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1
The Opioid Epidemic and the
Complications of Injection Drug Use
Laura Bamford, MD, MSCE
Philadelphia FIGHT Community Health Centers
October 17, 2019
2
Disclosures
• Gilead Sciences - Consultant and Speaker Bureau
• Alkermes - Consultant
The content of this activity may include discussion of off label or investigative drug uses.
The faculty is aware that is their responsibility to disclose this information.
3
Target Audience
• The overarching goal of PCSS is to train a diverse
range of healthcare professionals in the safe and
effective prescribing of opioid medications for the
treatment of pain, as well as the treatment of
substance use disorders, particularly opioid use
disorders, with medication-assisted treatments.
4
Educational Objectives
• At the conclusion of this activity participants should
be able to:
− Describe the epidemiology of the opioid crisis
− Discuss the complications of injection drug use
− Describe tools to combat the opioid crisis and
the complications of injection drug use
Note: When writing your educational objectives, please reference the link below to
access recommended leading verbs for formulating objectives:
https://www.phscpd.org/resources/pdf/list_of_verbs_for_formulating_objectives.pdf
5
6
70,237
total
deaths
7
Drug Overdose Death Rate by State, 2017
8
0 10 20 30 40 50 60 70
Santa Clara (San Jose)
Los Angeles
Bexar (San Antonio)
Harris (Houston)
Dallas
San Diego
New York City (5 counties)
Maricopa (Phoenix)
Cook (Chicago)
Philadelphia
Overdose per 100,000 Residents
Drug Overdose Death Rates in 2017 in Counties
Associated with 10 Largest U.S. Cities
9
10
*68,557 predicted deaths in 2018 representing first
decline since 1999
11
Modes of Injection Drug Use
• Intravenous or intra-arterial – “mainlining”
• Subcutaneous or intradermal – “skin
popping”
• Intramuscular – “muscle popping” or
“muscling”
12
Medical Complications of Injection Drug Use
• Viral infections: HIV, hepatitis A, B, and C
• Skin and soft tissue infections: abscesses, cellulitis, septic thrombophlebitis
• Pulmonary: Community acquired pneumonia, pulmonary tuberculosis, foreign body granulomatosis, septic emboli
• Cardiovascular: Infective endocarditis, lymphedema, thrombophlebitis
• CNS: Epidural abscess, brain abscess
• Lymphatic system: Splenic abscess
• Endovascular: Bloodstream infections, pseudo aneurysms, deep venous thrombosis
• Musculoskeletal: Psoas abscesses, septic arthritis, osteomyelitis, tenosynovitis
• Hematology: iron deficiency anemia
• Renal: AA (secondary) amyloidosis
• High risk behaviors: STIs, violence, trauma
13
Infectious Complications of
Injection Drug Use
• Bacteria or fungi present on the surface of the skin, in
saliva, in the drug itself, or in diluents or filters used to
prepare drugs for injection may be introduced into
subcutaneous tissues, muscles, or the bloodstream
• PWID are 16.3 times more likely to develop invasive
MRSA infections compared to the general population
• Hospitalizations for serious bacterial infections
including skin and soft tissue infections, infective
endocarditis, epidural abscesses, and osteomyelitis
are increasing in PWID in the United States
14
Injection Drug Use Equipment
15
Skin and Soft Tissue Infections
• Most common medical complication in PWID and
top reason for hospitalization in these individuals
• Between 6% and 32% of PWID have an active SSTI
at any time
• Risk factors include female sex, frequent injection,
inadequate skin cleaning, subcutaneous or
intramuscular injecting, HIV infection, and needle
sharing
• Staph aureus and group A Streptococci are most
common pathogens, but oral flora, Pseudomonas,
and gram negative enteric bacilli are also seen
16
Infectious Endocarditis
• Compared with general population Staph aureus
most common cause of IE among PWID (68%
versus 28% of cases) and more often involves right-
sided valves
• Streptococci and Enterococci are the next most
common pathogens
• Less commonly fungi and gram-negative bacilli
cause IE in PWID
• PWID have higher rates of reinfection and valve-
related complications
17
HIV Infection and HIV-Associated Behaviors
Among Persons Who Inject Drugs - 20 Cities,
United States, 2015
• 27% of HIV negative respondents reported receptive sharing of syringes in the previous 12 months
• Receptive syringe sharing was higher among whites (39%) compared to Latinos (24%) and blacks (17%)
• 49% reported receptive sharing of other injection equipment with similar patterns as above by race and ethnicity (61%, 45%, and 41%)
• 52% received syringes from a syringe service program and 58% were screened for HIV in the same time period
18
IDU accounted
for 9% of new HIV
infections in 2016
19
20
Annual HIV Incidence
by Transmission
Risk Factor
in Philadelphia
33 new infections in
PWID in 2016
(5.2%)
21
HIV Outbreak in PWID in Philadelphia
*Represents a 115% increase in new HIV infections in PWID since 2016
43
Communication from PDPH/AACO
22
OPIOID OVERDOSE DEATHS AMONG PERSONS
WITH HIV INFECTION, UNITED STATES, 2011-2015
• Overall mortality among persons with diagnosed HIV was 12.7% less in 2015 (1630.6 per 100,000) than in 2011 (1,868.8 per 100,000)
• The opioid overdose death rate among persons with diagnosed HIV was 42.7% greater in 2015 (33.1 per 100,000) than in 2011 (23.2 per 100,000)
• Rates of opioid overdose deaths were higher for all subgroups examined by age, sex, race/ethnicity, transmission category, and U.S. Census region of residence at death, with the exception of the West U.S. Census region
• Deaths were highest among persons aged 50–59 years at death (41.9 per 100,000), females (35.2 per 100,000), whites (49.1 per 100,000), PWID (137.4 per 100,000), and the Northeast U.S. Census region (60.6 per 100,000)
23
24
HCV Treatment Cascade
0.0
0.5
1.0
1.5
2.0
2.5
3.0
Viremic Aware Treated in 2018 Cured in 2018
NU
MB
ER
OF
IN
DIV
IDU
AL
S
(MIL
LIO
NS
)
2,499,638
36%
888,512
280,439 266,025
11%
25
26
Preventive Care for PWID
• Screen for HIV and hepatitis A, B, and C
• Vaccinate for hepatitis A and B and tetanus
• Counsel about the risks associated with sharing injection
equipment
• Educate about safer injection practices
• Teach opioid overdose prevention and prescribe naloxone
• Provide access to sterile needles and syringes
• Distribute condoms and screen for STIs
• Prescribe medication assisted treatment
• Prescribe PrEP for HIV prevention
• Provide access to supervised injection facilities
• Educate about early signs of infection related to IDU
27
HIV Treatment and Viral Suppression
• HIV treatment has dramatically increased quality of life and life expectancy in individuals living with HIV
• HIV viral suppression prevents sexual transmission of HIV to uninfected partners
• Unknown but likely also reduces transmission via sharing syringes and other drug injecting equipment
28
Prescribe Rapid Initiation of ART
• In a randomized controlled trial in South Africa participants randomized to same day ART initiation were significantly more likely to be virally suppressed at 10 months
• In a similar study in Haiti same day initiation of ART resulted in significantly increased retention in care and viral suppression at 12 months
• A pilot study of 39 individuals in San Francisco suggested that initiating ART on the same day of HIV diagnosis might modestly shorten the time to achieving viral suppression
29
30
31
Strategies for Engagement in HIV Care Among PWID
• Built on decades of Prevention Point Philadelphia’s expertise in
harm reduction strategies and established trust in the
community in North Philadelphia
• Built on decades of Philadelphia FIGHT’s expertise in providing
high quality HIV and HCV care
• Location at the epicenter of the co-occurring HIV, HCV, and
opioid epidemics in Philadelphia
• Collocation of medical services, social services, and harm
reduction services
• Flexible appointment scheduling with walk-in follow-up visits
and new patient visits
• Medication delivery to Prevention Point with option for daily or
weekly DOT
32
Clinica Bienestar HIV Care Continuum
33
Population Characteristics
• Average age was 43.2 years
• 81% identified as male
• 40% reported being homeless in the previous month
• 44% reported that they went hungry in the previous
week
• 51% reported feeling very depressed in the previous
week
• 15% of participants were incarcerated in any given
month
• 89% were out of HIV care and 11% were newly
diagnosed with HIV
34
HCV Treatment in PWID
• Clinical trials among PWID reporting current IDU at the start of
HCV treatment and/or continued use during therapy
demonstrate SVR rates approaching 95%
• A cohort study of 89 patients treated for HCV in a primary care
clinic in New York found that regardless of active substance
use SVR rates were ≥95%
• The rate of HCV reinfection in PWID is lower (2.4/100 person-
years) than the rate of incident HCV infection in the general
population of PWID (6.1 to 27.2/100 person-years)
• Utilization of medication assisted treatment is associated with a
reduction in HCV reinfection in PWID
35
* CDC recommends daily, continuous pre-exposure prophylaxis with TDF/FTC
Prescribe PrEP
• Adult or adolescent person
• Without acute or established HIV infection
• Any injection of drugs not prescribed by a clinician in past 6
months
AND at least one of the following
• Any sharing of injection or drug preparation equipment in past 6
months
• Risk of sexual acquisition (also evaluate by criteria in Box B1 or
B2)
BOX B3: RECOMMENDED INDICATIONS FOR PREP USE FOR
INDIVIDUALS WHO INJECT DRUGSOX
36
PrEP in PWID
• PrEP with tenofovir reduced risk of HIV acquisition in PWID by 49%
• In separate analyses in participants known to be taking tenofovir consistently the risk declined by 74%
• 25% of PrEP eligible PWID in Baltimore had previously heard of PrEP and 63% of sample were interested in taking PrEP while only 2 were currently taking PrEP
• Barriers to PrEP utilization in PWID include low PrEP knowledge, low perceived HIV risk, negative experiences with HCPs, concerns about side effects, competing health priorities, homelessness, criminal justice system involvement, and HIV-related stigma
37
38
39
40
Safer Injection Techniques
• Wash hands and clean area to be injected with an alcohol swab
• Never share needles, syringes, tourniquets, cookers, water, or filters
• Always inject toward the heart at a 15 to 35 degree angle
• Veins in arms are preferred over legs
• Use different arms and different veins
• Use sterile or boiled water
• Prepare own clean area for use away from others
• Do not reuse needles
Adapted from Getting Off Right Safety Manual, Harm Reduction Coalition
41
42
Refer to Syringe Service Programs
• Reduce rates of HIV and HCV without increasing
drug use, number of PWID, or needles discarded
in an unsafe manner
• Medical providers in the District of Columbia and
all states except Delaware and Kansas are legally
allowed to prescribe or dispense syringes to PWID
http://www.temple.edu/lawschool/aidspolicy/50statesataglance.htm
43
Prescribe Naloxone
44
Increase Access to Medication Assisted Treatment
• Prescribe buprenorphine, oral naltrexone, or long-acting
injectable naltrexone or refer for methadone maintenance
• Buprenorphine and methadone significantly reduce opioid
use, increase treatment retention, and decrease overall
mortality
• HIV and HCV incidence are associated with participation
and duration in a methadone maintenance program
• According to a 2015 analysis based on data from the
National Survey of Drug Use and Health, only about 20%
of Americans with an opioid use disorder received MAT
between 2004 to 2013
45
Test for Fentanyl in Urine and Drug Samples
• Fentanyl has been found mixed into heroin, cocaine, methamphetamine,
MDMA, marijuana, K2, and pressed into counterfeit prescription pills
• People who use drugs may be unaware that fentanyl is used as an
adulterant
• Might rely on ineffectual information including smell, taste, color, and
word of mouth to assess for the presence of fentanyl
• Use rapid and confirmatory urine drug screen panels
that include fentanyl and norfentanyl
• Rapid fentanyl test strips are single-use
immunoassay tests for the qualitative detection
of fentanyl and norfentanyl
• Demonstrated 96 to 100% sensitivity and 90 to 98% specificity in
detecting fentanyl in illicit drug samples, compared to the gold standard
for this type of analysis, gas chromatography/mass spectrometry
46
Supervised injection facilities (SIFs) provide individuals
with SUDs a medically monitored and legally sanctioned
environment to more safely engage in IDU
SIFs are designed to keep PWID alive long
enough for them to engage in treatment for SUD
47
(also known as supervised injection sites, safe injection
sites, fix rooms, safer injection facilities, drug consumption
facilities, or medically supervised injection centers)
• The first SIF began operating in Bern, Switzerland in 1986
in response to increasing HIV infections and drug-related
overdoses
• There are now over 100 legally sanctioned SIFs in 10
countries and 66 cities in Europe, Australia, and Canada
• No legally sanctioned facility currently exists in the United
States
Supervised Injection Facilities
48
Services Provided at SIFS
• SIFs permit the injection of pre-obtained illicit
drugs under the supervision of medical staff
• SIFs differ by site, but these facilities typically
provide the supplies necessary to inject drugs in
a sterile manner, offer overdose response,
provide basic medical care including wound care,
offer safe injecting education, and refer to
substance use disorder treatment
• Many also offer HIV and HCV screening and
administer vaccinations
49
Benefits to the Individual
• Studies in Europe, Canada, and Australia
suggest that SIFs are associated with a
reduction in drug overdose deaths
• SIFs are associated with safer injection practices
reducing HIV and HCV transmission and
acquisition of bacterial and fungal infections
• SIFs are effective referral sites for substance use
disorder treatment and primary medical care
50
Benefits to the Community
• Use of SIFs is associated with
decreased public injection and
increased safe syringe disposal
• SIFs have not been shown to lead to
increased drug use, increased crime,
or increased drug trafficking in their
surrounding communities
51
References
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58
PCSS Mentoring Program
PCSS Mentor Program is designed to offer general information to
clinicians about evidence-based clinical practices in prescribing
medications for opioid addiction.
PCSS Mentors are a national network of providers with expertise in
addictions, pain, evidence-based treatment including medication-
assisted treatment.
• 3-tiered approach allows every mentor/mentee relationship to be unique
and catered to the specific needs of the mentee.
• No cost.
For more information visit:
https://pcssNOW.org/mentoring/
59
PCSS Discussion Forum
Have a clinical question?
http://pcss.invisionzone.com/register
60
PCSS is a collaborative effort led by the American Academy of Addiction
Psychiatry (AAAP) in partnership with:
Addiction Technology Transfer Center American Society of Addiction Medicine
American Academy of Family Physicians American Society for Pain Management Nursing
American Academy of Pain Medicine Association for Multidisciplinary Education and
Research in Substance use and Addiction
American Academy of Pediatrics Council on Social Work Education
American Pharmacists Association International Nurses Society on Addictions
American College of Emergency Physicians National Association for Community Health Centers
American Dental Association National Council for Behavioral Health
American Medical Association The National Judicial College
American Osteopathic Academy of Addiction
Medicine Physician Assistant Education Association
American Psychiatric Association Society for Academic Emergency Medicine
American Psychiatric Nurses Association
61
Educate. Train. Mentor
www.pcssNOW.org
@PCSSProjects
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Funding for this initiative was made possible (in part) by grant no. 1H79TI081968 from SAMHSA. The views expressed in written conference materials or
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