Combine and Conquer: The Integration of Infectious Disease and Addiction Medicine

This is the second article in a 2-part series on infectious disease and addiction medicine. Click here to read part 1 of this series.

With infectious disease (ID) physicians increasingly treating drug-use associated infections, some have begun to incorporate addiction management into their practices rather than limiting their role to treatment of the associated infectious complications. This shift in clinical practice has important public health implications for both infection control and addiction recovery.¹

In a paper published in 2020 in Clinical Infectious Diseases, physicians from Yale University, Boston University, and the University of Miami aimed to “give a name and define the role of these ID/addiction dual specialists… in clinical care, health administration, and research, as well as provide recommendations to bolster the supply and reach of this burgeoning subspecialty.”¹

The paper outlines a range of strategies needed to expand the field of ID/addiction medicine, including increasing opportunities for cross-disciplinary training programs and combined ID/addiction medicine fellowship programs. The authors also provided recommendations for actions needed at the level of ID physicians (eg, joint ID/addiction case conferences and grand rounds), at the ID society level (eg, inclusion of dual specialists on relevant guidelines committees), and at the research level (eg, encouraging application for funding by the National Institute on Drug Abuse and the National Institute of Allergy and Infectious Diseases).

We interviewed lead author David Phillip Serota, MD, MSc, assistant professor of clinical medicine in the division of infectious diseases at the University of Miami Miller School of Medicine, as well as Kinna Thakarar, DO, MPH, assistant professor of medicine at Maine Medical Center at Tufts University School of Medicine in Portland, Maine, and board-certified physician in internal medicine, infectious diseases, and addiction medicine, to discuss the growing area of dual specialization in ID and addiction medicine.

What prompted you and your colleagues to highlight the topic of dual specialization in ID and addiction medicine in your 2020 paper, and what changes have occurred since the paper was published?

Dr Serota: Although it might not be readily apparent to a lot of people, there is a tremendous amount of overlap between infectious diseases and substance use disorders (SUD). For ID clinicians, this overlap is highlighted on a daily basis as we care for patients hospitalized with infectious complications of drug use. I became interested in the idea of ID physicians treating SUD out of a feeling of helplessness as an ID fellow. We could tinker with antibiotics for these patients, but I felt powerless to help them with the underlying problems that led to their infection. 

Since publication of the viewpoint, my thinking has evolved and expanded beyond what I think was a more simplistic view that “addiction is a disease” and if we “treat addiction” then infectious disease harms will be mitigated. A lot of the medical care I provide now is through a syringe services program (SSP), which has expanded my understanding of the spectrum of drug use and the challenges faced by people who inject drugs (PWID).

I see harm reduction as the primary tool for helping to treat or prevent infections among PWID.² In some cases, this involves using medications to help people use drugs less or more safely. In other cases, it involves helping protect them from the stigma of the healthcare system while still taking care of their health needs in a culturally competent manner. All of this is grounded in an understanding of the social determinants of health and how these determinants contribute to negative health outcomes for PWID. 

Why is it important to increase the number of subspecialists providing both ID and addiction care?

Dr Thakarar: As ID providers, we are uniquely qualified to treat infectious diseases and SUDs. Similar to HIV infection, ID providers understand the need to address underlying psychosocial needs, as well as the need for integrated care for a patient population that is often stigmatized.

Not only are we seeing increases in infectious complications of drug use, such as infective endocarditis (IE) or other serious infections, we are in the middle of an overdose crisis. We have reached an all-time high in overdose deaths in the United States, with overdose death rates highest among individuals who are Black and those of American Indian/Alaska native ancestry.³ These inequities must be addressed, and we are in a position to do so.

Results from several studies have shown that the integration of ID and SUD treatment is cost-effective and improves both ID and SUD outcomes.^1,4 While meeting clinical needs is obviously important, I also think it’s important that we prioritize research in this field and use our voices to advocate for our patients, both locally and nationally. We need more subspecialists providing both ID and addiction care, not only because it is best for patient care but it is also simply the right thing to do.

How did you come to develop this subspecialty in ID and addiction?

Dr Thakarar: I think this subspecialty developed naturally as a response to meeting the underlying needs of patients who are often neglected by society. I remember during ID fellowship caring for a younger patient with IE and other various complications; he was hospitalized nearly 2 months. After finally being deemed medically stable, he was discharged to a skilled nursing facility. However, his methadone had been tapered off, and his underlying SUD had not been addressed.

Unfortunately, he was readmitted with prosthetic valve endocarditis, and I remember there was controversy about whether he “deserved” to undergo another cardiac procedure. I just remember being horrified by the whole situation. If someone with a diabetic foot infection were discharged from the hospital without insulin and readmitted with osteomyelitis, would their care be denied, or would they be stigmatized in the same way? Probably not.

And so, what can be done? Well, for this particular patient, we developed an informal version of a “Bridge” clinic, in which after his second hospitalization, he followed up in the ID clinic for outpatient parental antibiotic treatment as well as [SUD] treatment. The ID clinic managed his buprenorphine/naloxone prescription and helped him establish care with a primary care physician who eventually assumed management of his buprenorphine/naloxone regimen.

Broadly, what might a dual specialty approach look like in clinical practice?

Dr Serota: In 2020, the national academies of sciences, engineering, and medicine released a report highlighting the need and rationale for integrated ID and SUD care.⁵ The report also highlights existing models of care, including providing medications for opioid use disorder through HIV primary care clinics, and providing treatment for HIV and hepatitis C infection in [SUD] treatment programs. There are many opportunities to integrate SUD prevention, treatment, and harm reduction into ID care. 

Dr Thakarar: In clinical practice, some ID/addiction subspecialists may spend their time managing antimicrobials and/or [SUD] treatment. For some patients hospitalized with infectious complications from drug use, they may not be interested in engaging in SUD treatment. In practice, that also means ID providers taking a harm reduction approach to care, [such as] openly discussing safer [substance] use, helping to link people to appropriate resources such as SSPs, and offering pre-exposure prophylaxis, vaccinations, naloxone, etc.

Being an ID/addiction specialist could also involve playing an active role in multidisciplinary teams such as endocarditis teams, which also improve patient outcomes. On the outpatient side, ID/addiction specialists can integrate [SUD] treatment into their ambulatory practices, [including] HIV, hepatitis and/or outpatient parental antibiotic treatment clinics, or even mobile clinics. This type of practice could involve prescribing appropriate treatment for opioid, alcohol, tobacco, or other types of SUDs.

And of course, engaging trainees in ID/addiction topics is another important aspect for providers in academia. Every year at Maine Medical Center, for example, we have local community partners — some of whom have lived experience — interact with residents, fellows, and trainees and teach them about safer [substance] use practices and talk about topics like stigma. These sessions are always well received. In addition, through the Bridge program, trainees also learn how to treat hepatitis C, for example, but also treat underlying [SUDs].

What are recommendations for ID clinicians interested in integrating addiction care into their practices?

Dr Thakarar: Even starting simply, such as prescribing naloxone, promoting harm reduction approaches, and becoming familiar with preferred/less stigmatizing language in the addiction field is a great place to start. Partnering with community organizations is also crucial, and as providers, I think we have a lot to learn from our community partners.

In terms of integrating treatment, there are many helpful training resources ranging from the American Society for Addiction Medicine’s 1-hour buprenorphine mini-course to other education and training opportunities through the Providers Clinical Support System, for example. For those interested in becoming board certified in addiction medicine, the American Board of Preventive Medicine has a practice-based pathway so that ID providers can sit for the addiction medicine boards. At this time, providers can also apply for a buprenorphine waiver and treat up to 30 patients without required training activities.⁶

The ID/addiction field is also a very collaborative environment; in my experience, colleagues have been more than willing to share protocols, procedures, and other resources. From a practical standpoint, gaining support of staff and colleagues is also important to make this work sustainable. At the end of the day, even if you start small — with 1 patient — you can still make a difference, and working collaboratively with other colleagues and [PWID] is truly rewarding.

For those who may not be practicing ID providers just yet, there are a growing number of training programs with combined ID/addiction medicine fellowships, ID/addiction fellowship tracks (like we have at Maine Medical Center), and/or other opportunities such as Boston Medical Center’s Fellow Immersion Training in Addiction Medicine.

What other efforts are needed to further expand and support this area of specialization?

Dr Thakarar: In my opinion, addiction medicine training should be integrated into every ID fellowship. Whether it’s an addiction medicine rotation, developing a combined ID/addiction fellowship, requiring fellows to sign up for a buprenorphine waiver, observing SSP staff, or participating in other fellow training opportunities, programs can — and should — provide a spectrum of addiction medicine training.

In addition, ongoing support from professional societies such as IDSA (infectious diseases society of America); HIVMA (HIV medicine association); SHEA (society for healthcare epidemiology of America; ASAM (American society of addiction medicine); and AMERSA (association for multidisciplinary education and research in substance use and addiction) is key, as is inviting ID/addiction specialists to participate in local, regional, and national planning and programming. Also, advocacy to reduce barriers to ID/addiction work is important, [such as] lifting prior authorizations, further reducing barriers to the buprenorphine waiver, advocating to change methadone prescribing regulations, and addressing workforce shortages by pieces of legislature like the BIO (bolstering infectious outbreaks) Preparedness Workforce act.⁷ Finally, prioritizing funding for ID/addiction research will further advance this field.

References

1. Serota DP, Barocas JA, Springer SA. Infectious complications of addiction: A call for a new subspecialty within infectious diseases. Clin Infect Dis. 2020;70(5):968-972. doi:10.1093/cid/ciz804

2. Serota DP, Tookes HE, Hervera B, et al. Harm reduction for the treatment of patients with severe injection-related infections: description of the Jackson SIRI Team. Ann Med. 2021;53(1):1960-1968. doi:10.1080/07853890.2021.1993326

3. Gramlich J. Recent surge in U.S. drug overdose deaths has hit Black men the hardest. Pew Research Center. January 19, 2021. Accessed online February 18, 2022.

4. Levitt A, Mermin J, Jones CM, See I, Butler JC. Infectious diseases and injection drug use: Public health burden and response. J Infect Dis. 2020;222(Suppl 5):S213-S217. doi:10.1093/infdis/jiaa432. PMID: 32877539

5. 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

6. Substance Abuse and Mental Health Services Administration .Become a buprenorphine waivered practitioner. Updated January 3, 2022. Accessed online February 18, 2022.

7. Infectious Diseases Society of America. BIO Preparedness Workforce Act of 2021 (idsociety.org). Accessed online February 18, 2022.

This article originally appeared on Infectious Disease Advisor