1

Introduction

In his welcoming remarks, Admiral Brett Giroir, Assistant Secretary for Health at the Department of Health and Human Services (HHS), recounted a set of sobering statistics that reflect the mounting havoc and devastation that the opioid epidemic wreaks on the lives of people across the country. 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. An inexorable sequela of the opioid epidemic is the spread of infectious diseases, he said. CDC reports that hepatitis C virus (HCV) infections nearly tripled between 2010 and 2015, including an increase in HCV among pregnant women that increased the associated risk of perinatal transmission. Hepatitis B virus (HBV) infections had been decreasing in recent decades, but they increased by 20 percent between 2014 and 2015. Human immunodeficiency virus (HIV) infections among people who inject drugs have increased by 4 percent between 2014 and 2015. Hospitalizations for serious infections associated with opioid use have also quadrupled in the last decade at an added cost of nearly $15 billion to the health care system, according to estimates using data from the Agency for Healthcare Research and Quality. The increase in injection drug use appears to be the main driver for these infections.

Carlos del Rio, Hubert Professor and chair of the Department of

Global Health at the Rollins School of Public Health and professor of medicine in infectious diseases at the Emory University School of Medicine, reflected on his experience in the field of infectious disease, drawing parallels between the HIV epidemic that was emerging when he began his career and the opioid epidemic that the country faces today. Both of these public health crises have a particular impact on younger people, and the crises have been shaped and intensified by social stigma and discrimination. The latter components in the opioid epidemic outstrip the stigma and discrimination faced by people with HIV, he said; many providers will blatantly refuse to treat people whose lives are being destroyed by opioid use disorders. This underscores the need for an integrated response that calls for more than just treating the disease; it warrants close examination to intervene against the social determinants of health that are the epidemic’s underlying drivers, said del Rio. Addiction and its root causes are at the center of the opioid epidemic, and they can no longer be “someone else’s problem,” he warned. This is a critical juncture that offers an opportunity to divert the path of the epidemic’s destructive course, he said, and there are valuable lessons to be gleaned from the response to the HIV epidemic. He tasked workshop attendees with finding ways to move forward and integrate strategies into robust structures that already exist, such as settings for HIV and HCV care.

WORKSHOP OBJECTIVES

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 Board on Population Health and Public Health Practice in the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine. Participants discussed the scope of the problem, giving particular attention to viral hepatitis, HIV, and endocarditis. Attention was given to reducing the infectious disease comorbidities of injection drug use, especially strategies that emphasize empathy, respectful treatment, and patient satisfaction. Attention was also given to the specific impact on women. Speakers at the workshop presented on how the opioid epidemic has changed the epidemiology of infectious disease. In panel and open discussion, 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. Effective novel strategies were also discussed. Attention was paid to strategies that seem realistic, making efficient use of existing resources, as well as those that could not be implemented without additional funds. See Appendix C for the Statement of Task.

The workshop was sponsored by HHS’s Office of HIV/AIDS and Infectious Disease Policy (OHAIDP) and Office on Women’s Health (OWH) and was structured into four sessions held over 1.5 days. The first session addressed the scope of the problem. The second session focused on addressing opportunities for, and barriers to, treatment and prevention programs. The third session featured a roundtable discussion with representatives from two professional societies, the Infectious Disease Society of America and the American Society of Addiction Medicine, as well as a representative from the Patient-Centered Outcomes Research Institute. During the final session, participants discussed potential ways forward in addressing the epidemic. The workshop featured discussions among presenters, panelists, and participants during each session.

In accordance with the policies of the National Academies, the workshop did not attempt to establish any conclusions or develop recommendations about needs and future directions, focusing instead on issues identified by the speakers and workshop participants. In addition, the organizing committee’s role was limited to planning the workshop. This workshop proceedings was prepared by workshop rapporteur Anna Nicholson as a factual summary of what occurred at the workshop.

CHARGE TO THE WORKSHOP ATTENDEES

Quantifying the infectious disease consequences of the opioid epidemic, said Giroir, is merely the first step toward envisioning and implementing an aggressive new agenda to respond to the current crisis while also taking proactive steps to prevent future crises. He asked workshop participants to consider new and innovative ways to deploy the 6,500 members of the U.S. Public Health Service who are dedicated to protecting, promoting, and advancing the health and safety of the nation. Many service members are already stationed in communities of extreme need, working to respond to the opioid epidemic and the infectious disease crises in collaboration with agencies such as the Indian Health Service and the Bureau of Prisons; other commissioned officers are working with the Food and Drug Administration, the National Institutes of Health, and CDC implementing and managing critical programs to support our response to the epidemics. He envisioned the corps as playing an ever-increasing role in the national fight against opioids, infectious disease, and persistent health inequalities.

Giroir urged participants to explore ways to engage the full range of sectors being affected by the opioid epidemic and to find ways to integrate efforts into existing programs as well as to build new programs. Similarly, he suggested leveraging existing tools and services that are known to be effective. CDC statistics estimate that as many as 75 percent

of the new HIV and HCV infections can be prevented through the provision of comprehensive services including counseling, education, HIV and HCV testing, hepatitis A and HBV vaccination, access to sterile syringes, preexposure prophylaxis, and referral to substance use disorder treatment. Effective treatments are also at hand, he said. Treatment of HIV with appropriate regimens, adhered to correctly, can lead to very effective viral suppression that almost eliminates the chance of transmission. New treatments for HCV can result in a complete biological cure of the disease.

His department’s commitment to solving the opioid crisis is underpinned by its five-point plan for improvement in the following areas: better treatment, prevention, and recovery services; better targeting of overdose-reversing drugs; better data on the epidemic; better research on pain and addiction; and better pain management. He explained that OHAIDP leads the implementation and monitoring of the National HIV/AIDS Strategy as well as the National Viral Hepatitis Action Plan. Both of those national plans provide a framework designed to facilitate collaborations across sectors, to improve outcomes among priority populations, and to embark on the path toward eliminating HIV, HBV, and HCV. His office has committed to improving health through enhanced partnerships that extend beyond the academic community to the nonprofit, business, and law enforcement communities.

In his charge to the attendees, Richard Wolitski, director of the HHS OHAIDP, was optimistic that the workshop would represent an inflection point toward a new paradigm that recognizes fully the urgent need for a more inclusive and comprehensive approach that addresses the disastrous consequences of the opioid epidemic and the life-threatening infectious diseases that are intertwined with each other. These infections are shortening the lives of Americans, challenging families and communities, straining service delivery systems, and adding to an already increasing health care cost, he said. He challenged attendees to draw a line of demarcation between the old status quo and this new approach that leverages all available resources to the maximum benefit of the patient. The old approach was defined largely by siloed funding streams and organizational structures that kept responses separate and lacking in force. The new approach should bring to the forefront the needs of people battling opioid use disorder above all else, ensuring them the longest and healthiest lives possible, keeping their families together, and keeping them employed and out of jail. This approach could prevent their immune systems from collapsing, their livers from being destroyed, and their heart valves from failing, he entreated. This new approach should apply whether the client was encountered in an HIV testing program, an emergency room, a drug treatment program, a syringe services program, or the criminal justice system. Wolitski said the new approach should leverage and coordinate

the resources of multiple systems to provide comprehensive services that are responsive to the most urgent needs of the individual and their readiness to make change in one or more aspects of their lives.

The new system envisioned by Wolitski would facilitate the delivery of integrated, coordinated care while minimizing the amount of traveling needed, the number of different appointments required, and the number of times the same information is requested on a stack of intake forms. This coordinated approach builds a relationship with clients over time and extends that relationship to other programs and to other providers. All of those providers should share the common goal of seeing the client and the client’s family live healthier lives that are free of opioid use disorders and infectious diseases. Finally, he said, this new approach should not put the onus entirely on the client to maintain the patient–provider relationship: it should build in ways to retain patients in care, reengage them when they reenter through any entry point, and to find and reach out to patients who have dropped out of care by providing a path to bring them back in when they are ready. Health care systems should be accountable for their ability to retain patients in care for a given period.

Wolitski conceded that developing and implementing such a system will not be easy, but there are precedents for success in integrated care in the numerous HIV programs that have broken down the walls of clinics and have created new interactions and partnerships for information sharing among health care providers, health departments, and community-based organizations that allow people to be retained in care. Other movements are already under way that align with this approach, he added. HHS is undergoing a transformation that includes strategic shifts toward putting people at the center of its programs, making the department more innovative and responsive, generating efficiencies through streamlined processes, and leveraging the power of data. His office coordinates the National HIV/AIDS Strategy and the National Viral Hepatitis Action Plan, which are road maps to fighting these infections that affect more than 5 million Americans. Both plans recognize the importance of addressing the risks of injection drug users, he said, but neither anticipated the overwhelming growth of the opioid epidemic and the destruction that it has left in its wake. Both plans expire in 2020, but new plans are being developed to update them through 2030, he said, so the workshop represents an opportunity to inform those plans. Wolitski concluded his charge by imploring attendees to make the future he described a reality in order to better serve the men, women, and families whose lives have been torn apart at the intersection of these public health crises.

Jessica Tytel of the HHS OWH, speaking on behalf of the office director, Nicole Greene, remarked that the workshop is the latest in a series of collaborations between OHAIDP and OWH that seek to expand the con-

versations around the intersections between infectious diseases, women’s health, and the opioid epidemic. She explained that OWH was established within the office of the HHS Secretary in 1991 to improve the health of American women by advancing and coordinating a comprehensive women’s health agenda throughout HHS. Today, OWH provides national leadership and coordination to improve the health of women and girls through policy, education, and model programs. OWH collaborates on women’s health initiatives across HHS to educate and motivate women and girls to live healthier lives by giving them clear and accurate health information. For 2018, they chose to focus on seven key priority areas: preventing opioid misuse among women and girls, reducing childhood

obesity, addressing mental health issues, promoting health across the life course, reducing health disparities, addressing violence and trauma, and supporting health care services for women. Since 2015, OWH has partnered with public health and medical experts, policy makers, community groups, and women with lived experience to address the specific impact of opioid use on women’s health.

In 2016, OWH convened the first-ever national meeting on opioid use, misuse, and overdose in women, where experts and stakeholders examined issues associated with the opioid crisis focused through the lens of women’s health. The meeting provided an opportunity to foster a national conversation about best practices in opioid use disorder prevention and treatment for women, resulting in a white paper and a final report. Together, those publications highlight the unique aspects of this epidemic and how it affects women across age, race, geography, and income. OWH also works closely with the Substance Abuse and Mental Health Services Administration to develop policies and guidelines for the treatment of pregnant women who use opioids and their substance-exposed infants. These resources include information about the link between opioid use and the risk of viral hepatitis and HIV, and the potentially significant effect on the health of both the mother and the baby. Tytel hoped that the workshop would provide opportunities to gain new insight into how the opioid epidemic affects women’s health across the life course and how it affects their access to health care services (see Box 1-1).

ORGANIZATION OF THE PROCEEDINGS

This Proceedings of a Workshop is organized into five chapters. Chapter 2 focuses on the scope of the problem of opioid use disorder and its associated infectious diseases. Chapter 3 examines opportunities for, and barriers to, treatment and prevention in public health, in hospital settings, and in rural areas. Chapter 4 features presentations and discussions centered on the roles of correctional health, law, and law enforcement in addressing the opioid epidemic. Chapter 5 explores research directions, policy initiatives, and potential ways forward to integrate infectious disease considerations with the response to quell the epidemic and its infectious disease consequences. Throughout the proceedings generic names are used for the medications discussed. A brief description of these medications follows the acronyms and abbreviations list. The use of these medications is referred to in addiction medicine as medication-assisted treatment (or therapy) and as medication for addiction treatment. The proceedings uses these interchangeably, as used by the speaker. The acronym MAT refers to either of those terms.

This page intentionally left blank.