Dr. Sandra Springer: On the other epidemic fueled by the opioid crisis
This spring, Yale associate professor of medicine and infectious disease expert Sandra Springer participated in a national workshop to address a recent rise in infectious diseases related to the opioid crisis. Convened by the National Academy of Sciences, Engineering, and Medicine (NASEM), the workshop brought together top thinkers with a range of medical, public health, government, law enforcement, and community perspectives to develop an action plan for responding to the overlapping epidemics. YaleNews talked to Springer about her role in this effort and strategies she has outlined in a paper published by Annals of Internal Medicine. An edited version of the conversation follows.
How has the crisis of opioid addiction increased rates of infectious diseases such as Hepatitis C and HIV? What’s the connection?
We’ve seen a new epidemic in Hepatitis C and HIV over the last few years related specifically to a rise in opioid use. It has been linked to sharing injection drug using equipment mainly but is also associated with unprotected sexual intercourse that may be happening under the influence of the drugs.
The other epidemics that we’re seeing linked to the opioid epidemic are a rise in invasive bacterial infections, predominantly related to an increase in Staphylococcus aureus, including both methicillin-sensitive and methicillin-resistant staphylococcus aureus (MRSA), but also due to other organisms that have caused blood stream infections, and infections of the heart valves, skin, and soft tissues, and the joints and the bones. CDC data show that invasive MRSA cases among people who inject drugs rose from 4.1% to 9.2% between 2011 and 2016.
There have also been several published reports about how hospitals are being overwhelmed with this rise in infectious diseases associated with opioid use. Rural communities, where they don’t have specialists typically, are being inundated with these infectious diseases. Compounding this problem is the fact that infectious disease patients who have untreated opioid use disorder are often unable to stay in the hospital to complete their antibiotic treatment. They then leave the hospital but come back with the same infection, or die from the infection or opioid overdose. This vicious circle continues as long as the underlying disease, opioid use disorder, goes untreated.
Your paper mentions how the opioid epidemic parallels the early days of the HIV epidemic. In what ways?
In the early days of HIV, we didn’t have a unified healthcare system or physicians who were knowledgeable about the disease. Hospitals were being overwhelmed with new cases of infections that were rare, like PCP pneumonia and other infections that later were found to be associated with HIV and AIDS. In the beginning, hospitals and providers weren’t sure how to treat it. Even when they did identify the virus, they didn’t have the medications or knowledge to treat it. Later, when medications were finally approved by the FDA, there was no system in place to pay for the medications and they were very expensive. That led to the Ryan White Care Act, which allows states to have access to money to provide antiretroviral therapy for patients living with HIV. There were also guidelines developed focusing on how to identify patients with HIV and treat them.
Another parallel is the sheer numbers of individuals affected: The number of people who are dying related to the opioid epidemic surpasses the number cases of people who died from AIDS at the height of the AIDS epidemic in the United States.
Additionally, once there was knowledge about HIV and we identified it, there was a huge amount of stigma and some providers didn’t want to care for patients with HIV, even when they had the tools available. We see the exact same stigma now, maybe in some cases worse than what we saw with HIV, because many physicians don’t want to take care of patients with opioid addiction. We see a lack of providers’ willingness to treat, even in states where we have Medicaid coverage for medications.
The first action step you outline calls for screening for opioid use disorder. Do you recommend that for all patients? Or a subset?
In the action steps we talk about targeting people at highest risk for having opioid use disorder. Given resources and time, we initially focused on the group that we’re seeing in the hospitals that are related to infectious diseases. However, we had 65,000 people die from opioid use last year in this country alone. Since it’s so universal, it’s the number-one cause of death in the United States, I would advocate for screening everybody.
In steps two and three, you describe the need for medication to treat opioid addiction. How will that help with infectious disease care?
If we treat opioid use disorder like an infectious disease, with medications that can treat the craving and reduce opioid use, we could then stabilize patients so they wouldn’t leave the hospital, they wouldn’t need to use opioids, and they could then stay on their antibiotics. They would also be less likely to die of opioid overdose and other direct opioid-related morbidity and mortality. FDA-approved medications, including methadone, buprenorphine (Suboxone), and extended-release naltrexone (Vivitrol), are the best treatments for opioid use disorder. They reduce opioid overdose, improve adherence to medications for other diseases, such as antibiotics for infections and HIV and HCV antiviral medications, and reduce HIV and HCV transmission.
The goal of addiction treatment is to make people effective members of society. That’s the goal with the infectious diseases as well, to treat the opioid use disorder so patients can stay on their antimicrobial treatment, and effectively cure or manage their underlying infectious disease.
About the final two steps, one calling for provider training in addiction and the other for treatment access: It sounds like a multi-pronged effort and broad strategies are needed to address both health crises.
This is the biggest epidemic we’ve ever had in this country. But it’s not difficult to identify or treat. We did it with HIV. We have government agencies including the Health and Human Services and the Centers for Disease Control and Prevention that are addressing this issue. The president said that we have an opioid epidemic. We have strategies; we just need to help clinicians implement them and provide funding to patients to pay for the effective FDA-approved medications that treat opioid use disorder.
There’s free training and local experts available to help physicians learn to treat opioid use disorder, including buprenorphine waiver training that is available through the SAMHSA-funded Providers Clinical Support Service. The public policy part is already started but a major issue is health care, the funding and the capacity to provide medications for people and also to pay for clinicians to provide them.
That was one of the biggest take-home messages from the NASEM meeting. We can bring all of the experts together, and outline how to do this, but we need healthcare dollars, or insurance to help pay for the medications. To really address this epidemic, we need universal health care or funding directed to each state like the Ryan White Care Act has done for HIV. We need to do the same thing to provide funding to treat the opioid epidemic that includes opioid treatment medications I named, as well as naloxone for overdose prevention, and for behavioral counseling to support those who need it.
The NASEM recommendations and proceedings are available at the organization's website.