Along with the high rates of opioid-related overdose deaths, the opioid use disorder (OUD) epidemic has led to substantial increases in new cases of hepatitis C virus (HCV) and HIV infection, as well as hospitalizations for other OUD-related infections.1 Between 2002 and 2012, for example, rates of hospitalization for endocarditis, osteomyelitis, epidural abscess, and septic arthritis increased 1.5-, 2.2-, 2.6-, and 2.7-fold, respectively.2
“Optimal treatment of these conditions is often impeded by untreated OUD resulting in long hospital stays, frequent readmissions due to lack of adherence to antibiotic regimens or reinfection, substantial morbidity, and a heavy financial toll on the health care system,” according to a paper published in the Annals of Internal Medicine.1
However, clinicians and facilities that treat infectious diseases often lack the skills or resources needed to engage patients in OUD treatment. “There is thus an urgent need to implement and scale up effective OUD treatment in health care settings to address the intersecting epidemics of OUD and its infectious disease (ID) consequences.”
In a 2018 workshop initiated by the US Department of Health and Human Services, professionals from a wide range of relevant backgrounds (including medicine, research, law, and government) convened to explore these issues and potential solutions. They identified the following 5-point strategy:
- Better addiction prevention, treatment, and recovery services
- Better data
- Better pain management
- Better targeting of overdose reversing drugs
- Better research
To glean additional insights and recommendations regarding this topic, Infectious Disease Advisor interviewed Jessica Meisner, MD, MS, a postdoctoral fellow in the division of infectious diseases at the Hospital of the University of Pennsylvania-Penn Presbyterian in Philadelphia, whose main area of focus is the intersection of the opioid epidemic and infectious disease.
Infectious Disease Advisor: From your perspective, what are some areas in which ID doctors’ knowledge falls short regarding the intersection of ID and the opioid epidemic?
Jessica Meisner, MD: The first need is for ID physicians to recognize that this is an ID problem, and thus we are at the frontline of the opioid epidemic. Patients with substance use disorders, most notably with opiate-abuse, tend to engage in a limited manner with the health system. When these individuals do seek care at a hospital or clinic, it is often when they have an infection. Recognizing that as a window of opportunity is key.
I think most ID physicians already know that 10% of new HIV cases and approximately 50% of new HCV cases are a result of injection drug use.3 There is less knowledge about OUD and its treatment. A lot of people may not realize how high rates of relapse are without medication-assisted treatment. It is often shocking for clinicians to realize that individuals are 9.6-fold more likely to overdose within the first 28 days after a hospital discharge, and yet we often don’t give patients naloxone when we discharge them.4 Also, clinicians need to be comfortable obtaining a detailed drug history and speaking freely about harm reduction strategies with patients.
The ID community has started to take action, though. It was great to see that at IDWeek 2018, held October 3-7 in San Francisco, California, buprenorphine training was offered during the pre-sessions. There were multiple oral presentations on topics related to the opioid epidemic and even more posters on topics such as endocarditis in this population. I’ve met a lot of ID providers who are really passionate about addressing this problem, so I’m hopeful that things will change.
Infectious Disease Advisor: What are potential effects of this lack of awareness?
Dr Meisner: We often keep seeing the same patients come to the hospital and be readmitted or leave against medical advice, and it can be very frustrating or disheartening. And that will keep happening if we are not aware of the real problem. Patients leave against medical advice because they are so uncomfortable from withdrawal symptoms that are not adequately managed or because they are being treated poorly due to possible stigma and biases of healthcare providers.
Lack of awareness or knowledge may lead to patients not being screened for HIV or hepatitis C or B appropriately, or not given appropriate vaccines such as tetanus or hepatitis B. We need to realize that treating the infection is the easy part — we need to address the true underlying cause of infection in this patient population, which is their substance use.
Infectious Disease Advisor: What are some ways in which these knowledge gaps can be addressed?
Dr Meisner: Fortunately, there are already some great ways ID providers can bridge this gap. Getting buprenorphine treatment waived is a huge start. The training lasts 8 hours and is comprehensive. I did the training in person, but it can be completed online as well. [Online training is available through the SAMHSA-funded Providers Clinical Support System https://pcssnow.org.] Being able to offer your HIV, HCV, or endocarditis patients a form of medication-assisted treatment is a great way to integrate and improve care.
Getting involved in a hospital’s or city’s opioid task force is another way to learn about the problem on your local level and see what steps are being taken already. It is also invaluable to talk to and collaborate with other departments — for example, social work, psychiatry, emergency medicine, cardiothoracic surgery — that are seeing this problem. Another idea is to reach out to the syringe exchanges and methadone clinics in your community and see if there is a way to collaborate on pre-exposure prophylaxis (PrEP) programs, as well as HIV and HCV screening and treatment. Often multiple people are interested in or working on the same problem, but they may not yet have been connected to each other.
As a fellow I was presented with another possible mechanism to close those knowledge gaps: I completed a Fellow Immersion Training Program in Addiction Medicine. It was a great training course that taught me not only about addiction, but introducing participants to syringe exchange vans, naloxone training, Alcoholics Anonymous and Narcotics Anonymous meetings, and meetings with people in recovery. Just as important, there was mentorship on conducting research in this field.
Infectious Disease Advisor: What are some of the key lines of research currently being conducted in this area, and what are the remaining needs?
Dr Meisner: There have been many great publications related to understanding how big an effect the opioid epidemic is having in the ID field. This includes understanding the trends and outcomes related to endocarditis, such as in the article published by Dr Asher Schranz in the Annals of Internal Medicine, which examined endocarditis trends in North Carolina.5 There has also been research looking at how hospitals are doing with addiction interventions.6
In terms of HIV and HCV work, there have been studies showing successful treatment outcomes for HCV in people who inject drugs.7 In addition, there have been studies looking at PrEP treatment in this population and barriers and implementation of PrEP.8,9
I think continuing research in these areas is important, but also looking at innovative ways to engage and treat this patient population. I would love to see more research that looks at novel ways to treat systemic bacterial infections in this population or more implementation science research to integrate HCV and HIV care into new environments such as methadone clinics and syringe exchanges.
- Springer SA, Korthuis PT, del Rio C. Integrating treatment at the intersection of opioid use disorder and infectious disease epidemics in medical settings: a call for action after a National Academies of Sciences, Engineering, and Medicine workshop. Ann Intern Med. 2018;169(5):335-336.
- Ronan MV, Herzig SJ. Hospitalizations related to opioid abuse/dependence and associated serious infections increased sharply, 2002-12. Health Aff (Millwood). 2016;35(5):832-837.
- Centers for Disease Control and Prevention. HIV and injection drug use. https://www.cdc.gov/vitalsigns/hiv-drug-use/. Accessed February 8, 2019.
- Merrall EL, Bird SM, Hutchinson SJ. A record‐linkage study of drug‐related death and suicide after hospital discharge among drug‐treatment clients in Scotland, 1996–2006. Addiction. 2013;108(2):377-384.
- Schranz AJ, Fleischauer A, Chu VH, Wu L, Rosen DL. Trends in drug use–associated infective endocarditis and heart valve surgery, 2007 to 2017: a study of statewide discharge data. Ann Intern Med. 2019;170(1):31-40.
- Rosenthal ES, Karchmer AW, Theisen-Toupal J, Castillo RA, Rowley CF. Suboptimal addiction interventions for patients hospitalized with injection drug use-associated infective endocarditis. Am J Med. 2016;129(5):481-485.
- Eckhardt BJ, Scherer M, Winkelstein E, Marks K, Edlin BR. Hepatitis C treatment outcomes for people who inject drugs treated in an accessible care program located at a syringe service program. Open Forum Infect Dis. 2018;5(4):ofy048.
- Biello KB, Bazzi AR, Mimiaga MJ, et al. Perspectives on HIV pre-exposure prophylaxis (PrEP) utilization and related intervention needs among people who inject drugs. Harm Reduct J. 2018;15(1):55.
- Bazzi AR, Drainoni ML, Biancarelli DL, et al. Systematic review of HIV treatment adherence research among people who inject drugs in the United States and Canada: evidence to inform pre-exposure prophylaxis (PrEP) adherence interventions. BMC Public Health. 2019;19(1):31.
This article originally appeared on Infectious Disease Advisor