Overdose Prevention: An Infectious Disease Program Responsibility

By Magalie Lerman August 31, 2016

Today, on August 31st, NASTAD (National Alliance of State & Territorial AIDS Directors) joins hundreds of organizations across the globe in remembering people who have died from overdose as part of International Overdose Awareness Day. It has been more than a year since the CDC announced that the United States is experiencing an opioid epidemic, and overdose rates continue to rise. More than 47,000 Americans died in 2014 due to drug overdose and over 28,000 of those deaths were opioid-related. Hepatitis C infection (HCV) rates among people who inject drugs are rising at a similarly alarming rate. Health systems are under pressure to adapt to meet the complex healthcare needs of people who use drugs.

National overdose-related death rates and national HCV-related death rates are both increasing year-by-year
National overdose-related death rates and national HCV-related death rates are both increasing year-by-year

Health department overdose prevention and care efforts are unique in that they don’t reside in any one program within health departments. Some states, such as New Mexico and New York, have harm reduction programs where overdose prevention is integrated into the infectious disease program. In other jurisdictions, behavioral health programs take administrative responsibility; and in many jurisdictions, injury prevention has primary responsibility for overdose prevention and care. No matter who leads the charge, we all have a role to play in preventing overdose and the most effective responses have been those that mobilize resources, commitment, and political will from across state agencies and executive offices. Infectious disease is but one aspect of comprehensive healthcare and people who use drugs have to stay alive in order for us to help keep them disease free or virally suppressed. Furthermore, drug overdose is a common cause of non-AIDS death among people living with HIV.  

Perhaps a “silver-lining” to the opioid epidemic is that it has required infectious disease, injury prevention, and behavioral health partners to work more closely with one another. While overdose is not an infectious disease, state HIV and HCV prevention programs have extensive expertise in serving injection drug users, who are at-risk for HIV, HCV, and overdose, including through the integration of preventive services into drug and alcohol treatment programs and primary care. Once everyone gets past turf wars, programs can work together to ensure the best practice of offering naloxone alongside HIV and HCV testing at syringe services programs (SSPs), jails and prisons, methadone clinics and substance use treatment facilities, as well as homeless shelters and drop-ins. Furthermore, ensuring payers and systems cover and provide naloxone and that overdose prevention education is available in healthcare settings and community-based organizations (CBOs) ensures the widespread scale up and sustainability of these efforts. Leveraging partnerships and third-party reimbursement mechanisms takes the burden off of CBOs and syringe service programs (SSPs) who often use their limited funds to purchase naloxone at the wholesale acquisition price. As a safety net, health departments should be supplying naloxone wherever possible.

Health departments also play an important role in advancing sensible drug user health policies in their jurisdictions. For example, health departments have successfully supported local advocacy efforts to pass effective Good Samaritan laws that provide immunity to anyone who calls 911 in the event of an overdose. In addition, laws that allow for the widespread and uninhibited distribution of naloxone will advance overdose prevention efforts, as will innovative programs for people who use drugs such as supervised consumption rooms and pre-booking diversion programs. Health departments have an important public health voice to add to these state initiatives. On a federal level, NASTAD has called on Medicaid and commercial payers to remove discriminatory limitations that have barred people with a history of drug use from accessing curative HCV treatment. We commend the White House for their leadership on addressing the opioid epidemic and we are excited about the passage of the Comprehensive Addiction and Recovery Act (CARA).  On the Hill, we work to make the connection between the opioid epidemic and HCV and HIV epidemics so that Congress might extend the attention given to substance use recovery services to include the infectious disease needs of people who use drugs.

I came to NASTAD a year ago to work on removing systemic barriers that impede drug user health. I had been providing direct services at a SSP and realized that I can only help people so much before hitting up against a broken system. I gave positive test results but couldn’t connect people with HCV treatment. I taught safe injection practices but couldn’t provide sterile supplies 24/7 because of the lack of funding for SSP. I provided naloxone to people who use drugs via standing order but people are often using alone out of shame and stigma and therefore dying alone. I want to erase the “but” and everything that comes afterwards. My time at NASTAD working with health departments has reinforced the unique role that health departments play in breaking down the silos between programs in order to address the comprehensive healthcare needs of people who use drugs; ways in which infectious disease programs are accelerating drug user health infrastructure and addressing stigma within healthcare settings. Last year, Congress adjusted a 30+ year ban on federal funding for syringe service programs. I know we still have a long way to go, but look how far we have come. We have more tools now – we can prevent overdose; we can save lives.

This blog is dedicated to all the people I have lost in my life to overdose: Zach, Derick, Brittany, Trey, Indie, Fuzzy, Ty, Will, Raven, and Kenny. May their loss prevent the loss of many more like them. Rest in peace my friends.

Learn more about overdose prevention by visiting www.overdoseday.com and reading these stories:

The following resources were referenced for the development of this blog post:

  1. Green TC et al. HIV infection and risk of overdose: a systematic review and meta-analysis. AIDS. 2012 Feb 20;26(4):403-17.
  2. CDC. Viral Hepatitis Surveillance, 2011.
  3. NIDA Research Report: “Prescription Drugs: Abuse and Addiction”
  4. HHS Technical Consultation: Hepatitis C Virus Infection in Young Persons who Inject Drugs, 2013
  5. NASTAD. Statement of Commitment: Promoting Injection Drug User Health