News & Views: The Opioid Epidemic, Infectious Diseases and Vaccines

Recently, more attention has been paid to the opioid epidemic occurring in the U.S. Current statistics indicate that about 116 people died every day in 2016 from opioid-related drug overdoses, and about 11.5 million people misused prescription opioids. The 2016 societal costs were estimated to be around $504 billion. Even more alarming, in March 2018, Morbidity and Mortality Weekly Report (MMWR) published an article, "Vital Signs: Trends in Emergency Department Visits for Suspected Opioid Overdoses — United States, July 2016 – September 2017," indicating about a 30 percent increase in emergency department visits for opioid overdoses between July 2016 and September 2017. Rates increased across all age groups and in both females and males with the highest increases in metropolitan areas with a major city and a population of at least 1 million people. A decrease in life expectancy for the second year in a row is also being blamed on the opioid epidemic. U.S. life expectancy decreased from 78.9 in 2014 to 78.7 in 2015 to 78.6 in 2016.

Much of the focus on the epidemic has been on two aspects. First, increasing the use of antidotes, like naloxone, in the community, and second, decreasing the use of addictive painkillers, like Percocet®, a combination drug that contains acetaminophen and oxycodone (an opioid). However, another aspect of this crisis is also starting to gain attention. Specifically, as injection drug use increases, so too are health-related issues associated with injection drug use. These issues fall into two main categories — those caused by injecting needles and those caused by sharing needles:

• Health effects of injecting needles — A systematic review of injuries associated with drug injection by Larney and colleagues (Drug and Alcohol Dependence 2017; 171:39-49) identified abscesses and soft tissue infections that can also lead to further complications, such as endocarditis, sepsis, bone and joint infections, and thrombosis and emboli.
• Health effects of sharing needles — The greatest risks associated with the sharing of needles are those associated with transmission of infectious agents, particularly bloodborne pathogens. Increases in the number of HIV, hepatitis B and hepatitis C infections have been documented with the latter of these rising at a greater pace according to a perspective article by Liang and Ward (N Engl J Med 2018; 378:1169-71). Zibbell and colleagues (Am J Public Health. Feb. 2018; 108(2):175-81) completed an 11-year analysis (2004-2014) of the incidence of hepatitis C infections and rates of injection drug use and found that “increases in opioid injection mirrored those for reported cases of acute HCV infection among demographic subgroups.” Because the greatest increases are being seen in adults younger than 40 years old, particularly in women of child-bearing age, increasing numbers of babies are infected with hepatitis C virus at birth.
• A third category related to non-needle-associated health effects, such as increases in sexually transmitted diseases, including syphilis, has also been documented. Increases in the numbers of infants experiencing drug withdrawal after birth, called neonatal abstinence syndrome (NAS), are also being found (Zibbell and colleagues).

As indicated by the breadth of health-related issues mentioned and the age-span of those affected, healthcare providers in all clinical settings are by necessity responding to this public health epidemic. Perhaps most importantly, any healthcare provider prescribing or filling medications should do so responsibly. Because many people become addicted after being prescribed an opioid-based pain killer following a medical or surgical procedure, it is imperative to reframe the conversations we are having around pain with patients and to create better pain management strategies. Other considerations and practices:

• Prevention — Although HIV and hepatitis C are not vaccine-preventable, hepatitis B is. Make sure your at-risk patients are immune.
• Diagnosis — Monitor at-risk patients for infections, like hepatitis C and HIV, including newborns if indicated.
• Discussion — Talk with patients about pain management as well as to evaluate any need for support related to addiction and treatment.
• Support — Communicate with local treatment and support programs to create community networks, including syringe support programs. Support families of those affected with programming and literature to assist with navigating concerns or getting support. These efforts can include having a list of local treatment and support programs available for patients and families, holding community discussions, or serving on expert panels to answer questions.

Read more about federal and state responses.

Additional resources

• Department of Health and Human Services webpage
• National Viral Hepatitis Action Plan, 2017-2020
• Pandora’s Lab: Seven Stories of Science Gone Wrong, by Paul A. Offit, MD, includes a chapter, “God’s Own Medicine,” which describes the history and science behind these addictive drugs. Google’s online preview includes this chapter.