Three Medical Societies Identify Specific Infections of Concern in Relation to the Opioid Crisis

Cross-posted from HHS.gov

As part of the ongoing and evolving national dialogue about the opioid crisis that is wreaking havoc across the country, the Office of the Assistant Secretary for Health – including the Assistant Secretary for Health, the Surgeon General, and the Office of HIV/AIDS and Infectious Disease Policy – has been sounding the alarm about the rapid increase in infectious diseases that are  associated with injection drug use. The shocking and tragic increase in opioid-related overdose deaths have often dominated conversations, as have the burdens of non-fatal overdoses for first responders and emergency rooms in communities across the nation.

Too often overlooked is the intersection between opioid use and infectious diseases such as HIV, hepatitis C (HCV) and endocarditis. These and other infections that are efficiently transmitted via shared syringes or other injection equipment frequently go undetected and are only recently being linked to the opioid crisis. Thus we have characterized them as "hidden casualties" of the opioid crisis.

Better coordinated and more integrated approaches to address the infectious disease consequences of the opioid crisis are essential if we are to achieve the goals of the National Viral Hepatitis Action Plan and the National HIV/AIDS Strategy. These national plans call for expanded access to comprehensive, integrated prevention services for people who inject drugs.

In an important contribution to increasing awareness of the infectious disease consequences of the opioid epidemic, three national medical societies published a policy brief on Infectious Diseases and Opioid Use Disorder*in March 2018. The policy brief from the Infectious Diseases Society of America (IDSA), the HIV Medicine Association (HIVMA), and the Pediatric Infectious Diseases Society (PIDS) provides expert perspectives on the types of infectious diseases and bacterial infections that are increasing due to the opioid crisis and how we integrate them as part of our response to the epidemic. These include:

• Infective endocarditis (an inflammation of the heart valves due to infection),
• HIV infection,
• HCV infection,
• Hepatitis B virus (HBV) infection, and
• Skin, joint, and bone infections, which often require hospital stays and prolonged treatment.

According to the three medical societies, the incidence of all of these infections has increased or resulted in outbreaks due to the opioid crisis. Infectious disease physicians and other healthcare providers are increasingly concerned. These infectious disease consequences of opioid addiction constitute an additional public health threat that demands urgent, coordinated, evidence-based and sustained action.

Indeed, new hepatitis C infections in the United States more than tripled between 2010 and 2016, according to the Centers for Disease Control and Prevention. The upsurge is primarily a result of increasing injection drug use associated with America's growing opioid crisis. Further, despite the fact that hepatitis B is a vaccine-preventable disease and rates of new infection are falling in persons under 30, progress on prevention has stalled in many areas of the country because of increasing infections among unvaccinated individuals over 30. Local outbreaks of HIV infection have been reported, but prevention efforts have thus far averted substantial increases in new HIV infections among people who inject drugs.

The policy brief from the medical societies was released along with recommendations for actions that would better support stakeholders in their efforts to increase access to screening, treatment, and services to reduce and reverse these infectious disease trends. The new recommendations underscore the necessity of addressing infectious disease diagnosis, prevention, and treatment as part of a federal, state, and local response to the opioid crisis.

As your community, state, or region works to tailor, implement, and refine a comprehensive response to the opioid crisis, it is important to ensure that prevention and treatment of these associated infectious diseases are being integrated into addiction and substance use disorder treatment services. Doing so will enhance the opioid response and better meet the needs of people and communities affected because it will maximize opportunities to provide needed services to a hard-to-reach group, people who inject drugs. Actions may include:

• Assess whether there is data or other evidence of an increase in any of the infections identified by the experts in your community, state, or region;
• Identify if the needs of the community are being met in relation to these infections and, if not, what steps can be taken to improve services;
• Consider how prevention, diagnosis, and treatment of these infectious diseases can be better integrated into all community health services for persons who inject drugs including emergency services, comprehensive syringe services, correctional healthcare, and addiction and substance use disorder treatment services, and
• Make changes in HIV, sexually transmitted infection, and viral hepatitis programs to incorporate information and services related to the opioid crisis and expand  collaboration with substance use disorder treatment programs to ensure referral and placement of clients in need. CDC describes comprehensive prevention services as inclusive of naltrexone, medication assisted treatment, testing for infections such as HIV and hepatitis C, and syringe services.

Collaboration works best when all partners contribute as well as benefit. Assessment of community needs can help identify new partners, and collaborative planning helps to define and describe each partner's contributions to a shared, comprehensive response to the opioid crisis that provides the greatest benefits for people with substance use disorder and their communities. 

There are opportunities to engage and mobilize key partners from various sectors at the community, state, and national levels to better integrate our responses to both the opioid crisis and viral hepatitis. A more coordinated and comprehensive response will be key to ending the opioid crisis, reducing overdose deaths, and putting the United States on a path toward eliminating viral hepatitis and HIV transmissions.

* The findings of this brief are those of the authors.  They do not necessarily reflect the views of the Office of the Assistant Secretary for Health or the U.S. Department of Health and Human Services.