With the Opioid Epidemic, Communities See Dramatic Increases in Infectious Diseases

The morbidity and mortality associated with the opioid epidemic are substantial and increasing in the United States. Over the past 2 decades, heroin use and heroin-related overdoses have increased dramatically. Heroin use increased 65% between 2002 and 2013,^1-3 and drug overdoses accounted for 70,237 deaths in 2017, with 68% of those involving an opioid.^4,5

The US overdose epidemic is associated with 2 distinct but interconnected trends: a 15-year increase in fatal overdoses due to prescription opioids and a recent surge in fatal overdoses due to illicit opioids such as heroin and fentanyl.^6-10 Rapidly rising increases in heroin use are paralleled by increases in injection drug use, thus increasing exposure to blood-borne infections such as viral hepatitis, HIV, and serious bacterial infections.

The estimated per-act probability of acquiring HIV from an infected source via needle sharing during injection drug use is 63 per 10,000 expo­sures compared with 138 per 10,000 exposures for condomless receptive anal intercourse.¹¹ Young people who inject drugs (PWID) are at particularly high risk for acquiring blood-borne infections and differ in their risk behaviors from older people who inject. In a sample of individuals with opioid prescription misuse in Florida, the younger participants, aged 18 to 24 years, were significantly more likely to inject (odds ratio [OR], 8.4; 95% CI, 4.3-16.2) and more likely to reuse a syringe (OR, 3.2; 95% CI, 1.3-7.8) compared with those 45 years or older.¹²

The risk of acquiring blood-borne viruses may be partic­ularly high for people injecting prescription opioids because the agents are not easily dissolved in water compared with powdered heroin, so more steps are required to prepare and apportion the drug for injection.^13-16 Moreover, the population prevalence of young people aged 15 to 29 years who inject increased between 1996 and 2002 and continued to increase through 2007.^17,18

VIRAL AND SERIOUS BACTERIAL INFECTIONS AND INJECTION DRUG USE

Hepatitis C virus (HCV) is the infection most closely linked to increases in injection drug use and accounts for more deaths in the United States than all other reportable infec­tions combined.¹⁹ A dramatic decline in acute HCV cases occurred after blood supply screening began in the 1990s, but the past decade has seen an abrupt reversal of that trend, with the majority of new cases occurring in individ­uals aged 20 to 30 years.^20-21

Infections with hepatitis B virus have also increased among PWID, although the numbers are smaller than those for HCV. Many states are in the midst of outbreaks of hepatitis A among homeless populations and individuals using drugs. This represents a significant shift for a disease that was traditionally associated with restaurants and day care facilities.²²

The association between HIV and injec­tion drug use has been recognized since the beginning of the HIV epidemic, but HIV prevention efforts have been targeted mostly at preventing sexual transmis­sion of HIV. The increase in reported cases of HIV acquired through injection drug use necessitates a shift in preven­tion activities. For example, Scott County, Indiana, saw an outbreak of more than 200 cases of HIV acquired through sharing of drug injection equipment; 90% of those individuals with newly diag­nosed HIV were coinfected with HCV.23 Clusters of HIV among PWID have also been reported in urban settings such as Seattle, Washington, although the burden of disease has disproportionately affected rural communities that may not have easy access to harm reduction services such as syringe access programs and opioid agonist treatment.^24,25

Of significant concern is the increase in serious bacteremia and its sequelae. North Carolina saw a 12-fold increase from 2000 to 2015 in hospitalizations for endocarditis among individuals with a drug dependence diagnosis.²⁶ Review of national data sets has revealed nation­wide increases in admissions for injection drug use—associ­ated endocarditis, with affected individuals being younger and more often female than traditional cohorts, who were more often male.²⁷ Increases in soft tissue, bone, and joint infections among PWID have been reported as well.²⁸ Deep tissue and valvular bacterial infections require prolonged periods of antibiotic therapy, often prompting weeks to months of hospital admission.

OPPORTUNITIES TO INCREASE TREATMENT AND PREVENTION

Infectious disease (ID) and substance use disorders (SUDs) have a bidirectional causal relationship. By incorporating elements of SUD and ID care, clinicians can increase completion of antibiotic treatment, go upstream to reduce life-threatening endocarditis or deep tissue infections, and increase rates of vaccination for preventable disease. ID treatment providers can rapidly obtain substance use treatment skills and easily adopt them to improve clinical outcomes.

Motivational interviewing is a client-centered coun­seling style that promotes behavior change by main­taining rapport while allowing individuals to identify their own goals for lifestyle modifications. It has 4 prin­ciples: expressing empathy while avoiding arguing, devel­oping discrepancy, rolling with resistance, and supporting self-efficacy.²⁹ All staff in a clinic can use motivational interviewing techniques to promote medication adherence, increase the likelihood that patients will return for follow-up, allow incremental action toward sobriety, and reduce the number of times substances are injected.

Providing naloxone to patients with opioid use disor­ders will increase the chances they are alive to engage in their health care.³⁰ Clinicians should make every appointment or admission an opportunity to offer educa­tion about harm-reduction activities, like single use of sterile syringes, avoidance of shared equipment, and use of test strips to check for unintended opioids like meth­amphetamine cut with fentanyl. Providers should also offer vaccination for preventable disease and HIV pre-exposure prophylaxis for people with unknown or discordant injecting and sexual partners.

Effective medications to reduce substance-related death and increase ongoing engagement in care are available.^31,32 Clinicians can administer many medicines in an office-based setting or start them during a hospital admission. Prescription of buprenorphine requires an X waiver addi­tion to an existing Drug Enforcement Administration license; providers can obtain this either online or by attending an in-person course.³³ Naltrexone in oral or injectable form does not require additional licensing and is an effective adjunct to counseling for alcohol and opioid use disorders. Professional relationships with specialized substance clinics in clinicians’ regions can support efforts and allow easier referral for an individual who requires a higher level of care.

Clinicians working in ID are already aware of the nega­tive effect of stigma. Promote and use the descriptor PWID rather than intravenous drug user, and a person with substance use disorder rather than addict.³⁴ Individuals with substance use disorders anticipate judgment and carry shame in excess. If they experience interactions that make them feel welcome, they will be more likely to return for ongoing care.

CONCLUSIONS

The increasing morbidity and mortality from opioid and other substance use disorders are a call to action, and ID providers have a significant role to play. Rates of HIV, viral hepatitis, and life-threatening bacterial infections are increasing in US communities. By incorporating elements of ID and substance use treatment, clinicians can improve outcomes and increase satisfaction in the workplace. As ID providers, they can assist people with substance use disorders, and participation in their care can be a very rewarding experience.

Hurley is an infectious disease and addiction medicine physician at Denver Health and Hospital Authority in Colorado. Her work combines infectious disease and substance use treatment, with a focus on justice-involved individuals. Al-Tayyib is an associate research scientist at Denver Health and Hospital Authority who is trained in infectious disease epidemiology, with a research focus on substance use. Rowan is the associate director of HIV and viral hepatitis prevention at Denver Health and Hospital Authority. She specializes in the care of patients with HIV, hepatitis C, and sexually transmitted infections.

References:

1. Jones CM, Logan J, Gladden RM, Bohm MK. Vital Signs: Demographic and Substance Use Trends Among Heroin Users - United States, 2002-2013. MMWR Morb Mortal Wkly Rep. 2015 Jul 10;64(26):719-25.

2. Rudd RA, Aleshire N, Zibbell JE, Gladden RM. Increases in Drug and Opioid Overdose Deaths - United States, 2000-2014. MMWR Morb Mortal Wkly Rep. 2016 Jan 1;64(50-51):1378-82. doi: 10.15585/mmwr.mm6450a3.

3. Martins SS, Sarvet A, Santaella-Tenorio J, Saha T, Grant BF, Hasin DS. Changes in US Lifetime Heroin Use and Heroin Use Disorder: Prevalence From the 2001-2002 to 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions. JAMA Psychiatry. 2017 May 1;74(5):445-455. doi: 10.1001/jamapsychiatry.2017.0113.

4. Hedegaard H, Warner M, Minino A. Drug overdose deaths in the United States, 1999—2016. NCHS Data Brief. 2017 Dec;(294):1-8.

5. US Centers for Disease Control and Prevention. Wide-ranging online data for epidemiologic research (WONDER). CDC.gov. https://wonder.cdc.gov. Published 2018. Updated September 26, 2019. Accessed August 1, 2019.

6. Compton WM, Jones CM, Baldwin GT. Relationship between Nonmedical Prescription-Opioid Use and Heroin Use. N Engl J Med. 2016 Jan 14;374(2):154-63. doi: 10.1056/NEJMra1508490.

7. Dowell D, Noonan RK, Houry D. Underlying Factors in Drug Overdose Deaths. JAMA. 2017 Dec 19;318(23):2295-2296. doi: 10.1001/jama.2017.15971.

8. Warner M, Trinidad JP, Bastian BA, Minino AM, Hedegaard H. Drugs Most Frequently Involved in Drug Overdose Deaths: United States, 2010-2014. Natl Vital Stat Rep. 2016 Dec;65(10):1-15.

9. Seth P, Rudd RA, Noonan RK, Haegerich TM. Quantifying the Epidemic of Prescription Opioid Overdose Deaths. Am J Public Health. 2018 Apr;108(4):500-502. doi: 10.2105/AJPH.2017.304265.

10. Zibbell JE, Asher AK, Patel RC, et al. Increases in Acute Hepatitis C Virus Infection Related to a Growing Opioid Epidemic and Associated Injection Drug Use, United States, 2004 to 2014. Am J Public Health. 2018 Feb;108(2):175-181. doi: 10.2105/AJPH.2017.304132. Epub 2017 Dec 21.

11. US Center for Disease Control and Prevention. HIV Risk Behaviors. CDC.gov. https://www.cdc.gov/hiv/risk/estimates/riskbehaviors.html. Accessed August 13, 2019.

12. Surratt H, Kurtz SP, Cicero TJ. Alternate routes of Administration and Risk for HIV Among Prescription Opioid Abusers. J Addict Dis. 2011 Oct;30(4):334-41. doi: 10.1080/10550887.2011.609805.

13. Hagan H, Pouget ER, Williams IT, et al. Attribution of Hepatitis C Virus Seroconversion Risk in Young Injection Drug Users in 5 US Cities. J Infect Dis. 2010 Feb 1;201(3):378-85. doi: 10.1086/649783.

13. Thorpe LE, Ouellet LJ, Hershow R, et al. Risk of Hepatitis C Virus Infection Among Young Adult Injection Drug Users Who Share Injection Equipment. Am J Epidemiol. 2002 Apr 1;155(7):645-53. doi: 10.1093/aje/155.7.645.

14. Koester SK. The Context of Risk: Ethnographic Contributions to the Study of Drug Use and HIV. NIDA Research Monograph. NIDA Res Monogr. 1994;143:202-17.

15. Roy E, Arruda N, Leclerc P, Haley N, Bruneau J, Boivin JF. Injection of Drug Residue as a Potential Risk Factor for HCV Acquisition Among Montreal Young Injection Drug Users. Drug and Alcohol Dependence. Drug Alcohol Depend. 2012 Nov 1;126(1-2):246-50. doi: 10.1016/j.drugalcdep.2012.05.018. Epub 2012 Jun 13.

16. Bruneau J, Roy E, Arruda N, Zang G, Jutras-Aswad D. The Rising Prevalence of Prescription Opioid Injection and its Association with Hepatitis C Incidence Among Street-Drug Users. Addiction. 2012 Jul;107(7):1318-27. doi: 10.1111/j.1360-0443.2012.03803.x. Epub 2012 Mar 22.

17. Chatterjee S, Tempalski B, Pouget ER, Cooper HL, Cleland CM, Friedman SR. Changes in the Prevalence of Injection Drug Use Among Adolescents and Young Adults in Large U.S. Metropolitan Areas. AIDS Behav. 2011 Oct;15(7):1570-8. doi: 10.1007/s10461-011-9992-0.

18. Tempalski B, Pouget ER, Cleland CM, et al. Trends in the Population Prevalence of People Who Inject Drugs in US Metropolitan Areas 1992-2007. PLoS One. 2013 Jun 5;8(6):e64789. doi: 10.1371/journal.pone.0064789. Print 2013.

19. Ly K, Hughes E, Jiles R, Holmberg S. Rising Mortality Associated with Hepatitis C Virus in the United States, 2003-2013. Clin Infect Dis. 2016 May 15;62(10):1287-1288. doi: 10.1093/cid/ciw111. Epub 2016 Mar 1.

20. US Centers for Disease Control and Prevention. Viral Hepatitis. 2016 Surveillance. CDEC.gov. https://www.cdc.gov/hepatitis/statistics/2016surveillance/index.htm. Accessed August 13, 2019.

21. US Centers for Disease Control and Prevention. NCHHSTP Newsroom. Increase in Hepatitis C Infections Linked to Worsening Opioid Crisis. CDC.gov. https://www.cdc.gov/nchhstp/newsroom/2017/hepatitis-c-and-opioid-injection-press-release.html. Published December 21, 2017. Accessed August 13, 2019.

22. US Centers for Disease Control and Prevention. Viral Hepatitis. Widespread Outbreaks of Hepatitis A Across the United States CDC.gov. https://www.cdc.gov/hepatitis/outbreaks/2017March-HepatitisA.htm. Accessed August 13, 2019.

23. Peters PJ, Pontones P, Hoover KW, et al. HIV Infection Linked to Injection Use of Oxymorphone in Indiana, 2014-2015. N Engl J Med. 2016 Jul 21;375(3):229-39. doi: 10.1056/NEJMoa1515195.

24. Golden MR, Lechtenberg R, Glick SN, et al. Outbreak of Human Immunodeficiency Virus Infection Among Heterosexual Persons Who Are Living Homeless and Inject Drugs — Seattle, Washington, 2018. MMWR Morb Mortal Wkly Rep. 2019 Apr 19;68(15):344-349. doi: 10.15585/mmwr.mm6815a2.

25. Broz D, Zibbell J, Foote C, et al. Multiple injections per injection episode: High-risk injection practice among people who injected pills during the 2015 HIV outbreak in Indiana. Int J Drug Policy. 2018 Feb;52:97-101. doi: 10.1016/j.drugpo.2017.12.003. Epub 2017 Dec 24.

26. Fleischauer AT, Ruhl L, Rhea S, Barnes E. Hospitalizations for Endocarditis and Associated Health Care Costs Among Persons with Diagnosed Drug Dependence — North Carolina, 2010—2015. MMWR Morb Mortal Wkly Rep. 2017 Jun 9;66(22):569-573. doi: 10.15585/mmwr.mm6622a1.

27. Wurcel A, Anderson J, Chui K, et al. Increasing Infectious Endocarditis Admissions Among Young People Who Inject Drugs. Open Forum Infect Dis. 2016 Jul 26;3(3):ofw157. eCollection 2016 Sep.

28. Tyagi R. Extremity Infections in Intravenous Drug Abusers. Archives of Clinical Microbiology. April 2016. 7(3):18.

29. DiClemente C, Corno C, Graydon M, Wiprovnick A, Knoblach D. Motivational Interviewing, Enhancement, and Brief Interventions Over the Last Decade: A Review of Reviews of Efficacy and Effectiveness. Psychology of Addictive Behaviors. Psychol Addict Behav. 2017 Dec;31(8):862-887. doi: 10.1037/adb0000318.

30. McDonald R, Strang J. Are Take-Home Naloxone Programmes Effective? Systemic Review Utilizing Application of the Bradford Hill Criteria. Addiction. 2016 Jul;111(7):1177-87. doi: 10.1111/add.13326. Epub 2016 Mar 30.

31. Anton R, O’Malley S, Ciraulo D et al. Combined Pharmoacotherapies and Behavioral Interventions for Alcohol Dependence. The COMBINE Study: A Randomized Controlled Trial. JAMA. 2006 May 3;295(17):2003-17.

32. Lee J, Nunes E, Novo P, et al. Comparative Effectiveness of Extended-Release Naltrexone versus Buprenorphine-Naloxone for Opioid Relapse Prevention: a Multicentre, Open-Label Randomised Control Trial. Lancet. 2018 Jan 27;391(10118):309-318. doi: 10.1016/S0140-6736(17)32812-X. Epub 2017 Nov 14.

33. Providers Clinical Support System. Overview of Medication Assisted Treatment. https://pcssnow.org/medication-assisted-treatment. Accessed July 30, 2019.

34. Broyles L, Binswanger I, Jenkins J et al. Confronting Inadvertent Stigma and Pejorative Language in Addiction Scholarship: A Recognition and Response. Subst Abus. 2014;35(3):217-21. doi: 10.1080/08897077.2014.930372.