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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
THE NATIONAL ACADEMIES PRESS â 500 Fifth Street, NW â 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:â 978-0-309-65449-4 International Standard Book Number-10:â 0-309-65449-1 Digital Object Identifier:â 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.
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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 WisconsinâMadison 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 âJODYâ 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 AlabamaâBirmingham Study Staff ANDREW MERLUZZI, Program Officer ANNA MARTIN, Administrative Assistant REBECCA CHEVAT, Senior Program Assistant MISRAK DABI, Financial Business Partner ROSE MARIE MARTINEZ, Study Director v
Reviewers This Consensus Study Report 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 com- ments 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 at the 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 vii
viii REVIEWERS Although the reviewers listed above provided many construc- tive 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 car- ried 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.
Contents PREFACExiii SUMMARY1 1 INTRODUCTION 19 Charge to the Committee and Study Process, 21 The Committeeâs Approach, 24 Organization of the Report, 34 2 SCOPE OF THE PROBLEM 35 Interplay Between Opioid Use Disorder and The Infectious Diseases, 35 National Response to HIV and the Ryan White Care Act, 38 National Opioid Policy and Strategy, 40 Dissociation of Substance Use Treatment from Primary Care and Infectious Disease Treatment, 44 3 BARRIERS TO INTEGRATION 47 Prior Authorization Policies, 47 Data Waiver Requirement, 54 Lack of Data Integration and Sharing, 60 Inadequate Workforce and Training, 69 Stigma, 77 ix
x CONTENTS Payment and Financing Limitations, 83 Same-Day Billing Restrictions, 89 Limits on Harm-Reduction Services, 94 Disconnect Between the Health and Criminal Justice Systems, 100 REFERENCES111 APPENDIXES A Case Studies of Select Programs 135 B Public Meeting Agendas 189 C Committee Biographical Sketches 195
Boxes, Figures, and Tables BOXES S-1 Statement of Task, 3 S-2 Barriers to Integration of Opioid Use Disorder and Infectious Disease Services, 5 1-1 Statement of Task, 22 1-2 Acronyms and Abbreviations, 23 1-3 Assessment of Integrated Services, 28 1-4 Program Characteristics, Services Provided, and Model of Care, 34 3-1 Program Informant Comments on Prior Authorization Policies, 54 3-2 Program Informant Comments on DATA Waiver Requirement, 61 3-3 Program Informant Comments on Lack of Data Integration and Sharing, 67 3-4 Program Informant Comments on the Inadequate Workforce and Training, 78 3-5 Program Informant Comments on Stigma, 84 3-6 Program Informant Comments on Payment and Financing Limitations, 90 3-7 Program Informant Comments on Same-Day Billing Restrictions, 95 xi
xii BOXES, FIGURES, AND TABLES 3-8 Program Informant Comments on Limits on Harm-Reduction Services, 98 3-9 Program Informant Comments on the Disconnect Between the Health and Criminal Justice Systems, 108 A-1 Program Characteristics, Services Provided, and Model of Care, 136 FIGURES 2-1 National drug overdose deaths involving any opioid, number among all ages, by gender, 1999â2017, 36 2-2 Vulnerable counties and jurisdictions experiencing or at risk of outbreaks, 38 2-3 HIV care continuum, 39 2-4 Opioid use disorder care cascade: A proposed OUD care cascade, wherein each stage along the x-axis represents a point of intervention to reduce OUD prevalence and increase care, 43 3-1 State policies on Medicaid enrollment during incarceration, 2018, 105 TABLES A-1 Program Information, 137 A-2 Clinical Outcomes for Whitman-Walker Health Patients, 181
Preface Opioid use and infectious diseases are intertwined epidemics. Despite the fact that the United States is more than two decades into the opioid crisisâthe cause of tens of thousands of deaths every year on its ownâthe 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 diseases in stark relief. Preventing and treat- ing 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 result- ing 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 diseases and opioid use, the cost of inaction is high. Fortunately, there are xiii
xiv PREFACE feasible strategies to address these barriers, as outlined in the committeeâs 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 publicâs health. The committee would also like to express its great appreciation to the Department of Health and Human Servicesâ 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 committeeâs work. Others provided information, presenta- tions, 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 Uni- versity); Michael Fingerhood (Johns Hopkins University School of Medi- cine); 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 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, Chair Committee on the Examination of the Integration of Opioid and Infectious Disease Prevention Efforts in Select Programs