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Introduction

Opioid use disorder (OUD) and other illicit drug epidemics in the United States (Ronan and Herzig, 2016; Rudd et al., 2014, 2016; Ruhm, 2019) have led to concurrent infectious disease epidemics among persons who use drugs, resulting in a burden on the population’s health as a whole (Conrad et al., 2015; Cranston et al., 2019; Fleischauer et al., 2017; Golden et al., 2019; Jackson et al., 2018; Ronan and Herzig, 2016).

The relationship between infectious diseases and substance use is not new. For example, early in the human immunodeficiency virus (HIV) epidemic, it was realized that injection drug use was associated with HIV infection (Des Jarlais et al., 1989). Infectious diseases related to OUD and co-occurring stimulant use disorders include HIV, hepatitis A virus, hepatitis B virus (HBV), hepatitis C virus (HCV), invasive bacterial and fungal infections such as Staphylococcus aureus bacteremia, endocarditis, skin and soft tissue infections, and bone and joint infections (Conrad et al., 2015; Ronan and Herzig, 2016; Schranz et al., 2018; Wurcel et al., 2016; Zibbell et al., 2018).

In 2018, the Centers for Disease Control and Prevention (CDC) identified 220 counties at highest risk of HIV and HCV outbreaks among persons who inject drugs (CDC, 2018b). The counties at greatest risk were mostly rural, and a disproportionate number were within Kentucky, Ohio, Tennessee, and West Virginia. In 2019, HIV clusters were reported in Washington and West Virginia. Likewise, HCV has experienced a resurgence: data from four Appalachian states demonstrated a 364 percent increase in acute HCV infection from 2006 to 2012 among persons younger than 30 years old. The incidence of acute HCV in rural areas was more than

twice that of urban areas (Zibbell et al., 2015). Finally, the unprecedented increase in primary and secondary syphilis reported from 2013 to 2017 has been attributed, at least in part, to increasing methamphetamine and heroin use, along with sexual transmission (Kidd et al., 2019).

Although OUD itself is not communicable, infectious diseases that are easily transmitted among persons who use drugs create suffering and burden the public’s health. Though the United States is nearly three decades into the opioid crisis, there has been a lack of attention to preventing drug-related infections. Substance use has long been stigmatized. Viewed as a marker of poor behavioral choices and impulsivity, it has been segregated from traditional medical care (McLellan and Woodworth, 2014). Historical policies are key drivers of the connection between OUD and infectious diseases. For instance, several states still limit access to sterile syringes without a prescription (Abdul-Quader et al., 2013; amfAR, 2019). “War on drugs” policies incarcerate many people living with substance use disorder (SUD) who need treatment (Moore and Elkavich, 2008). Intensive drug-related surveillance (Cooper et al., 2005), high drug-related arrest rates (Mitchell and Caudy, 2017), and long sentences (Canadian HIV/AIDS Legal Network, 2006) may dissuade people who inject drugs from engaging in harm-reduction practices and services (Jensen et al., 2004; Mosher and Yanagisako, 1991). In addition, traditional models of SUD treatment are delivered without comprehensive prevention, screening, and treatment for infectious diseases (D’Aunno et al., 2014; Frimpong, 2013). As a result, the nation is experiencing an unprecedented number of HIV (Conrad et al., 2015) and viral hepatitis clusters and outbreaks (NIDA, 2018b) among persons who inject drugs. These outbreaks are occurring in both urban and rural locations across the country (CDC, 2018b). Experts believe that opioid injection is a significant obstacle to ending the HIV epidemic (Lerner and Fauci, 2019). Because of similar risk factors and behaviors, opioid injection also undermines national strategies to end viral hepatitis and sexually transmitted infections. A rise in injection drug use that resulted from the opioid epidemic has created a new generation of individuals susceptible to exposure to infectious diseases.

In response to new outbreaks of HIV and viral hepatitis and increasing rates of bacterial infections among persons who use drugs across the country, the president of the United States has called to end the HIV/AIDS (HHS, 2019c) and opioid epidemics (White House, 2018). The United States has also signed the United Nations Sustainable Development Goals, which include combating the epidemic of viral hepatitis. To achieve these goals, it is important to recognize that OUD and infectious diseases are inextricably linked.

Integrating medical services in primary care settings, behavioral health settings, health homes, or any other medical setting (e.g., emergency departments) is a well-recognized strategy for the delivery of comprehensive health

care (SAMHSA, 2019j), the goal of which is to treat patients in a holistic manner. When SUD treatment is moved from a stand-alone clinic to a general medical setting, the emphasis can expand to encompass harm reduction more broadly (a concept explained in more depth later in the introduction) including vaccinations, sexual health care, and preventing and treating infectious diseases. Furthermore, when SUD and infectious disease services are integrated, health care can be simplified, more accessible, and patient-centered. By reducing the number of providers, clinics, and appointments needed, integrated care promotes the delivery of comprehensive services.

There is a growing body of literature demonstrating the value of integrated services for OUD and infectious diseases and that SUD treatment improves infectious disease outcomes (Marks et al., 2018). In particular, there is evidence that medications for OUD (MOUD) approved by the Food and Drug Administration co-administered with antiretroviral therapy (ART) in persons living with HIV and OUD improves HIV viral suppression (Springer et al., 2012, 2018) and reduces the risk of HCV infection (Tsui et al., 2014).¹ Patients are also more likely to comply with treatment, including ART for HIV, when their treatment plan includes MOUD (Lucas et al., 2010). Importantly, persons living with HIV who have an undetectable HIV load do not transmit HIV (Fauci and Marston, 2015). Therefore, it is critical that OUD is treated in persons living with HIV to prevent new infections and similarly critical that OUD is treated in people without HIV to prevent them from contracting the virus (NIDA, 2018c). The same logic applies to patients with HCV, for instance; if medications are taken and a sustained virologic response is achieved, the patient cannot pass on the virus.

At the request of the Department of Health and Human Services’ (HHS’s) Office of Infectious Disease and HIV/AIDS Policy (OIDP), this National Academies of Sciences, Engineering, and Medicine study draws information from 11 programs throughout the United States seeking to integrate OUD and infectious disease services and provides information about related barriers. Furthermore, this study provides OIDP with recommendations to further promote integrated care in an effort to quell the dual epidemics of OUD and infectious diseases.

CHARGE TO THE COMMITTEE AND STUDY PROCESS

Box 1-1 shows the committee’s Statement of Task. 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

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¹ See NASEM (2019) describing the three approved medications for OUD.

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.²

The committee met in February, May, and June 2019 and also held a number of conference calls to continue deliberations. The committee identified programs working to integrate opioid and infectious disease services to include in its review, and National Academies staff conducted semi-structured interviews with program informants. The committee held two data-gathering sessions (May and June 2019) to obtain additional information from program informants and hear from other experts and practitioners in the field. The agendas of the data-gathering sessions can be found in Appendix B. The information provided by presenters and discussions at the data-gathering sessions informed the committee’s deliberations.

To identify programs for inclusion in the committee’s review, suggestions were gathered from OIDP, the Health Resources and Services Administration (HRSA), committee members, and other experts working in OUD or infectious disease services, or both. Twenty-seven programs were considered for inclusion. Per the Statement of Task and preliminary discussions with OIDP, the committee sought to include programs based on the following criteria: diversity in the degree of integration between OUD and infectious disease services (programs that had colocated services but had no concerted integration efforts were excluded, as the Statement of Task called for programs that were achieving integration), geographic diversity (programs from across the United States, including rural and urban settings), and diversity in programs (e.g., community

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² Acronyms and abbreviations used throughout this report are explained in Box 1-2.

health center programs, public health department programs, programs focused on serving criminal-justice-involved patients). Programs that were associated with committee members’ professional activities were excluded to avoid real or perceived conflict of interest.

The committee notes a number of difficulties in identifying programs that met the inclusion criteria. A database of integrated programs does not exist, so the committee took purposeful steps to identify candidates through existing literature and networks of experts; suggestions were gathered from OIDP, committee members, and other experts working in OUD or infectious disease services or both.

Attempts to identify programs in high-risk areas, such as Kentucky, Ohio, Tennessee, and West Virginia, were not successful because these were developing integrated programs as part of research activities but the

integrated programs were not yet functioning. The committee requested assistance from HRSA in identifying rural programs that received Ryan White HIV/AIDS Programs funds for mental health and SUD treatment services and found 10 such programs. National Academies staff reached out to these programs to further explore their eligibility for inclusion; two were included in the committee’s review.

The final programs selected, in consultation with OIDP, were the following:

• ARCare—Little Rock, AR
• King County Department of Public Health—Seattle, WA
• Southcentral Foundation—Anchorage, AK
• Greater Lawrence Family Health Centers—Lawrence, MA
• Plumas County Public Health Agency—Quincy, CA
• LifeSpring Health Systems—Jeffersonville, IN
• CrescentCare—New Orleans, LA
• Evergreen Health—Buffalo, NY
• Bronx Transitions Clinic—Bronx, NY
• Whitman-Walker Health—Washington, DC
• Philadelphia FIGHT Community Health Centers—Philadelphia, PA

The foundation for the report’s conclusions and recommendations came from several sources. A principal source was the semi-structured interviews with the 11 selected programs. Appendix A presents qualitative summaries of these interviews. An additional source of evidence was the literature. National Academies staff and the committee gathered relevant peer-reviewed literature, government documents, testimony, legislation, previous National Academies reports and proceedings, and transcripts from other professional meetings and educational events related to substance use and infectious diseases. This literature is cited throughout this report. In addition, National Academies staff interviewed other experts in the field, including research scientists, public health practitioners, and medical professionals working in or researching OUD and infectious disease services. Where relevant, information collected from these interviews is cited in the report.

THE COMMITTEE’S APPROACH

The following section outlines the committee’s strategy for gathering information from program informants, including the semi-structured interview, focus on the process of integrating services, and emphasis on harm reduction as a guiding principle in this study. In discussions with the committee and staff, OIDP emphasized that barriers to integrated services, rather than clinical outcomes, should be a central component

of the report. Therefore, the committee focused on the procedural and structural barriers to integration. Although the committee sought out a diversity of programs to include in this study, and while common barriers were found across many of the programs, it is possible that—on average—programs at the earlier stages of integration may experience these barriers differently compared to fully integrated programs.³ While not an explicit focus of this study, elucidating how various barriers impact programs at each level of integration should be addressed in future work.

Semi-Structured Interview and Integration Framework

In designing the methodology of this study, the committee determined that two principles should be central. The first was to incorporate a standard and generalizable framework of integration when reviewing the selected programs; this would allow the committee to ask key questions about integration and assess common barriers across programs at various levels of integration. The second was that that the committee should focus on how integration is implemented. Such integration is a nascent innovation, so the committee opted to focus on the processes and barriers to greater integration. This should, ideally, assist future programs in adopting and implementing best practices for service integration, including in cities, states, and regions not represented in the list of programs interviewed for this study.

The committee used the Substance Abuse and Mental Health Services Administration (SAMHSA)-HRSA Center for Integrated Health Solutions (CIHS) framework for guiding its review of the selected programs (Heath et al., 2013). This framework was intended for primary and behavioral health care organizations to improve patient outcomes by providing objective descriptions of integration along a continuum: the “six-level framework can be used for planning; creating a common language to discuss integration, progress, and financing; supporting assessment and benchmarking efforts; explaining integration efforts to stakeholders; and clarifying differences in vision” between otherwise disparate organizations. The framework makes distinctions between “coordinated,” “colocated,” and “integrated” models of care, with examples of how different units within an organization (or across multiple organizations) might be organized when providing care. For instance, at the “coordinated” level, two health care delivery units might have separate electronic medical records, communicate about shared patients, and meet as part of

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³ It is also possible that programs that operate in different settings will experience barriers in different ways. For instance, emergency departments attempting to integrate services may not experience certain barriers in the same way that a medical home does. It is the committee’s view that greater integration can and should occur throughout the health care system, wherein any contact between a patient, provider, or health care organization is an opportunity for holistic, integrated care.

a larger community. A fully integrated system will have the same facility, consistent communication, a shared vision, formal and informal meetings supporting integration, and roles and cultures that blur or blend. These examples of coordination, colocation, and integration guided the committee’s questions of each of the programs and its assessment of where programs fall along the continuum of integrated services. Brief descriptions of the programs and the committee’s judgment on their process of integration are shown in Box 1-3.

With respect to how programs integrate infectious disease and OUD services, the committee was guided by work on how innovations diffuse through organizations (Greenhalgh et al., 2004). The committee used this work to identify aspects of the organizational and external environments that could facilitate progress moving through the stages of integration in the CIHS framework. Specifically, through a semi-structured interview (see Appendix A for an interview guide and case study profiles), information was gathered on each program’s history of integrated services and the services delivered and model of care (see Box 1-4). For both categories, programs were also asked about barriers, including external factors impacting integration. Finally, programs were asked about clinical outcomes, though this was not the focus of the committee’s review.

National Academies staff conducted semi-structured interviews with each program’s informant for approximately 2 hours each. The interviews and programs’ presentations at data-gathering meetings were used to create the case study profiles found in Appendix A and are the basis of the review of the barriers to integrated services described in Chapter 3. Each program was provided an opportunity to review its case study profile for accuracy and submit any needed changes. The committee members used a grounded theory approach (Sbaraini et al., 2011) and their expert judgment as practitioners in the field to determine the primary barriers to integrated services. Using the semi-structured interviews as the data from which to draw out common elements brought up frequently across programs, the committee distilled these elements into the final set of barriers, many of which are similar to previous efforts to study the integration of services, particularly with respect to behavioral health and primary care services (SAMHSA, 2013). For instance, if a number of the programs independently mentioned one particular policy as a barrier to providing integrated services, it was presented as a primary barrier.

Harm-Reduction Approach

Harm reduction refers to a set of principles developed to address substance use and its consequences; it has since been applied to other health behaviors including tobacco use and sexual behavior (Bellis et al., 2002; Ritter and Cameron, 2006; Roche et al., 1997). Lessening the negative

effects of substance use is the primary objective of harm reduction, in contrast to other approaches that prioritize or insist on abstinence. Harm-reduction practices include syringe service programs, PrEP,⁴ condom distribution, supervised consumption sites, and safe injection, safe drug use, and safe-sex education. Harm-reduction practices are evidence based and have been shown to be effective in reducing HIV, HCV, and HBV infections; increasing safe drug use practices; increasing engagement in care, including HIV and HCV care; and treating SUD (Aspinall et al., 2014; Dutta et al., 2012; Hagan et al., 2011; Platt et al., 2016; Strathdee et al., 2006). In fact, a number of studies have demonstrated that harm-reduction programs lead to a net reduction in substance use through active referral to, engagement in, and retention in SUD treatment (Hagan et al., 2000).

Little research has been carried out to explore the role of harm reduction in improving the patient–provider relationship or clinical outcomes. Hawk and colleagues (2017) sought to conceptualize harm reduction as a “philosophy of care” and characterize how it is operationalized in clinical settings. Qualitative interviews with patients and providers were guided by the principles of harm reduction as set forth by Harm Reduction International (HRI), a nongovernmental advocacy organization that promotes the “rights of people who use drugs and their communities through research and advocacy.” HRI’s website lists these principles (HRI, 2019), similar to the principles outlined by the U.S.-based Harm Reduction Coalition (HRC, 2019). Hawk and co-authors (2017) identified six broad themes of harm reduction and examples of how they can be applied to health care settings:

• Humanism: Providers have respect for patients and the decisions they make, providing care without moral judgments.
• Pragmatism: Providers have realistic expectations and support a range of options for reducing harm.
• Individualism: Support is tailored to individual patients’ needs.
• Autonomy: Patients and providers negotiate the best plan of care.
• Incrementalism: Any positive change is acknowledged and reinforced.
• Accountability: Patients are responsible for (and experience) the consequences of their behavior but are given additional chances to improve.

Harm reduction’s emphasis on being nonjudgmental and patient-centered (“meeting patients where they’re at”) was taken as a starting point for the committee’s work, and the committee inquired of program

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⁴ PrEP: A medication that, when taken consistently, can prevent HIV infection.

informants and other experts whether and how a harm-reduction approach to providing care was relevant to integrating OUD and infectious disease services.

ORGANIZATION OF THE REPORT

The remainder of this report addresses the committee’s charge. Chapter 2 provides an overview of the relationship between OUD and infectious diseases, with a particular focus on the historical dissociation between these two types of care and the need for greater integration. Chapter 3 outlines nine barriers to effective integration of OUD and infectious disease services and provides findings from the literature and interviews conducted with 11 programs seeking to provide integrated services, as well as the committee’s recommendations. The list of references is included after Chapter 3. Case studies drawn from interviews are presented in Appendix A, and the public workshop agendas are in Appendix B. Appendix C contains the committee’s biographical sketches.