Action Plan for Treating Infectious Diseases in People Who Use Opioids: Public Health Watch

In the midst of the ongoing COVID-19 pandemic, it’s easy to forget that the United States was already in the midst of a crisis before the virus arrived on these shores: the opioid epidemic.

Now, a team of investigators has effectively issued a “call to action” for infectious disease specialists who are likely seeing the faces—literally—of this challenge of abuse, addiction, and corresponding public health firsthand.

Their commentary, borne out of an initiative launched by the National Academies of Sciences, Engineering, and Medicine (NASEM), was published on March 11^th by JAMA Network Open.

“ID specialists are on the frontlines, seeing infections in persons who use drugs,” coauthor Sandra Springer, MD, an associate professor of infectious diseases at Yale School of Medicine who also specializes in addiction medicine, told Contagion®. “Those of us who have taken care of persons living with HIV are best suited, as we have experience taking care of persons who have used drugs and who acquired HIV and/or HCV infections. We know that integrated care and providing wrap-around services like substance use disorder treatment, psychosocial services—social work, housing assistance—and psychiatric care are beneficial when trying to treat the HIV.”

As Springer and her colleagues note in their commentary, more than 2 million Americans have been diagnosed with opioid use disorder, and more than 700,000 people have died as a result of their struggles with addiction, either from overdose or other health consequences. Sadly, these figures are likely significantly underestimated, as only 1 in 10 of those with opioid-related substance abuse problems seek treatment.

Although the JAMA article articulates the task at hand for infectious disease and public health specialists—and it is further elucidated in the NASEM consensus report on the topic—Springer provided us with an advocacy to-do list for these clinicians (and others). It includes:

1. Pushing the Centers for Medicaid & Medicare Services (CMS) to withhold approval of Medicaid state plan amendments that require prior authorization for medications to treat opioid use disorder. Such prior authorization requirements serve to delay treatment for those who need it, she said.
2. Requesting that the Substance Abuse and Mental Health Services Administration (SAMHSA) either further align 42 CFR Part 2 (confidentiality of substance abuse patient information) with the Health Insurance Portability and Accountability Act (HIPAA) of 1996 or alter the definition for which specific service delivery programs fall under the provision.
3. Asking SAMSHA to support implementation of multilevel, 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.
4. Demanding that Congress authorize and appropriate funding for the Health Resources and Services Administration (HRSA) to comprehensively address the needs of low-income uninsured or underinsured individuals with concomitant opioid use disorder and infectious diseases—essentially creating a Ryan-White Care Act-like program.
5. Pushing HRSA to devote additional resources toward programs that incentivize providers to work in rural areas (perhaps via with telemedicine)—which have been ground zeros for the opioid epidemic.
6. Requesting that the Department of Health and Human Services explore incentives for methadone opioid treatment programs to offer a wider array of evidence-based medications and to institute opt-out testing for infectious diseases.
7. Pushing Congress to enact legislation permitting providers to deliver methadone treatment for opioid use disorder in primary care settings.
8. Enabling accreditation bodies to require training on integration of ID and substance abuse in health professionals’ training programs.
9. Lobbying Congress to allow federal funding to be used to purchase syringes at syringe service programs, which would effectively get clean syringes in the hands of addicts and prevent the spread of disease.
10. Pushing states to fund—and correctional facilities to offer—evidence-based screening and treatment for opioid use disorder.

“Prevention and treatment services for substance use disorder have been separated from traditional medical care,” Springer noted. “As a consequence, we are not treating these 2 intertwined diseases in an integrated way. We have had over half a dozen new HIV epidemics since the Scott County, Indiana outbreak in 2015 that have occurred among persons who are using heroin, fentanyl, and methamphetamine and cocaine. Even higher now are increases in endocarditis’s, abscesses, and osteomyelitis occurring in patients with a history of injection of fentanyl, heroin, and/or stimulants.”

A crisis indeed.