRONYMS AND ABBREVIATIONS ICER incremental cost-effectiveness ratio IDSA Infectious Diseases Society of America IDU injection drug use IMPACT Improving Addiction Care Team MAT medication(s) for addiction treatment (or therapy); medication-assisted therapy (or treatment) MERT medically enhanced residential treatment MOUD medications for opioid use disorder MSM men who have sex with men NHANES National Health and Nutrition Examination Survey NIS Nationwide Inpatient Sample NOSE Naloxone prescription for Opioid Safety Evaluation NSP needle services program OAT opiate agonist therapy OHSU Oregon Health & Science University OWH HHS Office on Women’s Health PCORI Patient-Centered Outcomes Research Institute PDMP prescription drug monitoring program PICC peripherally inserted central catheter PrEP preexposure prophylaxis PWID people who inject drugs PWUD people who use drugs RODS rapid opioid dependence screen SAMHSA Substance Abuse and Mental Health Services Administration SEP syringe exchange program SFDPH San Francisco Department of Public Health SSP syringe services program SUD substance use disorder WWID women who inject drugs WWUD women who use drugs PREPUBLICATION COPY—Uncorrected Proofs

Medications Term Definition Buprenorphine A partial opioid agonist Naloxone (also known as An opioid agonist naltrexone) Suboxone Trade name for a combination of buprenorphine and naloxone Vivitrol Trade name for an extended release form of naltrexone xv PREPUBLICATION COPY—Uncorrected Proofs

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According to the Centers for Disease Control and Prevention (CDC), 115 Americans die each day from an opioid overdose, which averages one death every 12.5 minutes. Between 1999 and 2016, the number of drug overdoses catapulted by 300 percent, with injection drug use increasing by 93 percent between 2004 and 2014 and opioid-related hospital admissions increasing by 58 percent over the past decade. And an inexorable sequela of the opioid epidemic is the spread of infectious diseases.

To address these infectious disease consequences of the opioid crisis, a public workshop titled Integrating Infectious Disease Considerations with Response to the Opioid Epidemic was convened on March 12 and 13, 2018, by the National Academies of Sciences, Engineering, and Medicine. Participants discussed strategies to prevent and treat infections in people who inject drugs, especially ways to work efficiently though the existing public health and medical systems. This publication summarizes the presentations and discussions from the workshop.

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