National Academies Press: OpenBook
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Opportunities to Improve Opioid Use Disorder and Infectious Disease Services: Integrating Responses to a Dual Epidemic. Washington, DC: The National Academies Press. doi: 10.17226/25626.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Opportunities to Improve Opioid Use Disorder and Infectious Disease Services: Integrating Responses to a Dual Epidemic. Washington, DC: The National Academies Press. doi: 10.17226/25626.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Opportunities to Improve Opioid Use Disorder and Infectious Disease Services: Integrating Responses to a Dual Epidemic. Washington, DC: The National Academies Press. doi: 10.17226/25626.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Opportunities to Improve Opioid Use Disorder and Infectious Disease Services: Integrating Responses to a Dual Epidemic. Washington, DC: The National Academies Press. doi: 10.17226/25626.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Opportunities to Improve Opioid Use Disorder and Infectious Disease Services: Integrating Responses to a Dual Epidemic. Washington, DC: The National Academies Press. doi: 10.17226/25626.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Opportunities to Improve Opioid Use Disorder and Infectious Disease Services: Integrating Responses to a Dual Epidemic. Washington, DC: The National Academies Press. doi: 10.17226/25626.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Opportunities to Improve Opioid Use Disorder and Infectious Disease Services: Integrating Responses to a Dual Epidemic. Washington, DC: The National Academies Press. doi: 10.17226/25626.
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Page viii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Opportunities to Improve Opioid Use Disorder and Infectious Disease Services: Integrating Responses to a Dual Epidemic. Washington, DC: The National Academies Press. doi: 10.17226/25626.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Opportunities to Improve Opioid Use Disorder and Infectious Disease Services: Integrating Responses to a Dual Epidemic. Washington, DC: The National Academies Press. doi: 10.17226/25626.
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Page R9
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Opportunities to Improve Opioid Use Disorder and Infectious Disease Services: Integrating Responses to a Dual Epidemic. Washington, DC: The National Academies Press. doi: 10.17226/25626.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Opportunities to Improve Opioid Use Disorder and Infectious Disease Services: Integrating Responses to a Dual Epidemic. Washington, DC: The National Academies Press. doi: 10.17226/25626.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Opportunities to Improve Opioid Use Disorder and Infectious Disease Services: Integrating Responses to a Dual Epidemic. Washington, DC: The National Academies Press. doi: 10.17226/25626.
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Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

OPPORTUNITIES TO IMPROVE OPIOID USE DISORDER AND INFECTIOUS DISEASE SERVICES: INTEGRATING RESPONSES TO A DUAL EPIDEMIC Committee on the Examination of the Integration of Opioid and Infectious Disease Prevention Efforts in Select Programs Board on Population Health and Public Health Practice Health and Medicine Division A Consensus Study Report of PREPUBLICATION COPY: UNCORRECTED PROOFS

THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001 This activity was supported by a contract 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-XXXXX-X International Standard Book Number-10: 0-309-XXXXX-X Digital Object Identifier: https://doi.org/10.17226/25626 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 2020 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. 2020. Opportunities to improve opioid use disorder and infectious disease services: Integrating responses to a dual epidemic. Washington, DC: The National Academies Press. https://doi.org/10.17226/25626. PREPUBLICATION COPY: UNCORRECTED PROOFS

The National Academy of Sciences was established in 1863 by an Act of Congress, 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 advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. John L. Anderson 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 advice 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 Medicine at www.nationalacademies.org. PREPUBLICATION COPY: UNCORRECTED PROOFS

Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typically 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 opinions 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

COMMITTEE ON THE EXAMINATION OF THE INTEGRATION OF OPIOID AND INFECTIOUS DISEASE PREVENTION EFFORTS IN SELECT PROGRAMS CARLOS DEL RIO (Chair), Hubert Professor and Chair, Hubert Department of Global Health, Rollins School of Public Health, Emory University, and Professor of Medicine, Emory University School of Medicine JULIE A. BALDWIN, Director, Center for Health Equity Research, Northern Arizona University EDWIN CHAPMAN, Medical Director, Medical Home Development Group, LLC HANNAH COOPER, Chair, Substance Use Disorders, Rollins School of Public Health, Emory University DAVID GUSTAFSON, Professor Emeritus, Industrial and Systems Engineering, University of Wisconsin–Madison HOLLY HAGAN, Professor and Codirector, Center for Drug Use and HIV/HCV Research, New York University College of Global Public Health ROBIN P. NEWHOUSE, Distinguished Professor and Dean, Indiana University School of Nursing JOSIAH “JODY” D. RICH, Professor of Medicine and Epidemiology, Brown University SANDRA SPRINGER, Associate Professor of Medicine, Yale School of Medicine DAVID L. THOMAS, Chief, Division of Infectious Diseases, Johns Hopkins University School of Medicine National Academy of Medicine Gilbert S. Omenn Fellow ELLEN F. EATON, Assistant Professor of Infectious Diseases, Department of Medicine, University of Alabama–Birmingham Study Staff ANDREW MERLUZZI, Associate Program Officer ANNA MARTIN, Administrative Assistant MISRAK DABI, Financial Business Partner ROSE MARIE MARTINEZ, Study Director PREPUBLICATION COPY: UNCORRECTED PROOFS v

Reviewers This Consensus Study Report 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 report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We thank the following individuals for their review of this report: OLUWASEUN FALADE-NWULIA, Johns Hopkins University School of Medicine RAHUL GUPTA, March of Dimes ELLEN MEARA, The Dartmouth Institute for Health Policy & Clinical Practice Geisel School of Medicine BETH MEYERSON, University of Arizona SARA ROSENBAUM, The George Washington University Milken Institute School of Public Health JEANETTE TETRAULT, Yale School of Medicine HANSEL TOOKES, University of Miami Miller School of Medicine JUSTINE WALDMAN, Reach Medical, PLLC Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report, nor did they see the final draft before its release. The review of this report was overseen by ANTONIA M. VILLARRUEL, University of Pennsylvania, and ELAINE L. LARSON, Columbia University. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies. PREPUBLICATION COPY: UNCORRECTED PROOFS vii

Contents PREFACE xi SUMMARY S-1 1 INTRODUCTION 1-1 2 SCOPE OF THE PROBLEM 2-1 3 BARRIERS TO INTEGRATION 3-1 REFERENCES R-1 APPENDIXES A CASE STUDIES OF SELECT PROGRAMS A-1 B PUBLIC MEETING AGENDAS B-1 C COMMITTEE BIOGRAPHICAL SKETCHES C-1 PREPUBLICATION COPY: UNCORRECTED PROOFS ix

Preface Opioid use and infectious diseases are intertwined epidemics. Despite the fact that the United States is more than two decades into the opioid crisis—the cause of tens of thousands of deaths every year on its own—the health system has not sufficiently addressed the morbidity and mortality of drug use coupled with infectious diseases. This is at least in part due to traditional models of substance use disorder care wherein substance use disorder treatment is delivered independently of other medical care, thereby inhibiting the delivery of comprehensive care. As a result, the United States is experiencing a drastic increase in infectious diseases that spread with drug use. This context places the importance of integrating services for opioid use disorder and infectious disease in stark relief. Preventing and treating opioid use disorder can improve outcomes for patients with infectious diseases. At the same time, identifying and treating infectious diseases can minimize harm by decreasing the risk that the diseases will spread. Yet, as this Consensus Study Report describes, significant barriers remain to integrating services for this dual epidemic. The committee authoring this report gathered evidence from 11 programs throughout the United States seeking to integrate their services for opioid use disorder and infectious diseases, as well as from the broader literature. The resulting evidence pointed toward a set of barriers to integration: policies at the federal and state levels, stigma, workforce needs, and lack of adherence to the best available evidence continue to prevent effective care from being delivered to patients who need it. With the current rates of infectious disease and opioid use, the cost of inaction is high. Fortunately, there are feasible strategies to address these barriers, as outlined in the committee’s recommendations. As chair, I would like to thank my fellow committee members for their dedication to this study, their novel ideas, and their commitment to improving the public’s health. The committee would also like to express its great appreciation to the Department of Health and Human Services’ Office of Infectious Disease and HIV/AIDS Policy for sponsoring this work, and in particular Corinna Dan and Chinedu Okeke for their consultation. Sincere gratitude is given to the individuals attempting to solve this dual epidemic every day. Through several hours of interviews, informants from the programs featured in this study shared their experiences and informed the committee’s work. Others provided information, presentations, and important perspective to the committee. Their commitment to their patients and to public health is evident throughout this report: Hilary Armstrong, Julie Dombrowski, Brad Finegood, Julia Hood, and Joe Tinsley (King County Department of Public Health); Laura Bamford (Philadelphia FIGHT Community Health Centers); Christopher Bositis (Greater Lawrence Family Health Centers); Jennifer Edelman (Yale School of Medicine); Honora Englander (Oregon Health & Science University); Emma Fabian (Evergreen Health); Judith Feinberg (West Virginia University); Michael Fingerhood (Johns Hopkins University School of Medicine); Aaron Fox (Bronx Transitions Clinic); Jason Halperin and Nick Van Sickels (CrescentCare); Heather Hauck (Health Resources and Services Administration); Sarah Henn (Whitman-Walker Health); Joyce Johnson (Stepworks Recovery Centers); Beth Keeney (LifeSpring Health Systems); Gregory Lucas (Johns Hopkins University School of Medicine); Paula Lum (University of California, San Francisco); Benjamin Oldfield (Yale School of PREPUBLICATION COPY: UNCORRECTED PROOFS xi

xii PREFACE Medicine); Barbara Schott and James Wilson (Plumas County Public Health Agency); Shira Shavit (Transitions Clinic Network); Andrew Talal (University of Buffalo); Steve Tierney (Southcentral Foundation); and Frank Vega (ARCare). The committee could not have completed this report without the guidance and dedication of the National Academies staff who shepherded it through to its conclusion. We thank Rose Marie Martinez, Andrew Merluzzi, Anna Martin, and Rebecca Chevat for their efforts. Carlos del Rio, M.D. (Chair) Committee on the Examination of the Integration of Opioid and Infectious Disease Prevention Efforts in Select Programs PREPUBLICATION COPY: UNCORRECTED PROOFS

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Opioid use and infectious diseases are intertwined epidemics. Despite the fact that the United States is more than two decades into the opioid crisis - the cause of tens of thousands of deaths every year on its own - the health system has not sufficiently addressed the morbidity and mortality of drug use coupled with infectious diseases. This is at least in part due to traditional models of substance use disorder care wherein substance use disorder treatment is delivered independently of other medical care, thereby inhibiting the delivery of comprehensive care. As a result, the United States is experiencing a drastic increase in infectious diseases that spread with drug use.

Opportunities to Improve Opioid Use Disorder and Infectious Disease Services examines current efforts to integrate care and describes barriers, such as inadequate workforce and training; lack of data integration and sharing; and stigma among people who use drugs and have also been diagnosed with an infectious disease. The conclusions and recommendations of this report will help to promote patient-centered, integrated programs to address this dual epidemic.

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