The Linkage Between Syringe Use and Infectious Disease

Introductory Paragraph

With drug use on the rise, a major concern for those with an SUD should be the potential catching or spreading infectious diseases. Infectious diseases associated with substance use, such as HIV, AIDS, and Hepatitis C are largely contracted through both unsafe substance use conditions and unprotected sexual intercourse, a high-risk behavior that may be attributed to impaired judgment. Infectious disease can be unknowingly passed to fellow users, sexual partners, an unborn baby, or to a baby through breastmilk. Those who have an SUD are often less likely to receive timely, routine health care needed for early diagnosis and treatment. Left untreated, these diseases can quickly decrease the quality of life and lead to serious health consequences as well as death.

Key Information

Hepatitis C virus (HCV) infections tripled between 2010 and 2015. Among people who inject drugs, Hepatitis C is three times more prevalent than HIV. In most countries, more than half the people who inject drugs live with Hepatitis C. Substance abuse and infectious diseases share common populations, risk factors, social determinants, and even contracting venues. There is little collaboration between programs which provide services to these populations. Methadone clinics would be optimal venues for service integration because 60% of the population served by these clinics are injection drug users. Further, they have medical staff performing brief health assessments for all new clients. Methadone clinics already have some infectious disease screenings in place, including routine tuberculosis testing and intermittent opt-in HIV testing. One study showed that 68% of opioid treatment programs nationwide had staff capacity for HCV testing, but only 33% actually offered on-site HCV testing. Awareness of HCV infection among this particular population may motivate them to reduce their consumption and related high-risk behaviors.

Types of Infectious Diseases Related to Substance Use

The most commonly known SUD-related infectious diseases include HIV, AIDS, and HCV. Substance use can also cause or contribute to many other infectious diseases which are life-threatening.

• Human Immunodeficiency Virus (HIV) infects the body’s immune cells that are needed to fight infections, making the person increasingly vulnerable to other infections and diseases and unable to effectively fight them off. HIV is most commonly spread through shared injection equipment and unprotected sex. While there is no current cure, the earlier it is diagnosed, the better and longer it can be managed with medication. Symptoms of HIV may come and go, varying at different stages, or a person may be asymptomatic for years, increasing the likelihood of unknown transmission to others. If HIV is left untreated, it can lead to AIDS.

• Acquired Immunodeficiency Syndrome (AIDS), the last stage of HIV, occurs when the immune system is severely damaged and leaves the person with less than 200 CD4 cells - white blood cells that are an essential part of the human immune system. The normal range is 500-1,600 CD4 cells, and with less than 200 CD4 cells, the person cannot fight off “opportunistic infections," such as pneumonia, tuberculosis, and toxoplasmosis. Without treatment, a person with AIDS will have a life expectancy of 1-3 years. Opportunistic infections can still occur without the presence of HIV or AIDS. Continued substance use has been linked to “increased susceptibility to infections” and have “marked immunomodulatory effects” which prevent efficient healing and can increase the likelihood of spreading the infection. These infections can be viral, bacterial, fungal or parasitic and have devastating health effects when not diagnosed and treated in a timely manner and/ may be exacerbated by continued substance use.

• Hepatitis B is most commonly spread through injection drug use. It can be spread through contaminated needles as well as shared drug equipment. Hepatitis B is highly contagious and has no cure, but it can be managed with medication. Patients may be asymptomatic or experience acute symptoms (jaundice, fatigue, nausea vomiting). Those who develop a chronic infection are likely to develop cirrhosis of the liver.

• Hepatitis C is spread through the use of injected substances, from mother-to-baby during birth, and unprotected sexual intercourse. Hepatitis C is a blood-born infection, meaning it can spread through contact with the blood of an infected person, whether or not that person has any symptoms. It has a high transmission rate (50% of people with an SUD contract Hepatitis C). . Data shows that 50-85% of patients with Hepatitis C will have chronic infections which can cause fibrosis and cirrhosis of the liver along with hepatic carcinoma. Early diagnosis is made difficult due to the fact that Hepatitis C can remain asymptomatic for an extended period of time.

• Sexually Transmitted Infections. STIs are a common comorbidity with SUDs and pose a significant public health issue. It has been well-documented that substance use disorder is associated with high-risk behaviors, such as engaging in unsafe sexual encounters, whether recreational or for the purpose of buying or selling drugs. . This, coupled with delayed healthcare, allows the spread of STIs to go undetected and untreated in vulnerable populations.

Implications. The consequences of a comorbid SUD and infectious disease are vast and impactful, both on the individual and the community. Below are just a few examples of the risks and implications of substance use-related infectious diseases:

• Comorbidity and SUD often go hand-in-hand, with patients often having more than one type of persistent infection or disease and increased likelihood to have other medical and psychiatric comorbidities which increase the likelihood of mortality. These can make it difficult to treat, as addiction treatment providers are often not trained to evaluate for infectious diseases.
• Lack of screening and testing increases likelihood of late presentation stages in SUD-related infectious diseases, causing unintended transmission to others and poorer health outcomes.
• Continued drug use may make it easier for HIV to enter the brain, causing increased nerve cell damage and impaired cognition and memory
• A few examples of the social costs of SUD-related infectious diseases:
  • Average lifetime medical cost of HIV is $510,000 per person
  • A 2016 Hepatitis outbreak cost $367 million in hospital costs
  • Invasive bacterial infections associated with drug use cost communities over $700 million in 2012

The need for improved screening for infectious diseases is well-documented:

• Globally, about ⅔ of injected drug users contract Hepatitis C
• More than 50% of persons in the United States who inject drugs have tested positive for Hepatitis C
• About 6 in 100 infants born to mothers with Hepatitis C become infected with the Hepatitis C virus.
• Fewer than half of U.S. treatment facilities conduct infectious disease screenings
• A study of young adults (18-25 years old) who had been diagnosed with an STI showed 38.4% had also used illicit drugs at the time of contraction
• Increased use of injected opioids has been linked to 400% increase of Hepatitis C and 119% increase in Hepatitis B among 18-29 year olds
• People who inject drugs account for 9% of HIV diagnosis, and many states are experiencing a plateau in early reduction rates

Facilities most likely to provide on-site screenings are federally-funded facilities, opioid-specific treatment sites, and hospital inpatient sites. Despite the prevalence and the personal and public health issues that result, fewer than half of all treatment facilities conduct infectious disease screenings as part of their standard-of-care. It is imperative that early screening and education be expanded and improved in order to prevent the spread of infectious disease and to provide early intervention for those who are already infected.

Relevant Research

Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. Chapter 6 of this report titled, “Health Care Systems and Substance Use Disorders,” highlights the need to integrate SUD treatment and care with both mental and physical health care for a comprehensive, collaborative approach to treatment. Along with interagency collaboration, increasing health coverage for SUD treatment and expanding healthcare technology and accessibility is integral in reaching more people with an SUD and provide early detection of infectious diseases. Chapter 7 of this report discusses the proposed public health approach model based on clinical evidence.

The Johns Hopkins Center for Substance Use & Infectious Disease Care Integration is testing the efficacy of improving SUD and infectious disease treatment through collaborative and integrative efforts and innovative interdisciplinary efforts. Studies focus on peer-supportive collaborative care, outpatient links for MAT in emergency departments, tele-health access, and rapid HCV treatment approaches for people who inject drugs.

Literature Review. This article titled, "Infectious Diseases Occurring in the Context of Substance Use Disorders: A Concise Review," is user-friendly and accessible across disciplines. It covers the types of infectious diseases associated with SUD and the problems it poses for early detection, especially in the addiction treatment context. It also includes recommendations for providers.

Infective Endocarditis is a potentially fatal inflammation of valves in the heart. This article documents a large, five-year (2012-2017) cohort study for SUD-related infective endocarditis. Those diagnosed with infective endocarditis and subsequently diagnosed with an SUD increased from 19.9% to 39.4%. Hospitalizations for infective endocarditis among those with an SUD more than doubled, and 50.3% of these hospitalizations also had a co-morbid Staphylococcus Aureus infection.

Impactful Federal, State, and Local Policies

• The CDC has launched State-led Vulnerability Assessments to use local data to identify high-risk areas, along with finding prevention and intervention gaps to develop plans to address these gaps and disparities.

• The Harm Reduction Grant Program is a federal program designed to help support community-based programs that focus on reducing the harmful impacts of opioid use. This includes overdose prevention, syringe services, and other harm reduction services. Communities can use this to implement proper and consistent screening protocols for infectious disease, comprehensive treatment, and educational outreach

• The Virginia Department of Health provides a Comprehensive Harm Reduction (CHR) program that allows CHR sites to be established in any Virginia jurisdiction. This removes several restrictions regarding safe syringe sites, referrals to treatment, testing, and access to many other services. CHR sites need authorization from the State Health Commissioner, and once approved, will be protected from prosecutorial actions regarding paraphernalia distribution (in line with treatment) and will no longer need support letters to apply.

Available Tools and Resources

• National Harm Reduction Technical Assistance (TA) Center. SAMHSA and the CDC have collaborated on this effort to move beyond education, in order to expand individual and community efforts in harm reduction. This means providing support for Naloxone distribution and administration, safer sex kits, HIV and viral hepatitis testing, COVID-19 response, reduction of community stigma, and opportunities for collaboration between harm reduction and other community efforts (e.g., peer-delivered recovery support efforts).

• Screening for Infectious Diseases Among Substance Abusers Treatment Improvement Protocol (TIP). A comprehensive toolkit created by SAMHSA's Center for Substance Abuse Treatment covers the definitions of substance abuse, infectious disease related to SUD, guidelines and recommendations for screening, implementation, role of the counselor, risk assessment, testing procedures (pre- and pos-), contract tracing, and much more.

• TIP 53 Screening for Infectious Diseases Among Substance Users: Quick Guide For Clinicians is a quick pocket-guide based on the toolkit listed above for clinicians to reference.

Promising Practices

• Project ECHO (Extension for Community Healthcare Outcomes) was developed by the University of New Mexico Health Sciences Center. ECHO uses tele-health technology to bridge the gap in services for providers and patients in rural communities or areas without specialists. The model provides training and support for providers, as well as consultations with specialists. This model can easily integrate screening and treatment services which are hard to come by in rural and impoverished communities.

• Philadelphia. This website is an example of a resource for people seeking to identify if they have hepatitis, next steps they can take, and where they can find care or assistance.

• Tennessee. The "Test, Listen, Cure" (TLC) community awareness campaign for Hepatitis C provides information about how the Hepatitis infection is transmitted, risk factors for the disease, the importance of screening and treatment, and the availability of improved treatment for the disease.

• Vermont uses the hub-and-spoke model to integrate providers across primary, acute, and behavioral health settings to collaboratively treat patients with MAT while also addressing other physical, mental, and life problems. This interagency effort allows patient access to all necessary treatments in a systematic implementation, including medical assessment and treatment for infectious diseases.