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Suggested Citation:"Summary." 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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Summary

Epidemics of opioid use disorder (OUD) and other drug disorders have resulted in co-occurring infectious disease epidemics. Diseases that are transmitted among people who use drugs cause suffering and burden the public’s health. The relationship between infectious diseases and substance use is not new. For example, in the 1980s, it was realized that human immunodeficiency virus (HIV) could be transmitted via injection drug use. Today, infectious diseases related to OUD include HIV; hepatitis A, B, and C viruses; and bacterial, fungal, and other infections (transmitted either via injection drug use or risky sexual behaviors).

Despite the fact that the United States is more than two decades into the opioid crisis, the health system has not sufficiently prevented drug-related infections. This is at least in part due to traditional models of substance use disorder (SUD) care wherein SUD treatment is delivered independently of other medical care, thereby preventing the delivery of comprehensive care (e.g., prevention, screening, and treatment for HIV, viral hepatitis, and sexually transmitted infections). At the same time, SUD treatment is not commonly integrated into primary medical care, and specifically within infectious disease care. As a result, the United States is experiencing an unprecedented number of HIV and viral hepatitis outbreaks among those who inject drugs and people who use drugs and engage in risky sexual behaviors. Due to overlapping risk factors, injection opioid use and risky sexual behaviors undermine national strategies to end HIV, viral hepatitis, and other infectious diseases.

Suggested Citation:"Summary." 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.
×

Even well-intentioned policies have exacerbated the link between opioid use and infectious diseases. For instance, prescription drug monitoring programs and other measures to limit access to prescription opioids triggered a transition to heroin and, eventually, injection use among people who had become dependent on prescription pain relievers. At the same time, primary care clinics have not adequately screened, treated, and retained patients in treatment for SUDs. The resulting increase in the number of people who inject drugs has also increased the overall risk of infectious disease outbreaks. Other policies have similarly exacerbated the link between OUD and infectious diseases. For instance, policies that limit access to sterile syringes tend to increase infectious disease risk among people who inject drugs, as do the broad array of “war on drugs” policies that incarcerate individuals rather than connect them to treatment and harm-reduction programs. A number of studies have demonstrated that such programs—especially syringe services—lead to a net reduction in substance use through active referral, engagement, and retention in SUD treatment.

This context places the importance of integrating services (i.e., prevention and treatment) for OUD and infectious diseases in stark relief. There are opportunities to improve the public’s health by integrating treatment of OUD in clinics that treat infectious diseases, focusing on screening and treating infectious diseases in SUD care settings, removing policy barriers to treatment, better integrating care at all points where a patient interacts with the health system, and recognizing that preventing and treating OUD improves prevention and treatment outcomes for infectious diseases. This represents a key strategy to ending this dual epidemic.

Integrating medical services—such as by colocating services, sharing a common vision, and aligning processes—is a well-recognized strategy for the delivery of comprehensive health care. The goals of integration are to improve the experience of care, improve the health of populations, and reduce per capita health care costs. When SUD treatment is moved from a stand-alone clinic to a general medical setting, the emphasis may expand to encompass harm-reduction tactics and principles, including strategies for safer drug use, minimizing risk of overdose, and preventing transmission of infectious diseases. The same is true when primary care services—including infectious disease services—are integrated with SUD prevention and treatment. As this study makes clear, integration will improve both SUD and infectious disease outcomes, as it allows for a more seamless delivery of services between overlapping illnesses. For instance, a growing body of literature demonstrates that treatment for SUD improves infectious diseases outcomes. Patients are more likely to comply with HIV medication regimens, for example, when their treatment plan includes medications for OUD. In this way, removing barriers

Suggested Citation:"Summary." 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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for OUD treatment is, in itself, a process to improve prevention and treatment for infectious diseases. Furthermore, when SUD and infectious disease services are integrated—regardless of the setting—health care can become simpler, more accessible, and patient-centered. By reducing the number of providers, clinics, and appointments needed, integrated care is better for patients.

To identify the barriers to greater integration of OUD and infectious disease services, the Department of Health and Human Services’ Office of Infectious Disease and HIV/AIDS Policy requested that the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine conduct a study on the topic. The study, commenced in October 2018, draws information from 11 programs throughout the United States seeking to integrate services, and provides strategies to reduce the barriers to service integration. The committee’s full Statement of Task is presented in Box S-1.

STUDY PROCESS

The National Academies convened an ad hoc, 10-member interdisciplinary committee that included academicians and medical professionals with expertise in the social determinants of health, health equity, family medicine, epidemiology, addiction medicine, infectious diseases, implementation science, nursing, correctional systems, and public health policy. The report’s scope addresses both OUD and infectious diseases, primarily through the routes of transmission of injection drug use and high-risk sexual behaviors that are common among people who use drugs.

Suggested Citation:"Summary." 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.
×

The foundation for the report’s conclusions and recommendations came from several lines of research. A principal source of information was evidence drawn from semi-structured interviews with 11 programs seeking to integrate OUD and infectious disease services. The interview questions focused on the program’s characteristics and history of integration; services provided and model of care; barriers to integration; and clinical outcomes, when available.

A supplemental literature review was conducted to further explore barriers identified in these interviews. The committee held three open sessions to gather additional information and hear from experts, such as program informants, academicians, and practitioners in the field.

RECOMMENDATIONS

The committee found that many of the barriers programs face when integrating OUD and infectious disease prevention and treatment services relate to factors in the external environment that directly impact service delivery (e.g., federal, state, and local policies). These specific barriers are described in Box S-2 and addressed in more detail in Chapter 3 of the report.

The committee developed a number of recommendations aimed at various actors, all with the intent of reducing the barriers to greater integration of OUD and infectious disease prevention and treatment. Specifically, for each of the aforementioned barriers, the committee recommends taking specific actions at the congressional, federal, and/or state levels; addressing gaps in training and workforce development; or improving practices around care delivery, including in correctional facilities.

Prior Authorization Policies

The committee recognized the importance of policy adjustments at the state and federal levels to better integrate services (particularly because states have jurisdiction over many issues related to care in the absence of federal action). With regard to state Medicaid programs, the committee found evidence from the interviewed programs and from the literature that policies intended to contain costs could often come at the expense of timely, evidence-based care. Prior authorization policies—and other associated requirements such as step therapy, lifetime limits, or the requirement for concurrent psychosocial therapy—imposed by state Medicaid programs and private insurers are one such measure. The committee found that prior authorization policies to prescribe medications for OUD are an administrative burden for providers and prevent medications from reaching patients, thereby both preventing the delivery of holistic, patient-centered care in a timely fashion for patients with concurrent OUD and infectious diseases, as well as increasing the population risk of infectious diseases.

Suggested Citation:"Summary." 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.
×
Suggested Citation:"Summary." 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.
×

Recommendation 3-1: The Centers for Medicare & Medicaid Services (CMS) should withhold approval of a Medicaid state plan amendment from states that require prior authorization for medications to treat opioid use disorder (OUD). Independent of CMS action, states should remove prior authorization requirements for all Food and Drug Administration–approved medications to treat OUD in state Medicaid programs and state-regulated private insurers, allowing providers to prescribe whichever formulation and dose is best for an individual patient and without restrictions such as concurrent psychosocial therapy, step therapy, or lifetime limits.

Drug Addiction Treatment Act Waiver Requirement

Despite the urgency of the opioid crisis, there is a shortage and misdistribution of providers who can prescribe buprenorphine and other medications to treat OUD, thereby increasing the population at risk of contracting infectious diseases and reducing access to care for patients with concurrent infectious diseases and OUD. One contributing factor is the Drug Addiction Treatment Act (DATA) waiver requirement to complete training (8 or 24 hours), which poses a barrier for some providers. Opportunities for training providers independently of the DATA waiver could be made available. Another restriction is the limitation on the number of patients a provider can treat with medications for OUD. In the past, providers have been limited to 30 and 100 patients. In 2016, the allowable limit for certain eligible physicians was increased to 275 patients, though the lower limit remains in place for the first year that a provider is eligible to prescribe.

Recommendation 3-2: Congress should amend Section 303 of the Controlled Substances Act to allow buprenorphine and other medications for opioid use disorder to be prescribed by physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, or certified nurse midwives without undergoing the mandatory training currently required by law, requiring a Drug Addiction Treatment Act waiver, or limiting the number of patients that can be treated.1

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1 The committee notes that clinically relevant training should nonetheless be widely available to trainees and providers, as outlined in the remaining recommendations of this report.

Suggested Citation:"Summary." 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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Pursuant to the DATA 2000, training already exists for providers seeking to prescribe medications for OUD (and is in fact a required training by law for such providers). Though the committee finds that the DATA 2000 is out of step with the current opioid crisis and therefore recommends removing it as a requirement (see Recommendation 3-2), it is nonetheless important that providers are well trained in prescribing medications for OUD and feel comfortable doing so (both to treat the disorder and to reduce the population risk of infectious diseases as well as to treat patients with co-occurring diseases more holistically). As is described in this report, many providers feel that the training they have received through the DATA 2000 waiver is inadequate and clinically irrelevant or that they do not have access to experienced providers for advice. In light of this, the committee recommends that organizations currently offering training should take steps to update their training, ensure trainings are useful and comprehensive, and provide newly trained providers with greater access to experienced peers.

Recommendation 3-3: To improve and expand education and training on medications for opioid use disorder (OUD) and infectious diseases:

  • The Providers Clinical Support System—as the primary federal grantee for training clinicians on evidence-based training, mentoring, and educational resources on medications for OUD—should consult further with practicing providers and amend their training programs to ensure they are clinically relevant and commensurate with the practitioner’s intended role and needs (including for prescribing of medications for OUD), and should prioritize growth of its mentorship system.
  • The Substance Abuse and Mental Health Services Administration should provide additional funding in future grant announcements specifically to expand mentorship networks for providers.

Lack of Data Integration and Sharing

In the course of the committee’s study, data integration and sharing surfaced as an issue that requires additional research. In particular, a greater understanding is needed regarding the balance between loosening and restricting regulations regarding sharing of patient information related to substance use. While 42 CFR Part 2 has undergone revision in recent years, the committee determined there is still confusion surrounding the regulation (e.g., when it does and does not apply and how

Suggested Citation:"Summary." 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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it interacts with the Health Insurance Portability and Accountability Act of 1996). Furthermore, there is significant debate about whether and how changing this regulation would jeopardize patient privacy or allow providers to deliver more coordinated, effective care (particularly for infectious diseases that may be co-occurring with OUD). Engagement with stakeholders and additional research may be required to resolve these issues.

Recommendation 3-4: The Substance Abuse and Mental Health Services Administration (SAMHSA) should either further align 42 CFR Part 2 with the Health Insurance Portability and Accountability Act of 1996 or alter the definition of which specific service delivery programs fall under 42 CFR Part 2. To inform this decision, SAMHSA should formally engage with patients, advocacy groups, the general public, and legal experts to better understand the benefits (e.g., greater data access for providers) and costs (e.g., loss of privacy for patients, danger of uncoordinated care) of changing regulations around sharing of substance use information. This engagement should focus on the effects of allowing disclosures of substance use disorder information for treatment rather than solely for payment, health care operations, audits, and evaluations; on the strengths and weaknesses of informed consent as a method for sharing information; and on clinics’ current data-sharing practices.

Inadequate Workforce and Training

A key theme across programs and the literature on integrated services was the need for more robust training systems and a better-equipped workforce. Because the OUD and infectious disease epidemics are intertwined, it is crucial to have a constellation of workers well versed in how to prevent, manage, and treat both diseases. At a broad level, it is the committee’s view that providers should have educational exposure to OUD and infectious disease prevention and treatment across their careers, from their training in school through their clinical experience and continuing education. This training should be evidence-based, comprehensive, and flexible enough to meet the needs of a diverse population of patients. As programs from this study mentioned, the current silos between OUD and infectious disease clinicians and organizations come at the expense of comprehensive, quality care. To this end, the committee recommends that the Health Resources and Services Administration direct additional resources toward workforce development that breaks down such silos and does so for all providers who would interact with patients struggling with OUD, infectious diseases, or both.

Suggested Citation:"Summary." 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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Recommendation 3-5: In addition to the Opioid Workforce Expansion Program for behavioral health trainees, the Health Resources and Services Administration should fund high-quality, clinically relevant training on the care and management of co-occurring opioid use disorder (OUD) and infectious diseases for clinicians working in a wide variety of settings (e.g., primary care clinics, infectious disease care settings, and other settings that treat people with OUD and related infectious diseases).

Rural areas of the country have experienced some of the highest rates of OUD mortality and morbidity, as well as outbreaks of infectious diseases, and yet access to SUD and infectious disease providers is limited. A number of Health Resources and Services Administration programs could incentivize more providers to work in rural and underserved areas.

Recommendation 3-6: The Health Resources and Services Administration should devote additional resources toward—and more widely promote—programs that incentivize providers (including psychiatrists, health service psychologists, licensed clinical social workers, psychiatric nurse specialists, marriage and family therapists, and licensed professional counselors) to work in rural areas where opioid and infectious disease outbreaks are most likely to occur (one such program is the National Health Service Corps Rural Community Loan Repayment Program, in coordination with the Rural Communities Opioid Response Program within the Federal Office of Rural Health Policy).

Recommendation 3-7: The Health Resources and Services Administration should widen the scope of its Substance Abuse Treatment Telehealth Network Grant Program to support telemedicine approaches for integrating both opioid use disorder and infectious disease services, particularly in rural areas.

The committee notes that there were more than 1,600 opioid treatment programs nationwide in 2018, serving more than 380,000 patients annually. Despite treating thousands of patients with OUD and concurrent infectious diseases, these programs and providers do not frequently provide testing or treatment for a range of infectious diseases. The committee determined that this is a missed opportunity and recommends that efforts should be made to integrate services further by leveraging opioid treatment programs as testing and treatment sites for infectious diseases. Moreover, given that methadone is a proven therapy for treating OUD—and that it has been historically divorced from primary care settings

Suggested Citation:"Summary." 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.
×

for this purpose—the committee seeks to further integrate methadone into primary care settings, thereby allowing patients and providers more options for treating OUD and so reducing the risk of infectious disease transmission. The Controlled Substances Act currently allows methadone to be prescribed for the treatment of OUD only within specially licensed and regulated facilities (opioid treatment programs), but not in office-based medical practices.

Recommendation 3-8: The Department of Health and Human Services should explore policy incentives for providers and clinics to provide a wider array of evidence-based medications for opioid use disorder and to institute universal, opt-out testing and connection to treatment for infectious diseases, especially at methadone-based opioid treatment programs.

Recommendation 3-9: Congress should amend Section 303 of the Controlled Substances Act to permit providers to deliver methadone treatment for opioid use disorder in primary care settings.

The Drug Enforcement Administration (DEA) requires that providers register to prescribe buprenorphine. A $731 fee must be paid to obtain a registration number for a 3-year cycle. Removing financial barriers to obtain a DEA registration number would serve as an incentive for health professionals to independently treat individuals for OUD instead of relying on the registration number of their supervisor or the training hospital. In turn, a greater number of providers able to treat OUD can diminish the overall burden on the population’s health by reducing the risk of infectious diseases (as it has been shown that adherence to treatment for OUD promotes adherence to medication for infectious diseases).

Recommendation 3-10: The Diversion Control Division of the Drug Enforcement Administration should waive the fee associated with gaining a registration number for health professionals (i.e., medical residents, physician assistants, and qualified nurses) in their residencies or soon after their training is finished to incentivize them to gain buprenorphine prescribing authority early in their careers.

The committee concluded that training the next generation of providers with evidence-based practices is also essential to ending the concurring epidemics of OUD and infectious diseases. Training on treatment and case management for co-occurring OUD and infectious diseases was found to be lacking in medical schools, residency programs, physician’s assistant programs, and nursing programs. The Association of American Medical

Suggested Citation:"Summary." 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.
×

Colleges and the American Medical Association are both represented on the Liaison Committee on Medical Education, which is the accrediting body for medical schools and sets standards for accreditation, including for curricular content. The Accreditation Council for Graduate Medical Education—for residency and fellowship programs—and accrediting bodies for nursing and physician assistant programs perform similar functions and can incentivize training programs to improve and expand education on OUD and infectious disease services. While clinician training programs have typically adopted a focus on patient-centered care, the committee concluded that it is important to ensure that trainees are educated on evidence-based, harm-reduction practices. This includes providing low-threshold treatment, recognizing that relapse is common, providing nonjudgmental and non-coercive care, and empowering patients to reduce their use of drugs and use drugs in the safest ways possible. It is the committee’s view that these practices are essential for maintaining patients in care and therefore for treating OUD and reducing risk of infectious diseases.

Recommendation 3-11: To better integrate training on opioid use disorder (OUD) and infectious diseases in health professions training:

  • The Liaison Committee on Medical Education (LCME) should assure that medical students receive practical, clinically relevant, harm-reduction-focused, case-management-based training on OUD and infectious disease assessment, management, and treatment in response to LCME’s curricular content standard 7.5 (societal problems).
  • The Accreditation Council for Graduate Medical Education should, among its common program requirements, require that residents and fellows receive practical, clinically relevant, harm-reduction-focused, case-management-based training on OUD and infectious diseases.
  • The accreditation bodies for nursing education should assure that students receive practical, clinically relevant, harm-reduction-focused, case-management-based training on OUD and infectious disease assessment, management, and treatment through their curricular, programmatic, or competency criteria.
  • The Accreditation Review Commission on Education for the Physician Assistant, Inc. (ARC-PA) should assure that students receive practical, clinically relevant, harm-reduction-focused, case-management-based training on OUD and infectious disease assessment, management, and treatment in response to ARC-PA’s program curriculum standard number B2.08 (social and behavioral sciences).
Suggested Citation:"Summary." 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.
×

Once trainees become part of the workforce, and as new evidence on best care practices is developed, the committee concluded that it is essential that providers maintain an up-to-date knowledge base on best practices to prevent and treat OUD and infectious diseases. Given the severity of the opioid epidemic and the potential for harm-reduction practices to reduce the population’s overall risk of infectious diseases, the committee recommends that professional licensure bodies encourage and support continued education on these topics.

Recommendation 3-12: State medical boards (and equivalent licensing bodies for other health professionals) should encourage providers to take continuing education focused on harm reduction in fulfilling their continuing education requirements.

Stigma

Stigma remains difficult to overcome and was raised by programs as a perennial problem, as was the potential for additional stigma among people who use drugs and have also been diagnosed with an infectious disease. There are several forms of stigma. Self-stigma occurs when a person internalizes negative stereotypes, and social stigma or public stigma refers to negative stereotypes held among the public. Stigma can cause low self-esteem, shame, and hopelessness, which may keep someone from seeking care. The committee identified a need for specific interventions to reduce the stigma surrounding SUDs and infectious diseases, both generally and especially in clinical settings. Provider stigma occurs when providers attribute negative stereotypes to patients with SUDs or infectious diseases, and it can result in different treatment for certain patients. The Substance Abuse and Mental Health Services Administration (SAMHSA) provides a broad range of information, training, and technical assistance to programs and providers related to stigma. As described in this report, some research exists on interventions to reduce stigma, and these interventions should be scaled across systems of care.

Recommendation 3-13: The Substance Abuse and Mental Health Services Administration should support implementation of multi-level, sustainable, evidence-based, and measurable intervention strategies aimed at reducing stigma in clinical settings against people who use drugs, people who inject drugs, and people undergoing treatment with medications for opioid use disorder or who have infectious diseases. Such efforts should be targeted toward a range of health professionals (e.g., counselors, prescribing health professionals, front-desk staff,

Suggested Citation:"Summary." 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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and others) across geographic regions of the United States, and the evaluations and results from these interventions should be made publicly available.

Payment and Financing Limitations

Syringe service programs are an essential piece of a harm-reduction strategy toward integrating responses to OUD and infectious diseases. Currently, syringe service programs face a barrier in that federal funds cannot be used to purchase syringes. This restriction stems from the Consolidated Appropriations Act of 2019 and previous appropriations bills. In addition, a lack of overall funding and barriers at the state level have resulted in too few syringe service programs relative to the national need.

Recommendation 3-14: Congress should ensure that federal funds can be used to purchase injection equipment at syringe service programs.

SAMHSA has provided technical advice to programs on the concepts of integration of primary and behavioral health services. This work could be further expanded via greater technical support to assist programs that are moving to integrate OUD and infectious disease services.

Recommendation 3-15: The Substance Abuse and Mental Health Services Administration should support programs attempting to implement quality care through integrated services (e.g., from colocated services to fully integrated) through grants that provide technical assistance on implementation of integration strategies, while also collecting data to form an evidence base about the best strategies for future integration.

Monitoring and improving services to address the opioid epidemic and co-occurring infectious disease epidemics will require data collection on the OUD care cascade. Similar data collected as part of the HIV care continuum allowed providers and policy makers to monitor progress in addressing the HIV epidemic. Data related to the OUD care cascade would include the number of individuals who are engaged in care, initiate medications for SUD treatment and infectious disease treatment if needed, and remain in treatment 6 months later.

Recommendation 3-16: The Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration and other government funders should require

Suggested Citation:"Summary." 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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that organizations receiving funding for opioid use disorder (OUD) and infectious disease services submit information on a regular basis with data related to the opioid care cascade model and their plans for using the care cascade model to prevent, identify, treat, and promote recovery for patients with OUD.

The mortality rate associated with the opioid epidemic is now higher than that of HIV at its peak, although effective medications exist to treat OUD. Given that infectious diseases are contracted from injection drug use and other risky behaviors associated with drug use, the committee recommends that Congress take action to end the opioid epidemic through a significant increase in prevention, treatment, and recovery services available to people who use drugs. Congressional action to address the HIV epidemic through a comprehensive program—the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act (Pub. L. No. 101-381)—has demonstrated that comprehensive programs can be effective in reducing the overall mortality and morbidity of a nationwide epidemic. Any new services to address the opioid epidemic must therefore be similarly comprehensive, providing wraparound services to support treatment plans and recognizing that OUD and infectious diseases cannot be approached as separate epidemics.

Recommendation 3-17: Congress should authorize and appropriate funding for the Health Resources and Services Administration to comprehensively address the needs of low-income uninsured or under-insured individuals with co-occurring opioid use disorder and infectious diseases. Such an effort should encompass a full range of services—including integration of prevention and treatment services—as well as services that address the social determinants of health (e.g., housing and transportation). Furthermore, the effort should develop clear metrics of success and require participating organizations to report these metrics as a condition for participation. The committee recognizes that policy makers will need to wrestle with program specifics such as the specific services to be covered, coordination with other federal programs, program standards, and eligibility levels.

Any newly implemented services should be premised on the idea that preventing and treating OUD is fundamental to preventing and treating infectious diseases, as the patient populations overlap. This could be done by leveraging existing programs and resources or expanding into new programmatic capabilities where needed.

Suggested Citation:"Summary." 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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Same-Day Billing Restrictions

One issue that programs reported as undermining service integration was the state restrictions on billing for both behavioral and physical health care visits on the same day, referred to as “same-day billing.” Such restrictions, intended to contain costs, often force patients to come back to medical centers on a different day or require that the medical center takes a financial loss on providing same-day care. Many state Medicaid programs (and private insurers) have already taken steps to remove same-day billing restrictions, and it is the committee’s recommendation that the remaining states should amend their policies to allow greater access to treatment for those who need it. While federal guidance does not prohibit same-day billing, the Centers for Medicare & Medicaid Services could use its communication tools, such as an Information Bulletin to state Medicaid programs, to communicate the importance of removing such restrictions in the interest of better integrating OUD and infectious disease services.

Recommendation 3-18: State Medicaid administrators should revise their billing policies to allow for more than one service in a given day (e.g., allow for one physical and one behavioral visit per day; allow multiple providers to bill on the same day for the same patient; or allow the same provider to bill on the same day for different diagnoses, such as opioid use disorder and infectious diseases).

Recommendation 3-19: The Centers for Medicare & Medicaid Services should issue an Information Bulletin to state Medicaid programs, sharing information about how states have removed same-day billing restrictions and highlighting the importance of removing these restrictions for providing integrated care.

Limits on Harm-Reduction Services

As the findings of this study demonstrate, harm-reduction strategies are essential to decrease the risk of infectious diseases and serve as an entry point for treatment for OUD. Health care delivery programs that seek to provide patient-centered care would more effectively achieve this goal by adopting harm-reduction practices and/or connecting patients with harm-reduction practices in their communities.

Recommendation 3-20: Individual clinics, health care programs, and providers should incorporate harm-reduction strategies into both infectious disease and opioid use disorder care, such

Suggested Citation:"Summary." 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.
×

as by linking patients to syringe service programs, distributing naloxone, adopting a harm-reduction philosophy focused on patient-centered care, prescribing pre-exposure prophylaxis, and providing safe drug use and safe-sex education.

The committee recognizes that harm-reduction practices are not as widespread as is necessary to address the dual epidemics of OUD and infectious diseases. The committee concluded that individuals in need should have access to a full suite of evidence-based, harm-reduction services that decrease the risk of infectious disease transmission and serve as an entry point for other medical care and that SAMHSA can spur research on how best to integrate services using harm reduction as a focal point.

Recommendation 3-21: States should lift remaining bans on evidence-based syringe services, offering syringe services at publicly funded health departments and allowing for independently operated syringe service programs.

Recommendation 3-22: The Substance Abuse and Mental Health Services Administration should make available grants for researchers from a broad set of disciplines (medicine, nursing, epidemiology, behavioral science, health policy, and implementation science) to conduct research on the integration of opioid use disorder and infectious disease care under a harm-reduction lens.

Disconnect Between the Health and Criminal Justice Systems

The committee’s findings make clear the opportunities to improve care for patients with OUD and/or infectious diseases, both while incarcerated and following release from criminal justice settings. Formerly incarcerated individuals are especially prone to overdose and may lack connections to infectious disease treatment in the weeks after release. Hence, it is the committee’s conclusion that there is a need for communication and collaboration between correctional systems and medical care organizations to better connect patients with services. In addition, it is the committee’s conclusion that the public’s health would be improved if evidence-based treatment were offered at the time a patient enters a correctional facility.

Recommendation 3-23: Through federal grant funding, state block grants or direct appropriations, states should fund—and correctional facilities should offer—evidence-based screening and treatments for opioid use disorder and co-occurring infectious diseases.

Suggested Citation:"Summary." 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.
×

Recommendation 3-24: Clinics and organizations that treat opioid use disorder and infectious diseases should coordinate with law enforcement and correctional facilities to better track and maintain records of patients entering and exiting the criminal justice system.

The committee also recommends that states place greater focus on individuals recently released from correctional facilities, as opportunities for health are often missed at this stage (including linkage to infectious disease treatment) and the risk of overdose is particularly high in the weeks following release. The committee concluded that correctional facilities have a duty to provide care to individuals who are incarcerated and that the ultimate goal should be to increase the health of currently incarcerated and recently released individuals through reentry programs and connection to harm-reduction systems. In light of this, the committee concluded that states should both eliminate policies counter to this overall goal and institute policies aligned with it. Specifically, states should ensure that individuals exiting the criminal justice system are insured and have access to reentry services that promote health.

Recommendation 3-25: Through federal grant funding, state block grants or direct appropriations, states should fund high-quality, evidence-based reentry services for prisons and jails, including medications for opioid use disorder and infectious diseases, as well as linkage to care in the community and harmreduction services following release (e.g., naloxone to reduce the risk of fatal overdose).

Recommendation 3-26: State Medicaid administrators should adjust policies to ensure that individuals previously enrolled in Medicaid before entering the criminal justice system are automatically re-enrolled at the time they are released.

As these recommendations make clear, there is a great deal to be accomplished at the intersection of OUD and infectious diseases at many points in the health care system, as well as across society more broadly. It is essential to dismantle the barriers impeding prevention and treatment. Patients, families, and society writ large cannot afford delay, and it is the committee’s hope that the strategies outlined here may alleviate the burden of these dual epidemics.

Suggested Citation:"Summary." 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:"Summary." 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:"Summary." 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:"Summary." 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.
×
Page 3
Suggested Citation:"Summary." 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:"Summary." 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:"Summary." 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:"Summary." 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:"Summary." 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:"Summary." 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:"Summary." 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:"Summary." 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:"Summary." 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:"Summary." 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:"Summary." 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:"Summary." 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:"Summary." 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:"Summary." 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:"Summary." 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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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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