Integrating Responses
at the Intersection of
Opioid Use Disorder
and Infectious Disease
Epidemics

PROCEEDINGS OF A WORKSHOP

Anna Nicholson, Rapporteur

Board on Population Health and Public Health Practice

Health and Medicine Division

THE NATIONAL ACADEMIES PRESS
Washington, DC
www.nap.edu

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: 978-0-309-47794-9
International Standard Book Number-10: 0-309-47794-8
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 disease epidemics: Proceedings of a workshop. Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/25153.

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, Yale School of Medicine; Director, Infectious Disease Outpatient Clinic–Newington, and Attending Physician–West Haven, Veterans Affairs Connecticut Healthcare System, Newington

DACE SVIKIS, Deputy Director, Institute for Women’s Health, Virginia Commonwealth University

CHUCK WEXLER, Executive Director, Police Executive Research Forum

Health and Medicine Division Staff

KATHLEEN STRATTON, Scholar, Study Director

HOPE HARE, Administrative Assistant

ALEXIS WOJTOWICZ, Senior Program Assistant

ROSE MARIE MARTINEZ, Senior Director, Board on Population Health and Public Health Practice

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¹ The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published Proceedings of a Workshop rests with the workshop rapporteur and the institution.

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Reviewers

This Proceedings of a Workshop was reviewed in draft form by individuals 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, Engineering, 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 comments and draft manuscript remain confidential to protect the integrity of the process.

We thank the following individuals for their review of this proceedings:

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 School of Public Health. 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.

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Contents

ACRONYMS AND ABBREVIATIONS

MEDICATIONS

1 INTRODUCTION

Workshop Objectives

Charge to the Workshop Attendees

Organization of the Proceedings

2 THE SCOPE OF THE PROBLEM

Geography of Infectious Diseases Related to the Opioid Epidemic

Modeling the Prevention of Infectious Diseases Among People Who Inject Drugs

Economic Implications of Treatment Programs

Perspectives of Patients and Providers

References

3 EXPLORING OPPORTUNITIES FOR, AND BARRIERS TO, TREATMENT AND PREVENTION IN PUBLIC HEALTH, HOSPITALS, AND RURAL AMERICA

Role of Public Health Departments

Improving Care for Hospitalized Adults with Substance Use Disorder

Exploring Challenges and Opportunities in Rural America

Panel Discussion

References

4 EXPLORING OPPORTUNITIES IN CORRECTIONAL HEALTH, LAW, AND LAW ENFORCEMENT

Correctional Health and the Opioid Epidemic

Using Law to Address Addiction and Its Consequences

Opportunities for Law Enforcement and First Responders

Panel Discussion on Law and Law Enforcement

References

5 RESEARCH DIRECTIONS, POLICY INITIATIVES, AND POTENTIAL WAYS FORWARD

Research Directions and Policy Initiatives

Roundtable Discussion

Presentations by Session Rapporteurs

Potential Ways Forward

Final Remarks

APPENDIXES

A Workshop Agenda

B Speaker and Planning Committee Member Biosketches

C Statement of Task

Boxes and Figures

BOXES

1-1 Impact of the Opioid Epidemic on Women

2-1 Network Effects in Hepatitis C Treatment Targeting Specific People Who Inject Drugs

2-2 Incremental Cost-Effectiveness Ratio

2-3 Veda Moore’s Story

3-1 Misperceptions Around One-to-One Needle Exchange

3-2 Case Example of a Patient with Opioid Use Disorder

3-3 Multiple Epidemics in West Virginia

4-1 Ensuring the Safety of Responding Police Officers

4-2 Personal Stories of “Not My Child” Panelists

5-1 Highlights from Session Rapporteur Presentations

5-2 What Is This All About?

FIGURES

2-1 Number of persons living with diagnosed HIV attributed to injection drug use (2014) from a state-level perspective and a county-level perspective

2-2 Incidence of reported acute hepatitis C in the United States (1982–2008)

2-3 Incidence of acute hepatitis C by age group in the United States (2000–2015)

2-4 Estimated hepatitis C antibody prevalence rate per 100,000 persons (2010)

2-5 Age-adjusted drug overdose death rates by opioid category, United States (1999–2016)

2-6 Rebound in chronic HCV prevalence if HCV treatment is halted after achieving a 90 percent decrease in prevalence or incidence in 2030

2-7 Estimated number of transmissions among individuals in U.S. care cascade (2009)

2-8 Effect of HCV screening and treatment on new HCV infections in the community

2-9 Efficiency frontier of HIV prevention packages

2-10 Effect of substance disorders on medical and behavioral health expenditures by age group

3-1 Overdose deaths by opioids in San Francisco (2006–2016)

3-2 Opioid-related hospitalizations in the United States (2005–2014)

3-3 Increasing rates of infectious diseases in the rural South

3-4 U.S. counties with physicians with waivers to prescribe buprenorphine

4-1 Opioid euphoria and withdrawal

4-2 Opioid effect versus log dose for opioid agonist, partial agonist, and antagonist

4-3 Distribution of Kentucky, Ohio, and West Virginia counties with needle exchange programs and high infectious disease risks (January 2017)

4-4 Cycle of implementation science

5-1 The Patient-Centered Outcomes Research Institute’s complementary role

Acronyms and Abbreviations

Medications¹

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¹ This text was revised after prepublication release.

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