As a result of the opioid use disorder (OUD) epidemic (1), new epidemics of hepatitis C virus (HCV) and HIV infection have arisen and hospitalizations for bacteremia, endocarditis, skin and soft tissue infections, and osteomyelitis have increased (2–4). Optimal treatment of these conditions is often impeded by untreated OUD resulting in long hospital stays, frequent readmissions due to lack of adherence to antibiotic regimens or reinfection, substantial morbidity, and a heavy financial toll on the health care system. Medical settings that manage such infections offer a potential means of engaging people in treatment of OUD; however, few providers and hospitals treating such infections have the needed resources and capabilities (5). There is thus an urgent need to implement and scale up effective OUD treatment in health care settings to address the intersecting epidemics of OUD and its infectious disease (ID) consequences (6). The American College of Physicians (7), the Infectious Diseases Society of America (8), and the National Institutes of Health (9) have issued calls for action. Providers who treat the infectious complications of OUD, including ID physicians, hospitalists, emergency medicine physicians, intensivists, surgeons, obstetrician-gynecologists, pediatricians, nurses, advanced practice registered nurses, and physician assistants are at the forefront of these epidemics and are well-positioned to integrate OUD treatment in the context of ID management.
To address these intersecting epidemics, the U.S. Department of Health and Human Services (DHHS) requested that the National Academies of Sciences, Engineering, and Medicine convene a workshop, "Integrating Infectious Disease Considerations with Response to the Opioid Epidemic." The workshop took place on 12 and 13 March 2018 in Washington, DC, and participants included ID physicians, hospitalists, primary care providers, nurses, health policy experts, epidemiologists, law enforcement personnel, and staff from the DHHS and the Centers for Disease Control and Prevention. Videos and slides of the presentations are available at http://nationalacademies.org/hmd/Activities/PublicHealth/IntegratingInfectiousDiseaseConsiderationswithResponsetotheOpioidEpidemic/2018_MAR-12.aspx.
The workshop identified parallels between the current opioid epidemic and the early days of the HIV epidemic. Care of HIV-infected patients benefited greatly from the development of a highly trained interdisciplinary workforce and expanded access to treatment through the Ryan White Comprehensive AIDS Resources Emergency Act (Ryan White CARE Act) and other public health policies. Workshop participants agreed on the need for partnership across treatment settings and specialties, increased access to addiction care and funding, and improvement of addiction treatment expertise among providers who manage the infectious complications of OUD. On the basis of the workshop discussions, we agreed on 5 action steps.
Action Step 1: Implement screening for OUD in all relevant health care settings. All persons who are evaluated in medical settings for overdose, endocarditis, bacteremia, skin abscesses, vertebral osteomyelitis, HIV infection, and HCV infection should be screened for OUD. The Rapid Opioid Dependence Screen (created by S.A.S.) (10) takes less than 5 minutes to administer. Because ID specialists are likely to be consulted for anyone requiring long-term antibiotic therapy or patients with HIV and HCV infection, OUD screening should be a standard part of an ID consult assessment.
Action Step 2: For patients with positive screening results, immediately prescribe effective medication for OUD and/or opioid withdrawal symptoms. Opioid withdrawal and pain syndromes should be addressed with opioid agonist therapies to optimize ID treatment and relieve pain. Although complex pain syndromes may require initial management with short-acting full opioid agonists, treatment for OUD can begin as soon as possible during hospitalization. Three medications that are approved by the U.S. Food and Drug Administration (FDA) for treatment of OUD are effective at preventing relapse: methadone, buprenorphine, and extended-release naltrexone. Methadone and buprenorphine are opioid agonists that can be used for pain control and also to treat opioid withdrawal and prevent relapse. Extended-release naltrexone is a long-acting injectable opioid antagonist that...
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