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.

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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

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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

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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%)

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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

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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

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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

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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

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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

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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

pcss@aaap.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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