Message on Opioids From HIV Docs to Colleagues Is Clear: Get Training, Prescribe Buprenorphine, Save Lives
Although IDWeek is over, many conference presenters sought to impart one lasting message to their colleagues: Start treating your patients with opioid use disorder and get political about it.
As the opioid epidemic rages on, it is becoming obvious that the crisis is inexorably intertwined with outbreaks of infectious diseases such as HIV and hepatitis C. Because these epidemics are interwoven, it's more important than ever for infectious disease clinicians to have some basic training in how to help their patients suffering from opioid use disorder.
"In addition to the increase in opioid overdose death, there's also a huge gap in treatment," said Chinazo Cunningham, M.D., M.S., Department of Medicine, Division of General Internal Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York. "There are 22.5 million Americans with substance use disorder. Only 12% of patients get treatment."
Multiple speakers at IDWeek encouraged their colleagues to complete the eight-hour training that's required to start prescribing buprenorphine, proven to be one of the safer and more effective ways to help patients start treatment for opioid use disorder.
Other speakers presented data that upends long-held assumptions that people who inject drugs are incapable of taking once-daily pills as prescribed. They implored clinicians and hospital administrators to eliminate stigmatizing language from their staff's vocabulary.
And many researchers ended their talks by encouraging physicians to get political. The opioid epidemic has strong parallels to the HIV epidemic of the 1980s: It's a massive crisis that hasn't received adequate resources because of stigma and fear. Infectious disease clinicians, presenters argued, can no longer afford to sit on the sidelines.
In fact, Melanie Thompson, M.D., of the AIDS Research Consortium of Atlanta, who presented a summary of HIV clinical research in a ballroom packed with thousands of people, ended her talk with a simple request to her colleagues: "Please vote," she said.
Better yet, she continued, "Activate your inner activist." She used her allotted stage time to compound her plea, displaying the ACT UP slogan across several jumbo screens and sending a clear message to the attendees of IDWeek 2018 that "Silence = Death."
Lesson #1: Get Trained, Start Prescribing
Like antiretrovirals for HIV, opioid addiction treatment is a lifelong process.
"There is no cure," said Cunningham. However, "we only have three medications [for opioid use disorder], so it's not that hard."
"We need to be able to identify individuals with opioid use disorder, assess whether they're ready to begin recovery, and then provide treatment," said Christopher F. Rowley, M.D., M.P.H., Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston.
"Know who is the right candidate for methadone. Know that the individual who has both the combination of opioid use and alcohol disorder may be a candidate for naltrexone. Also know that buprenorphine is a lifesaving medication that can be started in-house," Rowley said.
Cunningham noted that buprenorphine is one of the safer treatment options because it's very difficult to overdose. A large study called BHIVES looked at HIV patients taking buprenorphine and found that HIV outcomes improved with retention in buprenorphine treatment.
Some physicians might worry about prescribing buprenorphine for patients who also use cocaine or methamphetamine, noted Cunningham. It's true that buprenorphine does nothing to treat these addictions, yet Cunningham said that, in her experience, many patients use opioids and stimulants simultaneously, so when they stop using opioids they often stop using stimulants, as well.
Meanwhile, according to the most up-to-date research, there are "very little drug/drug interactions with buprenorphine and [antiretrovirals] -- unlike methadone, which has a lot of drug interactions," Cunningham said.
If providers plan to start treating opioid addiction in their patients, it's important for them to also brush up on how to read urine toxicity test results, so Cunningham pointed to a cheat sheet called My Top Care as a good place to start.
The bottom line is that it's becoming increasingly important for infectious disease clinics to offer opioid addiction services, said Rowley.
Rowley pointed to his own personal experience in Boston. Several years ago, he noticed an uptick in the number of patients hospitalized for a bacterial infection typically associated with injection drug use.
He launched a study to look into this trend and was horrified when he found that the hospital was seeing increasing cases of infectious endocarditis, but "we were doing nothing to help [patients'] opioid use disorder," he said.
Lesson #2: Treat Patients, Check Your Assumptions
For Rowley, the 2016 study was a wake-up call. He began to investigate why his clinic wasn't providing optimal care for people with opioid use disorder, and he discovered that stigma certainly played a role.
"We still think [addiction] is a moral failing or a personal choice," he said. "We need to get rid of judgmental terms."
In particular, Rowley said that certain words should be eliminated from every clinician's vocabulary, and he offered alternative phrases. Don't refer to urine tests as "clean" or "dirty," he said. Avoid describing dose de-escalation as "detoxification." Terms like "drug abuser" or "addict" should be replaced with "person with substance use disorder." And, because addiction treatment is life long, it's best to say that patients are living "in recovery" rather than "clean."
While these may seem like obvious steps to dismantle stigma, evidence indicates that provider stigma runs deeper than merely the words they use to describe addiction.
"In a study that was published in 2016 that had surveyed specialists at a specialist conference, only 10% said they would treat hepatitis C among person who were using drugs," said Judith I. Tsui, M.D., M.P.H., Division of General Internal Medicine, University of Washington, Seattle.
"Providers may not want to treat patients they perceive as being nonadherent for fear of failing. What I think is a major concern, personally, is provider concerns about failure," Tsui said.
In fact, there have been two major clinical trials (C-EDGE and CO-STARS) studying hepatitis C treatment success and reinfection rates among injection drug users. These studies found high cure rates and low rates of reinfection, only 4.6 infections per 100 person years, Tsui said.
"I like to refer to opioid agonist therapy as the other 'treatment as prevention' when it comes to hepatitis C," she added, pointing to a recent Cochrane review finding that opioid agonist therapy reduces the risk of acquiring hepatitis C among people who inject drugs by 50%. When combined with syringe services, the risk drops by 75%.
Finally, Thomas Kerr, Ph.D., BC Centre on Substance Use, University of British Columbia, Vancouver, Canada, presented findings from more than 40 peer-reviewed studies on the outcomes of North America's first supervised injection facility, called Insight.
Notably, Kerr found that people who used the facility frequently were about 70% less likely to report syringe sharing. Moreover, the site had a positive impact on the community, with a 35% decline in the number of overdose deaths in the Vancouver neighborhood where Insight is based.
But even in Canada, opposition to supervised injection sites has been fierce; in the United States, these facilities don't exist.
"Sadly, the science of supervised injection has been grossly politicized," said Kerr. That's why it's important for infectious disease physicians to advocate on behalf of their patients -- and for public health, he noted.