Jan. 23, 2020

Policy, Financing, Stigma, and Workforce Barriers Stand in the Way of Addressing Co-Occurring Opioid and Infectious Disease Epidemics

WASHINGTON — The opioid epidemic in the U.S. is driving a simultaneous epidemic of infectious diseases — including HIV, hepatitis C virus (HCV) and bacterial infections, and sexually transmitted infections — but workforce shortages, stigma, and financial and policy barriers are preventing the integration of opioid use disorder (OUD) and infectious disease services, says a new report from the National Academies of Sciences, Engineering, and Medicine. The report recommends state and federal policy actions, including removing insurance requirements on prescribing medications for OUD (i.e., buprenorphine), expanding access to medications in criminal justice settings, and lifting state bans on syringe service programs.

The rise of infectious diseases related to OUD is attributed to sharing needles, having unprotected sex, and lacking access to medical care, says Opportunities to Improve Opioid Use Disorder and Infectious Disease Services: Integrating Responses to a Dual Epidemic. Over the past few years, four states hardest hit by the opioid epidemic — Tennessee, Kentucky, Ohio, and West Virginia — have seen a 364 percent increase in acute HCV infections. In rural areas in particular, there is a shortage of providers — including physicians, social workers, therapists, and counselors — available to care for patients in an integrated way.

Methadone clinics, primary care clinics, and jails and prisons see thousands of patients with concurrent OUD and infectious diseases annually, and should be leveraged as integrated care sites, the report says. However, some organizations are unable to provide integrated services because of restrictions on the types of services they can provide. For example, some state Medicaid laws do not allow billing for medical care and behavioral health services on the same day. Other states ban syringe service programs, despite evidence that these programs can link patients to more intensive treatment for OUD and infectious disease as well as prevent new cases of infectious disease.

“Substance and opioid use disorder treatment is already segregated from traditional medical care. Treating OUD and infectious diseases as separate epidemics only reinforces stigma,” said Carlos del Rio, professor of medicine at Emory University School of Medicine and professor of global health at the Rollins School of Public Health of Emory University, and chair of the committee that wrote the report. “The better we integrate services, the sooner we can connect people to diagnosis, treatment, and prevention and achieve successful health outcomes.”

The report identifies nine barriers to the integration of OUD and infectious disease care. These barriers, and the corresponding recommendations, were informed by interviews with 11 programs throughout the U.S. that are working to integrate their services for OUD and infectious diseases.

Prior Authorization Policies
Prior authorization requires that prescribers obtain approval from an insurer to prescribe buprenorphine (a treatment for OUD) to patients. This process delays care, which often means patients continue to inject opioids and partake in high-risk sexual behaviors, thereby increasing the risk of infectious disease. State Medicaid programs and private insurers should remove prior authorization requirements on OUD treatments, along with other requirements such as step therapy, limits on certain doses, or the requirement of concurrent psychosocial therapy.

DATA Waiver (“X-Waiver”) Requirement
Almost 20 million people live in counties without a single provider who is permitted to prescribe buprenorphine. Programs cited the time-consuming training (eight hours for physicians, 24 hours for nurses and physician assistants) as a major barrier to obtaining a waiver to prescribe. Congress should amend the Drug Addiction Treatment Act of 2000 (DATA Act) to allow eligible providers to prescribe buprenorphine without undergoing the mandatory training, the report recommends.

Limitations on Syringe Service Programs
Federal funding for syringe service programs has been minimal or inconsistent, the report says. Congress should lift the ban on using federal funds to purchase injection equipment at syringe service programs. States should also increase funding to these programs.

Same-Day Billing Restrictions
States should revise their billing policies to allow for more than one service in a given day; allow multiple providers to bill on the same day for the same patient; or allow the same provider to bill for different diagnoses, the report recommends.

Disconnect Between the Public Health and Criminal Justice Systems
More than 200,000 people who use heroin enter jail or prison annually. Entry into the criminal justice system is strongly correlated with increased HIV and HCV acquisition among people who inject drugs (81 percent and 62 percent increased risk, respectively). Correctional facilities should offer evidence-based screening and treatments for OUD and co-occurring infectious disease, so patients do not lose viral suppression or relapse upon release. States should also ensure that individuals exiting the criminal justice system are re-enrolled in insurance and connected with appropriate care in the community, the report says.

The recommendations also include addressing workforce and training inadequacies and improving data sharing, reducing stigma in clinical settings, and promoting harm reduction strategies. These strategies are grounded in providers “meeting patients where they are,” and recognizing small successes toward better health. They include distributing naloxone to patients and their family members, prescribing PrEP, and providing safe drug-use and safe-sex education.

Because of the scale of these dual epidemics, the report recommends that Congress authorize and appropriate funding in order to provide comprehensive, integrated services to low-income uninsured or underinsured individuals with co-occurring OUD and infectious diseases.

The study — undertaken by the Committee on Examination of the Integration of Opioid and Infectious Disease Prevention Efforts in Select Programs — was sponsored by the U.S. Department of Health and Human Services, Office of Infectious Disease and HIV/AIDS Policy.

The National Academies of Sciences, Engineering, and Medicine are private, nonprofit institutions that provide independent, objective analysis and advice to the nation to solve complex problems and inform public policy decisions related to science, technology, and medicine. They operate under an 1863 congressional charter to the National Academy of Sciences, signed by President Lincoln.

Report Highlights

Stephanie Miceli, Media Relations Officer

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