Awakening to the Opioid Crisis: A Top HIV Clinical Development of 2017

Writing this just after finishing rounds on the in-patient medicine service where, of our 18 patients, four have complicated endocarditis due to injecting opioids, I can't feel anything but mournful for the carnage that the so-called opioid crisis has wrought. Seeing the mother of young children whose septic emboli led to a below-knee amputation on the left and spreading gangrene threatening the right, as well as the young man whose thrice-replaced aortic valve is again infected and abscessed and for whom we can offer little other than palliative care is, for me, as searing as the images I still have of skeletal men with purple lesions consuming their bodies.

Despite the magnitude of this epidemic, the first-ever governmental account of drug-related deaths in the U.S. was released only this year -- and it was issued largely in response to media pressure. According to this National Center for Health Statistics Centers for Disease Control and Prevention (CDC) report, there was a nearly 20% increase in overdose deaths in 2016 from the previous year -- with fentanyl and its analogues responsible for a five-fold increase in overdoses over the past three years. That the epidemic is not restricted to pockets in Appalachia is made clear, as states such as Maryland, Maine, and Delaware experienced some of the steeper increases in opioid-related deaths between 2015 and 2016.

Month-Ending Provisional Counts of Drug Overdose Deaths: United States
"Provisional Drug Overdose Death Counts," Centers for Disease Control and Prevention, Nov. 13, 2017

The president has declared this a "public health" emergency, although, disappointingly, he stopped short of fulfilling his campaign promise to make drug addiction a "national" emergency, which would trigger dedicated funding for a response. In addition, he convened a commission led by former New Jersey Governor Chris Christie to formulate a strategy to combat drug addiction. In a still draft report, the commission proposes a number of common-sense approaches, such as rapid expansion of substance abuse treatment including medication-assisted treatment, mandatory prescriber education, increased access to naloxone, measures to reduce the import of fentanyl and other synthetic opioids, better data sharing on opioid prescriptions, reduction of HIPPA (Health Insurance Portability and Accountability Act of 1996) barriers to data sharing, and enforcement of laws designed to prevent insurance companies from denying mental health and substance use treatment. Unfortunately, there is no recommendation for expanded needle exchange, an evidence-based intervention that Vice-President Pence reluctantly and only partially allowed to be implemented when he was governor of Indiana, but which helped quash the outbreak of injection drug-related HIV and hepatitis C in Scotts County.

Related: Why Did the Opioid Epidemic Develop and How Do We Stop It?

The Bottom Line

The parallels between the opioid and the HIV epidemics are painfully obvious. In both crises, our leaders ignored the problem until the waves of deaths came lapping at their ankles. In the case of HIV, strong advocacy and the fear of contagion spurred actions that, as described above, remain in place today but at some peril. As more families share stories of lost sons and daughters and morgues start to overflow, the opioid crisis is likewise getting attention. Yet, there has been little action (and, so far, no accountability for the drug companies and their enablers who created this nightmare). Promises of funding targeted initiatives will remain hollow until fulfilled while an estimated 142 people die of an overdose each day in the U.S.

A clear opportunity exists for our government to assume its most basic responsibility and protect its people from a real -- not an imagined or potential -- threat. The devastating burden of the opioid epidemic in some of the deepest red states might allow for bipartisan support for meaningful and evidence-based action. Now, that would be a top story of 2018.

Top 10 Clinical Developments of 2017
0. Introduction
1. The Cost of Cuts in HIV Spending
2. Awakening to the Opioid Crisis
3. Does It Work to Pay People to Come to Clinic?
4. Bictegravir -- It's Coming
5. A Better Second Chance
6. More Real World Test for Dual Antiretroviral Therapy
7. Heart Attacks in HIV Often Not Due to Atherosclerosis
8. How Long for Long-Acting Antiretrovirals?
9. ART Resistance Spreads
10. We Order Too Many CD4 Cell Counts, but Should We Really Stop?

David Alain Wohl, M.D., is a professor of medicine in the Division of Infectious Diseases at the University of North Carolina (UNC). He is site leader of the UNC AIDS Clinical Trials Unit at Chapel Hill, director of the North Carolina AIDS Education and Training Center (AETC), and co-directs HIV services for the North Carolina state prison system. In 2014, he became co-director of the UNC-Duke Clinical RM Ebola Response Consortium.