By Charlie Severance-Medaris | Vol . 28, No. 23 | June 2020
A QUICK LOOK INTO IMPORTANT ISSUES OF THE DAY
While the nation’s attention is focused on the coronavirus pandemic, policymakers continue to deal with the consequences of the ongoing opioid crisis. In addition to deaths from overdoses, the number of people who inject opioids is increasing. When people share needles to inject drugs, it substantially increases the risk of transmitting bloodborne viruses, including HIV, hepatitis C and hepatitis B. As a result, state actions go beyond preventing opioid misuse to addressing other consequences of the epidemic, including infectious diseases.
The Centers for Disease Control and Prevention (CDC) estimated that nearly 25,000 people in the U.S. became infected with hepatitis B and 44,000 with hepatitis C in 2017. The number of new hepatitis C infections more than tripled since 2010, and 32 states have reported increases in acute hepatitis B infections in adults over age 40. Health officials continue to detect outbreaks of viral hepatitis and HIV among people who inject drugs throughout the country.
The costs of treating these infections can be staggering. The lifetime cost of treating HIV, for instance, is approximately $485,000, and the average net cost of a 12-week course of hepatitis C treatment in 2016 was $47,124
State responses to the opioid epidemic have focused on prevention and early intervention, increasing access to treatment for substance use disorders (SUD), and implementing policies designed to reduce stigma and protect people who inject drugs (PWID) from infectious disease. States are also exploring innovative payment models for treatment.
Increasing access to SUD treatment through medication-assisted treatment (MAT) can prevent transmission of infectious diseases by reducing or eliminating a person’s use of injection drugs. States have expanded coverage of MAT and other SUD treatment through private insurance and Medicaid and expanded the number of providers who can prescribe these drugs. Wisconsin, as part of its legislative Heroin and Opioid Prevention and Education Agenda, enacted Act 262 in 2018. It qualified physician assistants and advanced practice nurses to provide MAT and detoxification treatment. Indiana’s HB 1007 expanded the state’s treatment capacity with nine new hospital-based opioid treatment programs. These programs must report the number of people served and treatment outcomes.
States have also implemented comprehensive syringe services programs (SSPs), also called syringe or needle exchange programs. Comprehensive SSPs provide sterile injection equipment, dispose of used syringes and connect those who use needles with care. At least 27 states have passed laws explicitly authorizing SSPs. In states where syringes are not considered drug paraphernalia, SSPs may also be permissible. Some states have used emergency orders or public health initiatives to permit SSPs. Comprehensive SSPs can provide access to SUD treatment. SSP participants are five times more likely to enter treatment and almost three times more likely to stop using drugs than non-participants. SSPs can also provide vaccines, like those for hepatitis A and B, and Pre-Exposure Prophylaxis (PrEP), which can prevent transmission of HIV, alongside other medical and social services.
States support the implementation of these programs according to local needs. In 2015, Kentucky enacted SB 192 allowing county health departments to operate SSPs. Kentucky’s SSPs refer participants to SUD treatment, provide overdose prevention education, test for infectious diseases and provide hepatitis A and B vaccinations. In 2009, New York’s SB 154 made the state’s pilot SSP permanent. The program now includes “second tier” SSPs, which are mobile and designed to reach remote communities. At least three states enacted legislation in 2019 authorizing SSPs. Georgia’s HB 217 encourages SSPs to include harm reduction counseling. Idaho’s HB 180 requires SSPs to provide information on SUD treatment, and Florida’s HB 171 requires educational and referral services.
States are using screening and treatment strategies as preventive measures. Over the next five years, Louisiana will screen for hepatitis C in prisons and jails and provide treatment to reduce transmission when individuals reenter the general population. Through a new “subscription” model with a pharmaceutical company, the state aims to treat all the estimated 39,000 Louisianans on Medicaid and people in the justice system who have hepatitis C. Similarly, Washington state’s subscription model will spend roughly $321 million to treat 30,000 individuals over four years.
The U.S. Department of Health and Human Services (HHS) offers funding and expertise to state and local leaders in addressing the infectious disease consequences of substance use disorders. The CDC is supporting efforts to strengthen comprehensive SSPs. Several projects tied to the Infectious Disease and Opioid Epidemic initiative began in 2019. Federal resources to support SSPs are available to jurisdictions experiencing or at risk for increased infections. Health departments can use some federal funds to support certain SSP functions after providing the CDC with evidence through a “determination of need” process.
The CDC is also working with states to conduct state-level vulnerability assessments to map increased risk of opioid overdose or infectious disease outbreaks. The Tennessee Department of Health expanded on the CDC’s work to improve the state’s vulnerability assessment. This work created a more nuanced understanding of opioid use, infectious diseases and which communities were most impacted.
The Substance Abuse and Mental Health Services Administration (SAMHSA) provides funding, research and other support for states addressing opioid misuse. Under the SUPPORT Act, SAMHSA is charged with distributing opioid-related grant dollars and facilitating interstate sharing of best practices.
To curb transmission of HIV in the U.S., HHS launched Ending the HIV Epidemic: A Plan for America. This strategy aims to diagnose new HIV cases quickly and connect individuals to treatment. Year one of the initiative focuses on geographic areas with the highest rates of transmission—more than 50% of new HIV diagnoses occurred in only 48 localities. HHS has funded state and local health departments to develop localized plans.