Opioid Use Disorder Should Be Thought of Like an Infectious Disease, Experts Say
The growth of opioid addiction in the United States has led to a significant convergence between substance use disorders and infectious diseases. Physicians who specialize in the latter need to take note.
Opioid use disorder (OUD) is not an infectious disease, but a new paper from the National Institutes of Health (NIH) and the University of Maryland argues that ID specialists need to start considering themselves as a first line of treatment against the disorder.
“The infectious diseases and [substance-use disorder] communities have important, overlapping, and optimally synergistic roles in addressing this crisis,” Anthony Fauci, MD, director of the NIH’s National Institute of Allergy and Infectious Diseases, and co-authors wrote this month in The Journal of Infectious Disease.
The opioid crisis remains a major public health concern, with some 47,000 people dying from overdoses of opioid-containing drugs in 2017 alone. Many people who become addicted to opioid painkillers begin with a prescription for oral medication. However, as the addiction worsens, some individuals turn to injecting prescribed or illegal opioids, a practice that often correlates with risky behaviors, including needle-sharing and unsafe sexual activities, all leading to an increased risk of infectious diseases.
When a patient with OUD contracts an infectious disease, 1 of the first individuals with the opportunity to help the patient is an infectious disease provider. In light of this fact, Fauci and colleagues write that infectious disease providers should seek to identify patients with underlying opioid disorders and refer them to treatment.
“Patients with [injection drug use-]-associated infectious diseases often receive treatment for the infection by an infectious diseases provider who may not recognize and/or address the underlying cause—OUD,” Fauci and colleagues wrote.
Sandra Springer, MD, an associate professor of medicine at the Yale School of Medicine, understands very well the links between infectious diseases and substance use disorders. Her work has focused on how opioid and alcohol use disorders affect HIV treatment. A decade ago, she was working with prisoners who had been diagnosed with HIV and were about to be released from incarceration. She realized some of these patients would leave prison with OUD, a condition that could impact their HIV treatment and exacerbate their risk for other infectious diseases. The problem Springer faced is that there was no way to differentiate patients with HIV who had OUD from those who didn’t.
Sandra Springer, MD
“I noticed there was no quick diagnostic tool, so I created it, validated it and produced it—free of charge for others,” she told Contagion®.
That tool, called the Rapid Opioid Dependence Screen, takes just a few minutes to administer and can give a provider an accurate indication of whether the patient sitting across from them is likely affected by OUD.
If they are, the physician can connect them to therapy.
“It is absolutely critical that ID clinicians screen for opioid and other substance-use disorders in order to cure/treat infectious disease as well as prevent new infections,” Springer said. “Treat opioid use disorder like an infectious disease.”
In fact, Springer and Joshua Barocas, MD, an assistant professor at Boston University School of Medicine, believe infectious disease specialists shouldn’t simply identify OUD, but they should be prepared to treat it themselves.
“Evidence suggests that if we integrate care for OUD into our infectious disease practices, they do better,” Barocas told Contagion®. “There’s a better continuum of care if you integrate it at the site.”
Treating the patient within the ID setting also lowers medical costs and reduces losses to follow-up.
Barocas, a member of the Infectious Disease Society of America, said ID specialists can treat many cases of OUD without significant additional training.
“Anybody can provide naltrexone, which is one of the 3 licensed treatments for OUD,” he said, “and almost anybody can prescribe buprenorphine, with a waiver.”
Joshua Barocas, MD
To receive the waiver, providers must complete an 8-hour course.
Methadone, the third approved OUD therapy, must be administered in a specialized clinic, and thus is not feasible for most infectious disease providers to administer.
If diagnosing and treating OUD is relatively quick and easy, it is not widely done at United States infectious disease clinics. One reason, Barocas said, is that physicians have limited time and tend to treat conditions hierarchically.
“[I]f you have 15 minutes with a patient that has endocarditis and HIV and hepatitis C and substance-use disorder—we all have to prioritize,” he said. “And so the thing that gets kicked down the road is the substance-use disorder, because of a lack of time and pressure on the system.”
Another issue is related to training and administration. In a 2018 paper proposing action steps to better integrate infectious disease medicine and substance abuse treatment, Springer recommended that hospitals and medical schools boost their training of all providers—physicians, nurses, physician assistants, and nurse practitioners—to ensure they are competent to identify and treat OUD. She also said hospitals and clinics need to establish clear protocols to initiate treatment for people diagnosed with OUD and create plans to ensure those patients are linked to care upon discharge.
One final piece of the puzzle is funding. In their paper, Fauci and colleagues noted that the Department of Health and Human Services has dedicated nearly $1 billion to expand access to evidence-based opioid treatment, and the NIH will spend $500 million to improve pain management and help treat patients with OUD.
Still, Springer said much of the NIH’s funding so far has been focused on HIV and substance use disorders. Although that’s important, it’s far from encompassing the entire problem.
“We need research about non-HIV-related infections and opioid use disorders like the rise in bloodstream bacterial infections leading to endocarditis and osteomyelitis, etc.,” she said.
Springer said funding is also needed to ensure states mandate and provide access to screening and treatment for substance-use disorders, including states that chose not to expand Medicaid coverage. Research money should also go to better understanding demographic-based risks and prevention strategies. She would also like to see the buprenorphine limitations relaxed in order to make it easier for ID prescribers to prescribe the therapy without the need for a waiver.
Barocas added that a philosophical change is needed, too.
“Part of treatment for substance-use disorder is harm reduction,” he said, “and until we start to really invest in needle and syringe programs, overdose prevention sites, counseling, and treatment, etc., we are again going to be chasing our tails.”
Springer said although screening and treating OUD and other substance-use disorders might require a change in mindset, it shouldn’t be thought of as any different than any other complicated condition.
“They have to have a team approach,” she said. “So screen like we do for everything else: diabetes, hypertension, colon cancer, breast cancer, etc. We have recommendations written and then we have people who can do treatment. The issue is if we don’t identify people with OUD then we can’t even think about treating them.”
There’s little evidence that the opioid epidemic will go away anytime soon, Springer said. Deaths from illicit fentanyl use, in particular, continue to increase, she noted. That means infectious disease specialists will need to get used to the idea of OUD being a significant part of their practices, whether it feels comfortable or not.
“We are having over 190 people dying every day that we know of,” she said, “and there is no decrease in sight at all.”