The dire picture of human harm associated with the prescription opioid epidemic in the United States is no secret. Drug overdoses are the leading cause of injury death in the country, killing more people than car crashes since about 2008, when the curves crossed. As of 2014, 47,055 people died from drug overdoses, while 32,719 died in car crashes. (NCHS Data Brief No. 81, December 2011; http://1.usa.gov/200Q7jn; MMWR 2016;64;1378; http://1.usa.gov/1PScwrW.)
Opioid overdoses (including heroin), accounted for 61 percent of overdose deaths, with natural and semisynthetic prescription opioids like morphine, oxycodone, and hydrocodone accounting for the largest share of these deaths. Synthetic opioids other than methadone — such as fentanyl and tramadol — are hot on their heels, however, with the death rate from these drugs nearly doubling between 2013 and 2014 alone.
These figures from the Centers for Disease Control and Prevention (CDC) and the National Center for Health Statistics are alarming enough. But the people who are dying from overdoses of prescription opioids — whether accidental or intentional — represent only part of the far-reaching consequences of opioid abuse.
The largest HIV outbreak in Indiana's history, in the spring and summer of last year, drew attention to HIV as another major health risk associated with prescription opioid abuse among individuals who inject their medications. The tiny rural town of Austin, population 4,200, found itself with at least 175 confirmed cases of HIV, an incidence rate that topped those of any country in sub-Saharan Africa, CDC Director Tom Frieden told the media at the time. (USA Today May 17, 2015; http://usat.ly/1HftleP.) At the outbreak's peak, some 22 people were being diagnosed with HIV every week while only five new cases of HIV had been diagnosed in the county in total throughout the previous decade. Most of the new infections were traced to injections of a relatively new opioid called oxymorphone. It is meant to be taken in pill form, but when abused is sometimes ground up and injected.
“This is the first outbreak of its type that we have seen documented in recent years,” Jonathan Mermin, MD, MPH, the CDC's director of the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, told reporters at the height of the outbreak. The Indiana eruption was particularly dramatic in size, and it is almost certainly not going to be the last. Among adolescent and adult men, new cases of HIV infection associated with injection drug use had declined dramatically in recent years, from 2,501 in 2009 to 1,575 in 2013, a drop of more than 200 new cases per year. But in 2014, there was a slight uptick again to an estimated 1,590 new cases. It was not a huge increase, but when the trend had been significantly downward, a reversal is alarming, experts said.
“This outbreak that we're seeing in Indiana is really the tip of an iceberg of a drug abuse problem that we see in the U.S. that is ... putting people at very high risk for infectious diseases,” Dr. Mermin said.
CDC director Thomas Frieden, MD, MPH, said he agreed, calling the Indiana outbreak a “sentinel event.”
Joan Duwve, MD, MPH, an associate dean of public health practice at the Richard M. Fairbanks School of Public Health at Indiana University-Purdue University Indianapolis, reported on interviews done by public health disease intervention specialists of the affected individuals in Austin as part of an intervention team that involved the state department of health and the CDC. The group found that injection drug use involving prescription opioids had become the norm in some families in the area, with as many as three generations of a family and multiple community members injecting drugs together.
“IDU [intravenous drug use] practices include crushing and cooking extended-release oxymorphone, most frequently 40 mg tablets. Syringes and drug preparation equipment are frequently shared,” meaning the drug is dissolved in non-sterile water and drawn up into an insulin syringe that is usually shared with others,” Dr. Duwve's group wrote in the May 1, 2015, edition of Morbidity and Mortality Weekly Report. (http://1.usa.gov/1RQcd89.) “The reported daily numbers of injections ranged from four to 15, with the reported number of injection partners ranging from one to six per injection event.”
The Perfect Storm
High-risk practices like these, combined with a lack of harm reduction programs, created a perfect storm of rapid HIV transmission, Dr. Duwve told Emergency Medicine News. “Any time there is injection drug use and opioid use disorder, the focus of individuals with opioid use disorder is on, ‘How do I keep from becoming sick, how do I get my next fix so I won't be dope-sick?’ There's not typically a whole lot of thought about how to prevent yourself from getting an infectious disease.
“In combination, there just wasn't a lot of awareness about the risks of HIV transmission in this rural community. Everybody took it for granted that if they didn't have hepatitis C, they would have it at some point. That was just kind of expected. But because there had been only a handful of HIV cases in the preceding 10 years throughout the entire county, that risk just wasn't really on anyone's radar,” she said.
Local authorities put harm reduction programs in place in the wake of the outbreak, including a syringe exchange program operated by the Scott County Health Department. Prior to the outbreak, needle exchange programs had been banned in Indiana, but Gov. Mike Pence lifted the ban temporarily as an emergency measure. A law was subsequently passed allowing county health officials to declare an epidemic of HIV or hepatitis C and then submit a request to the state health commissioner to operate a county syringe exchange program. Nationally, no specific state laws make needle exchange programs illegal, as in Indiana, but many state laws include syringes in their definition of drug paraphernalia. Carrying needles for the illicit use of prescription pain medications is also considered illegal, meaning that any needle exchange programs in those states would be operating outside the law.
“We've seen some evidence that attitudes are changing, and there is more awareness in this area,” Dr. Duwve said. “People who inject drugs in Scott County are making sure they and others have access to clean needles, and there is much more information about safe injection practices — not only not sharing needles but not sharing works, either. But there is still almost no access to medication-assisted treatment, and that is a key component of harm reduction. If someone is successful on methadone, buprenorphine, or naltrexone, they will not be injecting drugs. Even if they have setbacks, they may inject only one or two days a month, rather than every day or multiple times a day, which dramatically decreases exposure and risk.”
What role can emergency physicians play in addressing the growing risk of HIV transmitted through the injection opioids? A critical one, according to Dr. Duwve. “First, if you are treating someone for any kind of injection-drug overdose or any other injection-drug related illness in the emergency department, it's essential that you provide testing for both HIV and hepatitis C during that visit,” she said.
Indiana's Scott Memorial Hospital, in fact, has begun a universal HIV testing program for anyone presenting to the emergency department, Dr. Duwve said. “The rates are just that high. People can opt out, but at least it's offered to everyone.”
If your emergency department serves a community with a high rate of injection drug use or a high burden of hepatitis C — which frequently serves as a “canary in the coal mine” for injection drug use — she said she advises considering implementing a similar policy. “The sooner people are diagnosed with HIV and get into care, the sooner they have viral suppression, which means they are less likely to transmit the infection.” Studies have found that universal screening leads to a significantly higher proportion of HIV cases tested and diagnosed than does targeted screening.
Treat Them as Humans
Dr. Duwve said she also recommends that EDs serving areas hard-hit by opioid addiction consider establishing a direct-access program for linkage to treatment, such as a dedicated social worker or recovery coach permanently placed in the emergency department.
“Addiction is a relapsing-remitting disease, and people who try to stop using these drugs may not be successful the first time they try, or even the first few times. If you have something in place in the ED where you can really reach folks who have hit bottom — not just someone handing them a phone number but a true continuum of care — you will have higher success rates of getting people into recovery.”
She said emergency physicians can have an enormous impact on the care people with opioid use disorder receive in the future simply by the way they interact with them. “Talking to people in Scott County, they feel like they're treated differently,” she said. “There's a lot of stigma, and they don't like to go to see any health care provider because they're ashamed and they feel like they're not treated with respect, or even like they're human beings.”
Because of this stigma and avoidance of the health care system, the need to seek emergency care for something like an overdose may be one of the only opportunities someone with opioid use disorder has to speak with a health care provider. “You may represent the only health care these individuals are getting, and the language you use when you're speaking with them can really influence how they feel,” Dr. Duwve said. “Common terms like calling someone an addict, or using ‘clean’ or ‘dirty,’ with phrases like ‘You were clean for so long, what happened?’ or ‘Your urine's dirty’ can make someone feel like a second-class citizen and a moral failure. While there was a choice initially to start taking these drugs, it was often a physician prescription driving that choice. Once someone is taking opioids regularly, there are physiologic changes in brain chemistry that can lead to addiction. People with opioid use disorder have often burned bridges, lost relationships, lost everything. As an emergency physician, you have the opportunity to make sure that someone with an opioid use disorder gets the care he needs and is at reduced risk for contracting or transmitting HIV, simply by the way you treat him.”
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