By: Daniel Raymond
Last month, the Indiana Department of Public Health announced an HIV outbreak in Southeastern Indiana linked to injection of the prescription painkiller Opana. Since last December, 27 infections have been confirmed, with an additional ten cases suspected. While the majority of cases were found among injectors, some are attributed to sexual transmission.
This is the first documented HIV outbreak in the United States associated with injection of a prescription painkiller. HIV rates associated with injection drug use have declined substantially over the last twenty years in the U.S. At the same time, hepatitis C infections — which had shown a parallel decline — are now rising again, including in Indiana. Health advocates have been sounding the alarm that if hepatitis C is spreading among injectors, HIV won’t be far behind. Unfortunately we’re now seeing that prediction borne out.
We’re now in what I call the second phase of America’s opioid epidemic. The first phase, from the late ‘90s up through a few years ago, was characterized by a dramatic rise in the use and misuse of prescription painkillers. These drugs were heavily marketed, heavily prescribed, and readily available — resulting in skyrocketing rates of opioid dependence and overdose. But heroin use was largely stable, and injection of opioids was uncommon.
In this second phase, the prescription opioid overdose epidemic has morphed into a full-fledged opioid epidemic, with rising drug injection and heroin use. As more opioid users transitioned to injection, hepatitis C spread quickly through syringes and injection equipment shared within social networks. CDC estimates that between 2010 and 2012, new hepatitis C infections rose 75%, to about 23,000 new cases a year. Like HIV, hepatitis C is a blood-borne virus, but tends to spread more quickly among social networks of drug injectors through shared syringes and injection equipment.
In 2011, Indiana’s state health department worked with a mental health and substance abuse program to investigate a cluster of new hepatitis C infections, primarily in Eastern Indiana. They found that new hepatitis C cases typically occurred among white, rural injectors who had used prescription opioids before transitioning to heroin injection. The average age was 24, and split nearly evenly between men and women. This profile is similar to what we’re seeing in many parts of the country.
Under our current approach to the opioid epidemic, this latest HIV outbreak was inevitable. In the first phase of the opioid epidemic, the policy responses at the state and federal levels focused primarily on controlling the supply of prescription opioids. That meant shutting down pill mills, developing opioid prescribing guidelines, establishing prescription drug monitoring programs, setting up takeback days to dispose of unused prescription drugs, and other strategies to reduce the availability of prescription opioids.
These are all sensible policies, with some indications of success — prescription opioid overdoses seem to have leveled off in recent years — and you could argue that if these had been in place in the late ‘90s, we might never have experienced the current opioid epidemic. However, for hundreds of thousands of people, they came too late, and the initial supply-focused strategies failed to reckon with the large cohort of people who had become dependent on opioids.
That failure to address demand for opioids — through expanding harm reduction and drug treatment, prevention and education, in parallel with supply reduction approaches — has fostered the transition to injection and heroin use, growing rates of heroin overdose, more hepatitis C infections, and now an HIV outbreak. The deadly lag in addressing demand for opioids has left a fertile ground for heroin to spread to rural and suburban communities that had never had to grapple with heroin before.
We need to make a serious commitment to expanding harm reduction and drug treatment. This means syringe exchange programs on the frontlines, to engage prescription opioid and heroin injectors at risk of overdose, HIV and hepatitis C. We know syringe exchange is the most effective way to reach these people, protect their health, and link them to care and treatment. Kentucky is one state currently considering heroin legislation which includes a provision allowing syringe exchange programs. My organization, the Harm Reduction Coalition, is currently working with groups in Kentucky, Indiana, and Ohio that are hoping to start syringe exchange in their communities.
We’re also working with Congress to address the federal funding ban on syringe exchange, which handcuffs states and communities that are struggling to respond to their opioid epidemics and halt the rise in hepatitis C infections. For many, it seems counterintuitive to address a health problem linked to injection drug use by making syringes more readily available — but the reality is that it’s the shortage of syringes that leads to hepatitis C and HIV, and the availability of syringes does not increase drug use.
Some politicians fear that supporting syringe exchange sends the wrong message and condones drug use, but the message they’re inadvertently sending is that government is turning its back on people and communities struggling most with the opioid epidemic. We need to put this debate to rest — I don’t accept that the people getting infected today with hepatitis C and HIV are inevitable collateral damage of our failure to address opioid demand, and I am not willing to write off a whole generation of people caught up in the opioid epidemic.
We also need to prioritize effective drug treatment for opioid dependence. As a society, we’ve long been skeptical and reluctant to treat opioid dependence with medications such as methadone and buprenorphine. We need to ensure that medication-assisted treatment is the standard of care for opioid dependence.
Drug treatment programs and policies that do not prescribe or permit use of FDA-approved medications are committing malpractice and causing high rates of relapse and overdose. We’re seeing mounting evidence that methadone and buprenorphine not only treat addiction, allowing people to rebuild their lives and move into recovery, but also play an important role in reducing hepatitis C infections when they — like syringe access — are widely available.
Five years from now, I hope we can look back and say that this outbreak was an anomaly, and not a harbinger of a resurgent HIV epidemic. The Indiana health department has moved quickly to respond; other health departments should take note and strengthen their surveillance and policies to guard against similar outbreaks. And the federal government should support those efforts, committing more energy to hepatitis C prevention, drug treatment, and harm reduction.
Most of all, we can’t continue to prioritize “upstream” supply reduction strategies while neglecting “downstream” demand and harm reduction. The opioid epidemic is a major public health crisis which may have begun with opioid prescribing, but does not end there. We can no longer accept “winning” the opioid prescribing battle when we’re losing the broader war against addiction, overdose, and hepatitis C.