1/5 Natl Partners Response to the Opioid Epidemic & Inf. Diseases Pt 1 State Gov. Perspectives

1/5 Natl Partners Response to the Opioid Epidemic & Inf. Diseases Pt 1 State Gov. Perspectives


Good afternoon, everyone, and welcome to
“Hidden Casualties Webinars: The Consequences of the Opioid Epidemic on
the Spread of Infectious Diseases”, hosted by the Office of HIV/AIDS and Infectious
Disease Policy here at the Department of Health and Human Services. I’m really
thrilled to welcome all of you here this afternoon for a continuation of our work
to really explore what folks are doing nationally, at the state and local levels,
around the increases of infectious diseases related to the opioid epidemic
and to really foster a comprehensive response to the opioid epidemic overall.
I want to make sure that everyone is aware that, next slide please, the audio
for today’s webinar is via a phone line and that information should be available
through the confirmation that you received by email for this webinar. Next
slide, please. Also during today’s webinar, we have Eric Cortes helping us through Twitter. If you have questions throughout the
webinar, you can tweet those to @HHS_viralhep, use the hashtag “#opioidcrisis” and also use the question box in the chat feature
on the webinar interface. So there are a number of ways. We’ll also be opening it
up for oral questions after all of the presenters are complete. So with that, I’d
like to turn the webinar over to my colleague, our Director of the Office of
HIV/AIDS and Infectious Disease Policy, Richard Wolitski. Thanks so much, Corinna.
Hello everyone. Pleasure to be here with you today. I’m going to go ahead and just kind of cover some of the epidemiology that’s related to the opioid
epidemic and spread in the United States and talk about some of the infectious
disease consequences that we’re seeing in the data. Go ahead to the next slide.
And here’s a spike that kind of illustrates two main things to me. This
is the number of opioid prescriptions that are dispensed per 100 persons between 2006 because of …. and so you see that, one if you look at the darker color, the dark red colors, you
see the concentration of higher prescribing rates in the southern states.
And we also see, when we look at rates per 100 people, we’ve got rates as high as more in the highest category over 107. So we’re seeing way more prescriptions than
are probably medically necessary and programs are taking action to reduce
those prescriptions. Let’s go to the next slide. What we’ve seen, though, as a result
a combination of prescription, drug misuse, and the use of heroin and other
opioids, we;ve seen a massive increase in the number of deaths. This slide shows the
increase in deaths between 1999 and 2015. During a time when more than 500,000
people have died from an opioid overdose since 1999. And if you look at the lines,
we see an increase in heroin and synthetic opioids like fentanyl, as well
as an increase from among prescription opioids and no increase in methadone.So
this really seems to be driven by a combination of heroin, synthetic opioids,
and prescription drugs. Let’s go to the next slide. Here we really start to get
at the interconnection between drug overdose and new hepatitis C infections.
If you look at the red colors in the map of the U.S. on the left, you see drug
overdose death rates, with the red colors representing the higher rates. Now compare this to the figures that it’s next to it for reported new HCV infections in
the U.S. We see that there’s a good deal of correspondence between the two. We see correlation in the data between them. So in the places where there’s a greater
increase in overdose deaths, we tend to see a greater increase in hepatitis B
infection. Next slide. Overall, we’re seeing increase in
injection drug use as being driven by the opioid crisis. Overall, heroin use has increased more than 60% and it’s increased even more
rapidly to 114 percent among whites in recent years. The heroin and prescription
opioid epidemic could lead to new HIV outbreaks, and in fact we’ve seen that
happen in at least one jurisdiction. Next slide. This kind of breaks down the
data a little bit by age group and so what we see is that when we look at the
increase in opioid injection by age, we see that there was a 400% increase
amongst people between the ages of 18 and 29 and their admission for opioids
injections increased by over 600%. When we look at that people between the ages of
30 and 39 years old, we also see extremely high rates of HCV infection,
increasing by 325 percent during this period and admissions to hospital
emergency room for opioid injection by 83 percent – that’s per treatment program
probably treatment program admission, we see that increase by 83%. Substantial
increases over a relatively short period of time. One of the markers of how severe
this epidemic really is. Let’s take a look specifically about the
impact in women in the next slide. So we see that from 2004 to 2014, we see a
dramatic increase in opioid injection among women. It’s associated with a 99
percent increase in admissions for opioid injection and is followed by a
250 percent increase in new hepatitis C infections. Next slide. Sadly, we’re seeing
the impact even translate to infants. Forty percent of infants who are born to HBV virus-infected mothers will develop chronic infection and without treatment,
a quarter of them will die from liver disease. From 2009 to 2014, HCV infections among women giving birth nearly doubled. We’re seeing impact on really a wide
range of people, particularly youth people who inject drugs, women and their
infants. Next slide. After years and years of decline and consistent decline, we now
see beginnings of potential increase in new HIV infections among people who
inject drugs For the past 10 years we saw 63 percent decline in new diagnoses
among people living with HIV and new diagnosis of HIV among people who inject
drugs. But between 2014 and 2015, we’ve seen our first increase in quite a while.
There’s a 4% increase between those two years, signaling the potential for
national increase in new HIV infection rates. But the risk isn’t only limited to
HIV and viral hepatitis. We see a number of other infectious diseases being
affected by the opioid crisis as well. Go to the next slide. We know, we’ve seen from data
data starting from 2002 going up to 2012, hospitalizations associated with opioid use and dependence increasing for a number of infectious diseases. Endocarditis has gone up 46 percent. Septic arthritis has gone up 166 percent. Epidural abscesses have gone up 164 percent and osteomyelitis is gone up 115 percent.
This is something that has an implication for many conditions and
really threatens the health of a large number of people. And speaking more
specifically to that, the next slide looks at the distribution of counties
that CDC has identified as being potentially vulnerable to an outbreak of
HIV infection among people who inject drugs. That’s what are shown in small dots in the pink. You can see concentration of these
the southern Appalachian region and the northeastern U.S. as well. And what’s shown in green color in the states this is the 39 states, or states that contain counties, that have met the criteria, the Determination of Need, that
is required to allow the use of federal funds to support comprehensive syringe.
services programs. You see a pretty good correspondence between the states that
have been identified as having counties at with a high risk of an HIV outbreak
among people living with HIV, with people who inject drugs, but we don’t see
perfect correspondence and we’re concerned about the number of states
where these funds are not being used for prevention programs for people who inject
drugs, well, for syringe services programs. Next slide. We’re going to talk today
on the webinar more about the lessons that were learned in the outbreak in Scott
County. Indiana. As everyone knows, in 2015, we had just really a large outbreak
which was a sentinel event that really drew our attention to the intersection
between the opioid crisis, HIV, and HCV epidemics. This is the largest, best-documented outbreak of HIV and HCV infections among people who inject drugs and it shows us
the risk. But I think one of the things that we don’t focus on enough in
talking about Scott County and what was learned there is how it shows that when
you bring together the right resources, the right partners, the local state and
federal levels, that you can turn this around and you can stop an outbreak
dead in its tracks and we’ll be hearing more about what they’ve learned in Scott
County today. What we’ve been focusing on here at the federal level at HHS is
really what’s needed to develop a comprehensive response to the opioid
epidemic and how can we assist states and communities in building that type of
response. HHS has issued a five-point strategy to combat the opioid crisis
that’s comprehensive, evidence-based, targets drivers of the epidemic, and is
flexible to emerging threats. It focuses on better addiction,
prevention, treatment and recovery services that are overdoses services,
better research, better data, and better pain management. Now, when we look at this, though, what we don’t see and increasingly, we’re seeing this next
wave of consequences of the opioid epidemic that are related to infectious
diseases. So we’ve been working within HHS with a number of partners to define
a framework that articulates what is possible and which should be done with
regard to addressing the intersection of the opioid crisis, HIV, hepatitis, and
other infectious diseases. This model is one that’s patient-centered, is designed to
address multiple needs and risks of the individual. It starts with the client: what they need and what their risks are. It’s designed to
meet the needs of all people who use drugs and focuses primarily on people
who inject drugs but recognizes that all persons with a substance use disorder or
potential risk for progression to injection and additional risks
associated with injection. It’s focused on helping people to achieve the best
health outcomes that are possible for them. It involves collaboration across
programs and funding streams that extend beyond traditional partnerships, through
the barriers and services. It promotes information and resource sharing. It’s
integrated. It promotes integrated, co-located services and if that’s not
possible, active referral services that allow people
to easily access services offered by other programs. It builds on the
existing infrastructure. We don’t need to create another siloed program to address
the opioid crisis and infectious diseases that come with it. We can do
this with our infrastructure that exists already today. And I think this framework gives us a general starting place for looking at
what can, and should be done, to better address these intersections but I want to
acknowledge this is a work-in-progress and is continuing to evolve. Let’s move on to the next slide. We’ve seen in a number of ways that comprehensive community action is key to this. It’s something that we have to go where the
problem is, identify the areas of need, and mobilize
community health and law enforcement sectors to address the issue
collaboratively. We know that comprehensive prevention programs are
what’s needed. We need substance use treatment, naloxone, HIV and hepatitis
testing, linkage treatment for people who are diagnosed positive, and we know that
syringe service programs are an important component of a comprehensive response,
especially with regard to HIV. The evidence shows that people who use
syringe service programs are five times more likely to enter drug treatment and
three times more likely to stop injecting. This counteracts one of the
main concerns that people have about these programs, that they may increase the
risks but in fact, they don’t. And data are showing that these programs are cost-saving. These are good investments for our communities to make. They save lives
and they save healthcare costs as well. Okay, go on to the next slide. We’ve talked a little bit about this, but this is an evolving epidemic and each month, each
year that we go through it, we learn more. In the beginning, the earlier opioid
response focussed on activities that were about limiting supply and preventing
deaths, so expanded substance use disorder treatment and naloxone
availability. We know that many infectious disease programs have not fully
integrated key prevention services or partnerships to better serve people who
use drugs. And with this just being essentially, we have to have a two-way street here. We
have to have infecious disease programs doing their part to support the opioid response, and
we have to have the programs that are supported by the opioid response funding
to address infectious disease issues as well. And I think we have to recognize
that what we do and how we do it has the potential to make a huge difference in
how in our culture with regard to how people with injection drug use histories,
with HIV, with hepatitis are treated, stigma and how our public health system and our
healthcare systems work together to better serve the needs of the patient
and the community member. So this is going to be my last slide. And I want to kind of ask you to consider “what can you do”? I think one of the most basic things that those of you working in the field can do is to look at your programs
and activities to assess how you’re addressing the opioid and infectious disease risks
or needs of your communities and the clients you serve. We ask you to identify
opportunities and to join the response. Ask you to look for ways for how you can
enhance your programs that are serving people who are at risk for substance use
disorders. I want to encourage you to engage with new partners, to accept or to
refer recommended services. And we want you to communicate with leaders in your
community, the local governments, with funders about the needs of the community and to
provide them with the evidence that shows what works, what’s effective in
addressing these issues. This is a big problem; it requires all of us; and it
requires that we work with new partners in new ways. And I’m excited that you’re
here today with us to talk about it and to learn from some of our partners
who’ve been leading the way in this work. I want to thank you for listening to this
overview presentation of the data and I’m excited to hear with you what’s
really happening out in the field. So Corinna. Thank you very much, Rich. So now, I’d like to welcome Steve Daviss from the Substance Abuse and Mental Health
Services Administration. Steve is a Senior Medical Advisor in the Office of
the Chief Medical Officer and is joining us here today to talk a little bit about
the HIV- and viral hepatitis-related activities and SAMHSA’s work in
these areas. Steve? Oh, thank you, Corinna, appreciate it and thank you, Rich.
It’s a good tee-up of some of the data and sets the frame for all the work that
we’re doing. So I just want to spend the next five minutes or so talking
about some of the activities around HIV and viral hepatitis that SAMHSA is working
on. And my contact information is on my last slide as well if anyone wants to
reach out. So, next slide. So SAMHSA’s mission. I wanted to state that here for those for you that dont’ know. Our mission is to reduce the impact of substance use and mental
the impact of substance abuse and mental illness on America’s communities. The key
message, the four key messages, that we keep driving home is that behavioral
health is essential to health in general, that prevention works, treatment is
effective, and people do recover. Next slide. So this, the funds for from the Minority
AIDS Initiative are primarily what I’m going to be referring to here. And SAMHSA
is among eight other, a total of eight, I think, HHS agencies and Offices that are
responsible for implementation of the Minority AIDS Initiative or MAI. SAMHSA
receives MAI funding to provide mental health and substance use disorder
prevention and treatment services to improve health outcomes and reduce
disparities in minority communities at high risk for or living with HIV/AIDS or
viral hepatitis. We have, I think, it’s about one hundred and thirty million dollars
across three different Centers here at SAMHSA: the Center for Substance Abuse
Treatment, the Center for Substance Abuse Prevention, and the Center for Mental
Health Services. The next page. So I’m going to highlight the grants and
programs. I may leave a couple out but I think I’ve got the majority of them. And
probably the biggest one is this Targeted Capacity Expansion HIV grant
which you’ll sometimes hear referred to as TCE-HIV. So we’ve got about 120
grantees. So this is a pretty large program, and the activities that this program
results in includes an increase in engagement in care for high-risk
minority populations with SUD or substance use disorders;
substance use disorder treatment and recovery support; but also HIV and
hepatitis testing and vaccination which is critical because previously that
wasn’t done as much in many of these programs; referral and linkage to care
and case management for persons identified with HIV and or hepatitis; in
addition to housing support services; outreach; and enhancement and expansion
of infrastructure and capacity to retain clients in treatment. It’s great to get
them in but you got to keep them. Next slide. There’s also a Continuum of Care
Pilot MAI-CoC. Continuum of Care which has 34 grantees, and this grant
focuses on stimulating co-location and integration of HIV and hepatitis
services inside of behavioral health care settings and also provides for
behavioral health treatment and substance abuse prevention. It includes
set-aside funds for viral hepatitis prevention, vaccination, testing and
linkage to care and also, through some of the Secretary’s MAI funds, for some
grantees, establishes and enhances linkage between their programs and existing
community syringe service programs. Also included are wraparound services,
recovery support, outreach and other engagement strategies. Next slide, please. Three more grants I’ll talk about
briefly. The first is Minority-Serving Institutions Community-Based
Organizations or MSI-CBO. This provides substance misuse education and testing
in communities that are really at the highest risk for substance use disorders
with HIV and hepatitis C. A second grant, Capacity Building Initiative, CBI. The Capacity Building Initiative focuses
on education and awareness programs, in addition to social marketing campaigns,
testing services in non-traditional settings in high-risk communities,
particularly targeting youth and young adults. And then the Prevention Navigator
Program which uses a navigation approach to deliver comprehensive substance
misuse and HIV-related support services to youth and young adults and especially
for males who have sex with other males who are not in stable housing. Next slide,
please. Finally, just some other highlights of
other activities at SAMHSA that works on. There’s this Rapid HIV/Hepatitis Testing
I guess mechanism or forum for that is available to all grantees. And I saw
some numbers recently that we’ve had over 75,000 people tested. This includes
linkage to care for both prevention and treatment services. There’s also a
ongoing collaboration with HRSA’s Ryan White Program, with the CDC, with the
National Institutes of Health on multiple projects. We also collaborate on the
National HIV/AIDS Strategy, the National Viral Hepatitis Action Plan, and the
Federal Viral Hepatitis Implementation Group. And then internally because we
have three Centers within SAMHSA that all have different aspects of that, of these
grant funding responsibilities, and some of them overlap, we have a monthly HIV
Team meeting that we hold here. Next page, please slide. Before I go, I just
wanted to highlight a couple of new resources that SAMHSA has put out, just I
think in the past two weeks. One of them is TIP 63. TIP is “Treatment Improvement
Protocol” and this one focuses on medications for opioid use disorder.
We had previous TIPS that were older. One focused on buprenorphine; one
focused on methadone mostly. This really is a unified, updated TIP that combines
all the Medication Assisted Treatment options out there. So it’s available now
and if you go to our main page – it’s SAMHSA.gov (the link that is on the last page), you’ll see
it right in the front because it’s on the rolling screen that we have. The
other. So please download that. The other thing is, if any of you listening are
treating pregnant women or women who are parenting who have opioid use disorder
and their infants, we developed clinical guidance for treating this population
for women with opioid use disorder and that is also available now on our
website. Last slide, please. So again, I wanted to thank you for the opportunity
to speak to you all today and I will pass the baton back to Corinna. Thank you.
Thank you so much, Steve, really appreciate that overview. I think we’ve
been working with SAMHSA for a number of years, along with other federal partners
and really trying to facilitate that coordination that you were talking about
in the last couple of slides. So I appreciate your highlighting that,
and I hope that folks are aware that there are parts all across
government like SAMHSA, CDC, HRSA and others that are working to respond and
to encourage their networks to respond to the opioid epidemic. Produced by the US Department of Health and Human Services at taxpayer expense.

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