Age-Adjusted Rates of Death Related to POs and Heroin,

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1 Learning Objectives Upon completion, participants should be able to: Incorporate available tools to screen patients for IDU into routine practice Develop processes to mitigate infectious diseases risks of IDU, including HCV/HIV testing, medication-assisted therapy for opioid misuse, harm-reduction strategies, and PrEP Describe various resources to help rural primary care clinicians provide treatment to patients diagnosed with HCV and/or HIV 1

2 Age-Adjusted Rates of Death Related to POs and Heroin, Between 2000 and 2014, the rates of death from PO overdose nearly quadrupled In 2015, drug overdoses accounted for 52,404 deaths in the US, 63.1% (33,091) of which involved any type of opioid In 2015, heroin-related death rates were highest among year olds (13.2/100,000), increasing 22.2% from 2014 to 2015 No. of Overdose Deaths per 100,000 Population Heroin POs Year Compton WM, et al. N Engl J Med. 2016;374:154-63; Rudd RA, et al. MMWR Morb Mortal Wkly Rep. 2016;65: Number and Age-Adjusted Rates of Drug Overdose Deaths by State, US, 2015 From 2014 to 2015, the death rate from synthetic opioids other than methadone, which includes fentanyl, increased by 72.2%, and heroin death rates increased by 20.6% Natural/semisynthetic opioid death rates increased by 2.6%, whereas methadone death rates decreased by 9.1% WA OR NV CA AK ID AZ UT MT WY CO NM HI ND SD NE KS OK TX MN WI IA IL MO AR MS LA ME VT NH NY MA MI CT RI PA NJ IN OH DE WV MD VA KY NC TN SC` GA AL FL 2.8 to to to to to to 41.5 CDC. Drug Overdose Death Data. Rudd RA, et al. MMWR Morb Mortal Wkly Rep. 2016;65:

3 Opioid Prescriptions: Where You Live Matters Number of Painkiller Prescriptions per 100 People WA ME MT VT ND MN OR ID NH WI SD NY IA NE PA NJ NV IL IN OH DE UT CO CA MA CT RI MI WY WV KS MO MD VA KY NC AZ OK NM TN AR SC` MS TX AL GA LA AK FL State Abbreviation HI Number of Painkiller Prescriptions per 100 People Number of painkiller prescriptions per 100 people CDC. Opioid Painkiller Prescribing. Opioid Prescribing, by Specialty, % Percent Change From Baseline in Rate of Opioid Rx/Total Rx In 2012, rates of opioid prescribing were highest in pain medicine (48.6%), surgery (36.5%), and physical medicine/rehabilitation (35.5%) Although rates of opioid prescribing in primary care specialty groups were low (4.87.5%), those dispensed opioids accounted for almost 50% of all dispensed opioid prescriptions Additionally, nonphysician prescribers accounted for 11.2% of all dispensed opioids 10% Physical med and rehab Pain medicine Internal medicine General practice Nonphysician prescriber Family practice Total Surgery Dentistry Emergency medicine 5% 0% -5% -10% 2007 *Percentage change depicts the cumulative, absolute change away from 2007 rate for opioid prescriptions as a fraction of total prescriptions Levy B, et al. Am J Prev Med. 2015;49:

4 Impact of Nonmedical Use of POs in Adolescence on the Risk of Future Heroin Use Nonmedical use of POs increases the odds of riskier drug use, including heroin, in younger cohorts Prior use of nonmedical prescription opioids in adolescence is a strong predictor of heroin use onset Risk of heroin initiation was 13 times higher among individuals who reported nonmedical prescription opioid use than those who had no history (95% CI, ) Risk was highest among those who were first exposed to nonmedical prescription opioids in early adolescence (10-12 years of age) (HR, 15.42; 95% CI, ) Palamar JJ, et al. Drug Alcohol Depend. 2016;158:132-8; Cerda M, et al. J Pediatr. 2015;167:e1-2. Incidence of Acute HCV Among Persons Aged 30 years, by Urbanicity and Year (KY, TN, VA, WV, ) *95% confidence interval No. of Cases per 100,000 Population * Non-urban Urban Year CDC. MMWR Morb Mortal Wkly Rep. 2015;64:

5 Newly Reported (Chronic or Acute) HCV Infection, NM, Number of Reported Cases Year Age Age < Page K. Hepatitis C Epidemiology in New Mexico: The Role of Injection Drug Use. New Mexico Annual HIV & HCV Update Conference. Albuquerque, NM. April 30, HIV Outbreak in Scott County, IN Scott County ranks 92nd out of 92 counties in many social and health indicators Outbreak centered in the town of Austin, IN Population: ~4,200 19% of population living below the poverty line 10% unemployment rate 21% did not graduate high school Before the outbreak, free HIV testing had not been unavailable since 2013 Austin has only 1 PCP and the nearest hospital/ed is 5 miles away in Scottsburg, IN County Health Rankings. Scott County, IN. Janowicz DM. Top Antivir Med. 2016;24:90-2; Peters PJ, et al. N Engl J Med. 2016;375:

6 2015 Scott County Outbreak, Epidemiology a As of April 2016 b As of November 2015 In December 2014, multiple new cases of HIV were diagnosed in Scott County All cases linked to IDU, specifically to the injection of oxymorphone As of May 2016, 191 confirmed cases of HIV Median age: 34 years (18-60) a 58% male, 100% non-hispanic white a 92% coinfected with HCV (167/181) a 96% reported IDU (173/181) b 95% with annual income < $10,000 a Multigenerational sharing of injection equipment 513 total contacts traced 38% positivity rate among tested contacts Nearly 5% prevalence in Austin > 300 individuals remain at risk Conrad C, et al. MMWR Morb Mortal Wkly Rep. 2015;64:443-4; ISDH. Scott County Public Health Emergency Declaration Extended. Janowicz DM. Top Antivir Med. 2016;24:90-2; Peters PJ, et al. N Engl J Med. 2016;375: Epidemic Curve: Scott County, IN, Outbreak Count Nov Nov 14 7 Dec Nov Dec Dec Dec 14 4 Jan Jan Jan Jan 15 1 Feb 15 8 Feb Feb Feb 15 1 Mar 15 8 Mar Mar Mar Mar 15 5 Apr Apr Apr Apr 15 3 May May May May May 15 7 June Jun June Jun 15 5 Jul Jul Jul Jul 15 2 Aug 15 9 Aug Aug Aug Aug 15 6 Sep Sept Sept 15 Adams J. N Engl J Med. 2015;373:

7 Counties Within the 95th Percentile of Most Vulnerable to Future HIV and/or HCV Outbreaks Ranked Index Top 200 counties Van Handel MM, et al. J Acquir Immune Defic Syndr. 2016;73: Challenges in Reaching Rural PWID Dispersed and hidden populations Medically underserved Gaps and lacks in services and providers Poverty Cultural differences Stigma Fear of mistreatment and criminalization Shame Slide courtesy of Dr. Patrick Milligan. 7

8 HCV and HIV Prevention Toolbox for PWID Before exposure Drug treatment for opioid disorder HCV/HIV testing and counselling PrEP for HIV prevention Reducing HCV/HIV transmission in serodiscordant injecting and sexual partners Abstinence Point of transmission Change in injecting behavior Clean injecting equipment Needles Ancillary equip Alcohol, bleach After exposure HCV treatment Prevent HCV reinfection HIV treatment Slide courtesy of Dr. Patrick Milligan. Before Exposure: Screening for IDU in Primary Care Several evidence-based screening tools for drug use and opioid risk can be used in the primary care setting Screening Tool Patient Age Group Method of Administration Adult Adolescent Selfadministered Clinicianadministered Prescreens CRAFFT (Part A) X X X NIDA Drug Use Screening Tool: X See APA Adapted See APA Adapted X Quick Screen NM ASSIST tools NM ASSIST tools Opioid Risk Tool X X X Full Screens CAGE-AID X X CRAFFT X X X DAST-10 X X X DAST-20: Adolescent Version X X X NIDA Drug Use Screening Tool X X NIH. Chart of Evidence-Based Screening Tools for Adults and Adolescents. NIH. American Psychiatric Association Adapted NIDA Modified ASSIST Tools. 8

9 MAT for Opioid Use Disorder MAT can reduce the incidence of HIV and HCV infections by 54% and > 60%, respectively, but barriers to its implementation are disproportionately higher in rural areas The shortage of MAT providers and opioid treatment programs has improved largely in part to an increase in buprenorphine providers Shortages still remain disproportionately high in rural areas In 2011, 60% of small, non-metropolitan residents lived in shortage areas, compared with 5% of metropolitan residents Patients often lack insurance, experience onerous treatment demands, feel stigma, can be pressured to end MAT therapy by providers, and lack social support In many areas of need, including rural areas, insurance policies do not cover the therapy MacArthur GJ, et al. BMJ. 2012;345;e5945; Tsui JI, et al. JAMA Intern Med. 2014;174: ; Dick AW, et al. Health Aff (Millwood). 2015;34: ; Knudsen HK, et al. J Stud Alcohol Drugs. 2014;73: Before Exposure: Identifying PWID at Risk of HCV / HIV Medical settings Primary care Ante-natal care ED Drug-treatment programs Pharmacies Nonmedical settings SEPs (mobile and non-mobile) Jail Home Traveling providers, peer educators Community outreach centers Slide courtesy of Dr. Patrick Milligan. 9

10 Point of Transmission: Safer Injection Practices and SSPs Research shows that SSPs are a highly effective strategy to prevent HIV and possibly HCV among PWID HIV diagnoses among PWID dropped by 48% from 2008 to 2014, and HIV-prevention programs, including SSPs, were instrumental in this decline Basic services of SSPs allow PWID to exchange used needles and syringes for new, sterile needles and syringes 200 sterile syringes per injector per year for a high level of coverage (UNAIDS) Services can be expanded to included HCV/HIV testing, linkage to care, and treatment for substance use disorders amfar. Preventing HIV and Hepatitis C Among People Who Inject Drugs: Public Funding for Syringe Services Programs Makes the Difference. CDC. HIV and Injection Drug Use. Des Jarlais DC, et al. MMWR Morb Mort Wkly Rep. 2015;64: ; UNAIDS. People Who Inject Drugs. HIV Incidence and Public Funding, Laws allowing SSPs, permitting OTC sales of syringes, and providing public funding for SSPs are associated with reducing new HIV incidence and maintaining already low levels of incidence among PWID HIV Incidence and Public Funding, States With High Infection Rates That REMAINED HIGH, High new HIV infections yearly (> 2%) Florida Louisiana South Carolina Texas States With High Infection Rates That DECLINED TO LOW, Connecticut District of Columbia Maryland Massachusetts Michigan North Carolina New Jersey New York Oklahoma Pennsylvania Tennessee Virginia Wisconsin States With Low Infection Rates That REMAINED LOW, Arizona California Colorado Missouri New Mexico Ohio Oregon Utah Washington Low new HIV infections yearly (< 2%) Note: Bolded states are those that receive public funding for SSPs. Bramson H, et al. J Public Health Policy. 2015;36:212-30; amfar. Preventing HIV and Hepatitis C Among People Who Inject Drugs: Public Funding for Syringe Services Programs Makes the Difference. 10

11 OST, NSPs, and HCV Incidence 2.5 HCV Incidence, 95% CI Opioid substitution therapy High NSP vs no/ low NSP coverage Low NSP vs no NSP Combined: OST & NSP vs NSP (no OST) Combined: OST & NSP vs low NSP Slide courtesy of Dr. Kimberly Page. Laboratory Screening for PrEP Candidates HIV Must be HIV negative Renal function CrCl 60 ml/min HBV TDF/FTC may be recommended Referral to infectious disease specialist Pregnancy Positive pregnancy test does not preclude women from PrEP, but potential risks and benefits of PrEP should be discussed CDC. PrEP for the Prevention of HIV Infection in the US. 11

12 Clinical Study of PrEP in PWID Bangkok Tenofovir Study (2013) investigated the effects of a PrEP strategy for HIV prevention in 2,413 Thai PWID Cumulative Probability of HIV Infection, % Kaplan-Meier Estimates of Time to HIV Infection in the Modified Intention-to-Treat Population TDF Placebo Number at Risk Months Since Randomization TDF 1,204 1, Placebo 1,207 1, % reduction in HIV incidence (95% CI, ; P =.01) 73.5% reduction in HIV incidence in individuals with detectable drug levels (95% CI, ; P =.03) Choopanya K, et al. Lancet. 2013;381: Revised PrEP Algorithm (May 2015) Intake Visit - Risk assessment - Lab tests: - HIV viral load -CrCl - HBV sag - HBV sab -Verify insurance Viral load positive Risk assessment negative or CrCl < 60 - HIV Ab test - Refer for cart Viral load negative PrEP is contraindicated Initiation Visit (<7 days from Intake) - Verify labs - Counseling - Additional HBV counseling if necessary Prescribe TDF/FTC for 30 days, 2 refills 90-Day Visit - Counseling - Pill count - Check CrCl - HIV Ab test - Risk assessment 2-week visit for adherence (first time only) 30-Day Visit - Counseling - Pill count - Optional HIV Ab test 60-Day Visit - Counseling - Pill count - Optional HIV Ab test Janowicz DM. Persistent Challenges of HIV Transmission Control in Injection Drug Use: Lessons From the Indiana Outbreak. IAS Los Angeles, CA. April 25,

13 Project ECHO: Effect on HCV Care in Rural Settings Almost 94% of providers participating in an ECHO clinic in Utah and Arizona had no experience managing HCV After participating in the clinic, 46% of patients seen were started on treatment An ECHO program conducted through the Indian Health Service reported that 100% of its participants found benefits of participating, including being wellinformed, having access to expertise, collegiality, and decreased professional isolation One-half of respondents indicated they would not have treated HCV without regular participation in the ECHO clinics In New Mexico, the ECHO model was used to develop a program focused on the treatment of substance use disorders and behavioral health (Integrated Addictions and Psychiatry Clinic) Mitruka K, et al. MMWR Morb Mort Wkly Rep. 2014;63:393-8; Pindyck T, et al. SAGE Open Med. 2015;3: ; Komaromy M, et al. Subst Abus. 2016;37:20-4. Acknowledgment of Commercial Support This activity is supported by an educational grant from Gilead Sciences, Inc. Contact Information Call (toll-free) info@med-iq.com Please visit us online at for additional activities provided by Med-IQ. 13

14 To receive credit, click the Get Credit tab at the bottom of the Webcast for access to the evaluation, attestation, and post-test Unless otherwise indicated, photographed subjects who appear within the content of this activity or on artwork associated with this activity are models; they are not actual patients or doctors. 14

15 Abbreviations CDC = Centers for Disease Control and Prevention ECHO = Extension for Community Health Outcomes ED = emergency department HCV = hepatitis C virus HIV = human immunodeficiency virus IDU = injection drug use MAT = medication assisted therapy NSP = needle and syringe program OST = opioid substitution therapy OTC = over the counter PCP = primary care provider PO = prescription opioids PrEP = pre exposure prophylaxis PWID = people who inject drugs SEP = syringe exchange program SSP = syringe services program US = United States