In 2019, drug overdoses took the lives of more than 70,000 people in the United States. In West Virginia, which sees the greatest overdose rate in the U.S., recent legislation has substantially undermined syringe services program (SSP) delivery, which is a major part of the public health toolkit to prevent transmission of HIV and HCV (hepatitis C virus) infections and overdose from opioids. In the absence of what were widely available SSPs, the remaining tools involve clinicians in primary care who have the ability to screen for, treat, and prevent these adverse outcomes, especially in rural communities where services are limited.
Frederick Altice, MD, professor of medicine (infectious diseases) and of public health (microbial diseases) at Yale, has brought together team members from both Yale (Lynn Madden, PhD, MPA, assistant professor) and West Virginia University (Judith Feinberg, MD) to implement integrated care to take steps to curb these intertwined and devastating epidemics through providing coaching, new tools, and tele-education and support to primary care clinicians to provide specialized services in rural settings. With the support of a $6.6 million grant from the National Institute on Drug Abuse (NIDA), his team will join forces with the West Virginia Primary Care Association and the West Virginia Practice-Based Research Network at West Virginia University.
What is the importance of this grant?
Altice: Health care systems and funding remain very siloed. A patient struggling with opioid use disorder and HIV often requires referral to multiple specialists. While treatment and prevention for HIV, HCV, and opioid use disorder have become increasingly easy to provide, they often remain in the hands of specialty clinicians. The NIH is deeply invested in creating a potentially sustainable model where primary care providers could more holistically take care of patients.
Because primary care clinicians may not have the skill set to provide this kind of integrated care, the research involves providing tools embedded within the electronic medical record, expert coaching in process improvement, and a tele-education platform that is designed to democratize specialty care for primary care providers. Project ECHO, the training platform, provides didactic and case-based collaborative learning to bring primary care providers’ level of care up to the same level that patients would receive from a specialty provider. This is especially important where there are shortages of infectious disease specialists and addiction treatment specialists. We want to change the climate such that the primary care provider can more holistically care for their patients and limit referring a patient out to multiple specialists.
How are the opioid epidemic and HIV/HCV infection outbreaks intertwined?
The way that they are intertwined is through the injection of drugs with shared contaminated injecting equipment. This can transmit HIV very efficiently and is the primary route. One of the most effective tools to reduce overdose, HIV, and HCV, is medication for opioid use disorder. One medication, buprenorphine, is ideally situated to be prescribed by primary care providers. In addition, HIV can be transmitted sexually. The disinhibition of using a mind-altering substance—in this case opioids—increases the risk of sexual transmission. It’s a double whammy. Other medications can also be prescribed to prevent HIV (pre-exposure prophylaxis or PrEP) and both HIV and HCV can be treated. When they are, there are extraordinary prevention benefits to the community.
West Virginia has the highest overdose rate in the country and has experienced numerous HIV and HCV outbreaks. How urgent a public health crisis is this state facing?
On any given day in the United States, there are a couple hundred people who die from overdoses. If every night on the news, we learned that a Boeing-737 fell out of the sky, we would address the crisis as though it were one. Now, in West Virginia, the overdose rate is much higher than in any other state—and in this primarily rural state, specialty services are scarce. This is indeed an unabated crisis, and the number of people getting treatment is not appreciably increasing. Hence, many counties in West Virginia are now experiencing HIV and HCV outbreaks along with overdose-related deaths.
With the aid of the NIDA grant, what steps are you planning on taking to address this problem?
We’re going to stratify across the state and identify 20 primary care settings. Then, we’re going to give primary care clinicians an array of tools with ongoing supportive coaching so that they can more holistically screen, treat, and prevent these intertwined diseases. Central to the methods we propose is the use of collaborative learning, where primary care clinicians will initially learn from experts and then increasingly transition to teach and learn from each other. This kind of learning is more sustainable than strategic planning and protocols that may not be suited for their context. Central to this approach is setting expectations, supporting them through coaching and collaborative learning, and rewarding them for their efforts.
The legislature in West Virginia recently reversed many of its protections afforded by syringe services programs in the state. What were these protections, and what is the impact of their reversal?
The big picture is that legislators have made many of these harm reduction programs inoperable. Many of the programs that provided life-saving resources, such as naloxone for treating overdoses or sterile syringes to prevent transmission of HIV and HCV, are now illegal unless they are linked to some kind of health care delivery system. Harm reduction has its roots in the community and not in traditional healthcare settings. In the absence of widely available SSPs, the work we propose will become even more important until the new policies are reversed. Harm reduction and SSPs provide many effective tools we have to prevent the adverse consequences of drug injection. In the absence of these tools, we’ve lost a major phalanx in helping people who inject drugs remain safe. Our new grant is like giving with one hand but the reduction in SSPs is like taking away with the other.
How will this research help address the opioid epidemic in other parts of the country?
The recent expansion of Medicaid was designed to strengthen primary care clinics. The long-term implication of our project is that it will provide a framework and toolkit so that many counties identified as vulnerable to HIV and HCV outbreaks will potentially have a framework to better integrate services where there were none previously. If our study is as successful as proposed, then it will have a great likelihood of being adopted by other places around the country that are also highly vulnerable. The CDC identified 220 counties around the country that are vulnerable to HIV and hepatitis C outbreaks. Being able to use the tools we’ve created in West Virginia should be easily adapted to many other similar settings and serve as a model for elsewhere.
How will this research change lives?
The opioid crisis greatly impacts more than the individual – it also a crisis in the way it disrupts families. It affects parents, siblings, relationships, and children. A child, for example, who is growing up in a household with a family member with an opioid use disorder is at substantially higher risk of developing a substance use disorder. If primary care clinicians can disrupt this cycle by treating the opioid use disorder with highly effective medications, it has a high likelihood of helping families. If we don’t address this quickly, we run the risk of losing a generation or two unless we address it more like the crisis it is.
What are you looking forward to the most about this project?
There are too many things to select just one, but important to me personally is that I was born in and have family in West Virginia. Though I left a long time ago, I do look forward to going back my roots and hopefully contributing something positive.