Guest EditorialPublication Exclusive

Integrated, Sustainable Care of Substance Users Remains Critical

The recent outbreak of HIV among injection drug users in southeastern Indiana reminds us that, despite previous successes in dramatically reducing HIV transmissions among drug users, substance use and infectious diseases remain deeply interconnected in the United States. Earlier hepatitis C virus outbreaks among drug users in the same area provided fair warning that it was only a matter of time before new HIV transmissions occurred.

The resurgence of injection drug use and associated infectious diseases is not limited to the rural Midwest. Recently, the White House announced a new initiative to support heroin response strategies in five “high intensity drug trafficking areas” located in the Northeast and Appalachia. In these areas and elsewhere, more effective monitoring of opioid prescribing has had the unintended but unsurprising consequence of encouraging individuals who misuse prescription opioids to move on to heroin.

Why should infectious disease specialists care? In addition to the resulting increased disease burdens of HCV and HIV, as well as other complications of injection drug use such as skin and soft tissue infections and endocarditis, there is a substantial economic cost to caring for these patients. In a recent study, my colleagues and I estimated that from $229,800 to $338,400 in medical costs would be saved over a lifetime if only one high-risk person was prevented from contracting HIV in the U.S. Curative HCV treatment costs more than $100,000.

The medical costs for drug users fall disproportionately on Medicaid and other public payers that have limited resources. This leads to greater challenges in managing these patients, including maintaining their access to insurance coverage and addressing Medicaid treatment eligibility restrictions, particularly for HCV treatment. At the same time, public health resources are diverted to addressing outbreaks instead of preventing infections from occurring in the first place.

We know what strategies work to address the needs of substance users, yet the gap between medical providers and substance use treatment providers has often been too wide for effective collaboration. In infectious diseases, “treatment as prevention” has become a mantra for HIV treatment providers, but this concept has not always included evidence-based approaches to substance use treatment and harm reduction. Infectious disease specialists need to know that these approaches are available and advocate for their use in their own institutions and communities.

Treatment options are no longer limited to methadone maintenance programs, which are not attractive or accessible to many drug users, or abstinence-oriented detoxification, which has a very high relapse rate. Newer alternatives include office-based treatment with buprenorphine, which is effective as a maintenance treatment and has been successfully integrated into HIV care, and Vivitrol (injectable naltrexone, Alkermes), which is effective in relapse prevention. Syringe exchange programs are a proven public health intervention for individuals who continue to inject, but are most effective when they are not hindered by law enforcement and can operate as part of a broad network of syringe distribution and harm reduction services.

Bruce R. Schackman

An economic case can be made for adopting each of these evidence-based interventions because of their benefits in preventing infectious disease transmission. Unfortunately, arguments for global cost-effectiveness are not always received with enthusiasm by payers facing tight annual budgets. Moreover, much of substance use treatment has been paid for by state substance use authorities funded by federal grants rather than by Medicaid or other publicly funded health insurance programs.

Fortunately, some of these payment “silos” are going away with the expansion of health insurance under the Affordable Care Act and the institution of parity for coverage of physical and mental health benefits. The Department of Health and Human Services has set an ambitious goal of converting more than half of Medicare payments from fee-for-service to alternative payment models such as Accountable Care Organizations and bundled payments by 2018. As other payers follow these new models, health care systems are going to have to face up to the medical and economic consequences of providing inadequate substance use treatment services. In 2013, an estimated 7.6 million persons aged 12 years and older needed treatment for misuse of illicit drugs, but only 1.5 million received specialty treatment.

How can infectious disease specialists help? First, identify and reach out to champions at your own institutions and in your local communities who are providing treatment services to substance users. Learn about collaborative care models that can integrate treatment and prevention services such as HIV and HCV testing and care linkage for individuals in substance use treatment. In our ongoing work, my colleagues and I have shown that HIV and HCV testing in substance use treatment programs can be conducted with limited budgets and can be cost-effective, but only with strong linkages that ensure access to specialist care.

Second, re-examine the role that drug use treatment services and harm reduction play when setting priorities and developing action plans for infectious disease prevention and treatment in your jurisdiction. New threats of high-risk practices among uninfected drug users need to be identified and addressed; local HCV outbreaks may be the canary in the coal mine that require early attention to avoid the consequences experienced in Indiana. In New York, for example, substance use treatment policymakers were directly involved in developing a new blueprint for ending the AIDS epidemic with a goal of reducing the annual number of new infections from 3,000 today to 750 by 2020. The resulting blueprint includes recommendations related to targeted HIV testing of substance users, increasing statewide access to treatment with methadone and buprenorphine, and removing barriers to access to clean syringes.

Finally, infectious disease specialists must be the source for scientific expertise about how to treat patients who use drugs or have used drugs in the past with evidence-based care and without stigma. Treatment guidelines must reflect this expertise, and the guidelines must be followed. For example, more than half of state Medicaid programs restrict access to HCV treatment for people who inject drugs, despite American Association for the Study of Liver Diseases/Infectious Diseases Society of America guidelines that identify these individuals as a priority group for treatment.

While substance use disorders are chronic and relapsing conditions, and reinfection through relapse to injection drug use is possible, the effective care of substance users benefits both the individual and the community and is consistent with medical, public health and economic priorities. Infectious disease specialists are critical to ensuring that substance users receive integrated and sustainable care.

Disclosure: Schackman reports no relevant financial disclosures.

The recent outbreak of HIV among injection drug users in southeastern Indiana reminds us that, despite previous successes in dramatically reducing HIV transmissions among drug users, substance use and infectious diseases remain deeply interconnected in the United States. Earlier hepatitis C virus outbreaks among drug users in the same area provided fair warning that it was only a matter of time before new HIV transmissions occurred.

The resurgence of injection drug use and associated infectious diseases is not limited to the rural Midwest. Recently, the White House announced a new initiative to support heroin response strategies in five “high intensity drug trafficking areas” located in the Northeast and Appalachia. In these areas and elsewhere, more effective monitoring of opioid prescribing has had the unintended but unsurprising consequence of encouraging individuals who misuse prescription opioids to move on to heroin.

Why should infectious disease specialists care? In addition to the resulting increased disease burdens of HCV and HIV, as well as other complications of injection drug use such as skin and soft tissue infections and endocarditis, there is a substantial economic cost to caring for these patients. In a recent study, my colleagues and I estimated that from $229,800 to $338,400 in medical costs would be saved over a lifetime if only one high-risk person was prevented from contracting HIV in the U.S. Curative HCV treatment costs more than $100,000.

The medical costs for drug users fall disproportionately on Medicaid and other public payers that have limited resources. This leads to greater challenges in managing these patients, including maintaining their access to insurance coverage and addressing Medicaid treatment eligibility restrictions, particularly for HCV treatment. At the same time, public health resources are diverted to addressing outbreaks instead of preventing infections from occurring in the first place.

We know what strategies work to address the needs of substance users, yet the gap between medical providers and substance use treatment providers has often been too wide for effective collaboration. In infectious diseases, “treatment as prevention” has become a mantra for HIV treatment providers, but this concept has not always included evidence-based approaches to substance use treatment and harm reduction. Infectious disease specialists need to know that these approaches are available and advocate for their use in their own institutions and communities.

Treatment options are no longer limited to methadone maintenance programs, which are not attractive or accessible to many drug users, or abstinence-oriented detoxification, which has a very high relapse rate. Newer alternatives include office-based treatment with buprenorphine, which is effective as a maintenance treatment and has been successfully integrated into HIV care, and Vivitrol (injectable naltrexone, Alkermes), which is effective in relapse prevention. Syringe exchange programs are a proven public health intervention for individuals who continue to inject, but are most effective when they are not hindered by law enforcement and can operate as part of a broad network of syringe distribution and harm reduction services.

Bruce R. Schackman

An economic case can be made for adopting each of these evidence-based interventions because of their benefits in preventing infectious disease transmission. Unfortunately, arguments for global cost-effectiveness are not always received with enthusiasm by payers facing tight annual budgets. Moreover, much of substance use treatment has been paid for by state substance use authorities funded by federal grants rather than by Medicaid or other publicly funded health insurance programs.

Fortunately, some of these payment “silos” are going away with the expansion of health insurance under the Affordable Care Act and the institution of parity for coverage of physical and mental health benefits. The Department of Health and Human Services has set an ambitious goal of converting more than half of Medicare payments from fee-for-service to alternative payment models such as Accountable Care Organizations and bundled payments by 2018. As other payers follow these new models, health care systems are going to have to face up to the medical and economic consequences of providing inadequate substance use treatment services. In 2013, an estimated 7.6 million persons aged 12 years and older needed treatment for misuse of illicit drugs, but only 1.5 million received specialty treatment.

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How can infectious disease specialists help? First, identify and reach out to champions at your own institutions and in your local communities who are providing treatment services to substance users. Learn about collaborative care models that can integrate treatment and prevention services such as HIV and HCV testing and care linkage for individuals in substance use treatment. In our ongoing work, my colleagues and I have shown that HIV and HCV testing in substance use treatment programs can be conducted with limited budgets and can be cost-effective, but only with strong linkages that ensure access to specialist care.

Second, re-examine the role that drug use treatment services and harm reduction play when setting priorities and developing action plans for infectious disease prevention and treatment in your jurisdiction. New threats of high-risk practices among uninfected drug users need to be identified and addressed; local HCV outbreaks may be the canary in the coal mine that require early attention to avoid the consequences experienced in Indiana. In New York, for example, substance use treatment policymakers were directly involved in developing a new blueprint for ending the AIDS epidemic with a goal of reducing the annual number of new infections from 3,000 today to 750 by 2020. The resulting blueprint includes recommendations related to targeted HIV testing of substance users, increasing statewide access to treatment with methadone and buprenorphine, and removing barriers to access to clean syringes.

Finally, infectious disease specialists must be the source for scientific expertise about how to treat patients who use drugs or have used drugs in the past with evidence-based care and without stigma. Treatment guidelines must reflect this expertise, and the guidelines must be followed. For example, more than half of state Medicaid programs restrict access to HCV treatment for people who inject drugs, despite American Association for the Study of Liver Diseases/Infectious Diseases Society of America guidelines that identify these individuals as a priority group for treatment.

While substance use disorders are chronic and relapsing conditions, and reinfection through relapse to injection drug use is possible, the effective care of substance users benefits both the individual and the community and is consistent with medical, public health and economic priorities. Infectious disease specialists are critical to ensuring that substance users receive integrated and sustainable care.

Disclosure: Schackman reports no relevant financial disclosures.