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OR-HOPEOregon HIV/Hepatitis and
Opioid Prevention and Engagement
OPAT Summit May 31, 2019
The authors and presenters (Ann Thomas, Jude Leahy, Gillian Leichtling) have no real or
apparent conflicts of interest to report.
This project is supported by grant number UG3DA044831 (PI: P. Todd Korthuis, MD MPH) from the National Institute on Drug Abuse
Disclosures
Describe the impact of intertwined epidemics
of opioid use disorder, infectious diseases,
and overdose in Oregon
Discuss approaches to increase access to
screening, treatment, and harm reduction
services in rural Oregon
Identify the components of a comprehensive
rural model to address the medical
consequences of opioid use disorder
Learning Objectives
Injection drug use has led to outbreaks of hepatitis C and HIV in rural communities
Need to improve understanding of opioid use disorder, hepatitis C/HIV transmission, and treatment access
Need to increase access to treatment in rural areas
Background
Peters et al., 2016; Van Handel et al., 2016; Sigmon et al., 2014
6
PilotAugust 2017 – August 2019
OR-HOPE Communities
2 Pilot Counties▪ Douglas▪ Lane
9 Expansion Counties▪ Douglas, Lane▪ Clatsop▪ Columbia▪ Coos
▪ Curry▪ Josephine▪ Lincoln▪ Tillamook
ExpansionAugust 2019 – August 2022
Provider Level
Patient Level
Community/Structural Level
Data Collection and Interventions
Community/Structural LevelData Collection
▪ Environmental scan of resources and policies
▪ Analysis of county data on opioid/drug-related hospitalizations, deaths, infectious disease
▪ Stakeholder interviews
Interventions
▪ Communities integrate strategies to address illicit drugs and infectious disease into community response plans
Provider LevelData Collection
▪ Buprenorphine prescriber list
▪ Hepatitis C treatment prescriber numbers
Interventions
▪ Buprenorphine waiver trainings
▪ Addiction Medicine ECHO
▪ Hepatitis C ECHO
▪ HOPE curriculum on opioid use disorder, hep C, HIV
Patient LevelData Collection
▪ Risk assessment surveys with people who inject drugs (PWID)
▪ Qualitative interviews with PWID
Interventions
▪ Syringe exchange, mobile outreach
▪ Peer support specialists providing:
▪ HCV/HIV testing
▪ Harm reduction (naloxone, fentanyl test strips, syringes)
▪ Linkage to treatment and other services
PEER INTERVENTION
Pilot Peer Intervention
Who are they?▪ Have lived experience with SUD▪ Have completed Peer Support
certification▪ Supported by HIV Alliance
Joanna
LarryWhat do they do?
▪ Community and syringe exchange outreach
▪ Build relationships▪ Provide harm reduction
“gift bags”
▪ Offer HCV/HIV/syphilis testing▪ Facilitate linkage to substance
use disorder (SUD) tx, primary care, HCV/HIV tx
▪ Provide housing assistance
60% of participants (98 of 144) have accepted peer services. Among those, participants received assistance with:
6%
21%
24%
30%
21%
25%
29%
41%
46%
100%
43%
HOUSING
FENTANYL STRIPS
NALOXONE
MOBILE SYRINGE EXCHANGE
FAMILY SERVICES
LEGAL ISSUES
INSURANCE APPLICATIONS
GOALS SETTING
TRANSPORTATION
SUD SERVICE ENGAGEMENT
DAILY LIVING RESOURCES
Linkage to SUD Treatment
(N = 98)
14
10 Methadone
4 Buprenorphine
18% attended SUD
treatment appointments
18 participants started medications for opioid use disorder (MOUD)
Participant perspective on peer services
15
Peer support services are valued
“They’re more empathetic, usually, to someone’s situation because they’ve been in the same shoes. They’ve done it, so they’re living proof right in front of you that you can get out of living this hellish lifestyle that we’re in. And if you need encouragement and people who don’t ever give up, it’s nice to be shown that.”
SELECTED PILOT FINDINGS
Epidemiological Data Highlights
Statewide Rates of chronic HCV in persons < 30 2013-2017
Chronic HCV cases in persons < 30 years87% increase in intervention counties
0
10
20
30
40
50
60
70
2013 2014 2015 2016 2017
Rat
e p
er
10
0,0
00
Po
pu
lati
on
Intervention County Rate
PDX Area Rate
Oregon, Excluding Intervention Counties & PDX
Statewide Opioid Overdose Hospitalizations 2012-2016
Opioid Overdose Hospitalizations 26% increase in intervention counties
0
5
10
15
20
25
30
35
40
2012 2013 2014 2015 2016
Rat
e p
er
10
0,0
00
Po
pu
lati
on
Intervention County Rate
PDX Area Rate
Oregon, Excluding Intervention Counties & PDX
Methamphetamine/Psychostimulant Hospitalizations 2012-2016
Methamphetamine/Psychostimulant Hospitalizations 67% increase in intervention counties
0
2
4
6
8
10
12
14
2012 2013 2014 2015 2016
Rat
e p
er
10
0,0
00
Intervention County Rate
PDX Area Rate
Oregon, Excluding Intervention Counties & PDX
Most counties have few prescribers of HCV antivirals relative to the number of people with HCV
Highlights from Survey of People who Inject Drugs
(Douglas, rural Lane)
Participant Inclusion Criteria(Respondent-Driven
Sampling)
26
Any injection drug use in past 30 days (opioids or methamphetamine)
OrRecreational prescription opioid non-injection use in past 30 days
AndLive in study area
Age ≥ 18 years
English speaking
Consent for risk survey and future linkage of biologic and survey data to administrative data
Participant Demographics
(N = 144)
27
27% 19-29 years old
40% 30-39 years old
20% 40-49 years old
13% 50-60 years old
57% male 43% female
Participant Demographics
(N = 144)
28
80% White
8% Mixed race
7% American Indian
4% Other (combined)
Race
88% Non-Hispanic
10% Hispanic
2% Don’t Know
Ethnicity
Participant Characteristics
(N = 144)
29
68% homeless in
past 6 months
51% incarcerated
in past 6 months
37% on community
supervision in past 6 months
Drug preference split between
heroin and meth. Heroin users also
use meth.(N = 144)
30
Drug of choice
50% injected heroin
78% injected meth
Heroin44%Meth
49%
Other7%
Past 30 day injection
Almost half have shared
in past 30 days
(N = 125)
31
Past 30 days…
44%
Used needle after someone else
Used cooker / cotton / water after someone else
Let someone else use cooker / cotton / water after using
34%
45%
Half are HCV positive. Only 7
participants received HCV tx
in past 6 months.(N=133)
32
26% self-reported positive
27% new positive
50% negative
Most getting needles from pharmacy. Needle exchange also common. (N=132)
Pharmacy
60%
Someone who got them from needle exchange
41%
Needle exchange
46%
Friend / acquaintance
42%
Spouse / partner / gf / bf / family
19%
Drug dealer or street syringe seller
23%
Source of Sterile Needles
Most have witnessed an
overdose.Less than a third have naloxone.
(N=144)
34
42%
Ever witnessed an overdose
Ever overdosed
73%
28%Currently have naloxone
23% have not received recent
medical care(N=144)
35
Main place received medical care in past 6 months
10% ever hospitalized for
serious infection of heart/bone/joint
Other 1%
Health Dept 1%
Urgent Care 8%
Community Health Ctr 14%
None 23%
Private doctor 22%
Emergency Room 43%
Reasons for not seeking medical care (N=128)
14%
18%
21%
23%
26%
35%
39%
40%
43%
49%
50%
I treated myself
Treated poorly at clinic in past
Clinic hours were not convenient
Did not have transportation
Not sure where to go
Could not pay
Was too drunk or high
Don’t care about taking care of self
Don’t trust doctors
Did not want to be seen at clinic
Was afraid they’d treat me with disrespect because of my drug use
Many have received MOUD
for addiction. One in five
recently failed to get access to tx.
(N=144)
37
30%
BuprenorphineN=113
Methadone treatment
N=115
38%
Received ever
20% tried to get addiction tx but unable to
In past 6 months
Highlights from Qualitative Interviews with PWID
(Douglas, rural Lane)
Meth use among people who use opioids: reasons, implications
Barriers in accessing…
▪ Healthcare services
▪ Substance use disorder treatment
▪ Sterile syringes
Highlighted Topics
What are the reasons for
increased meth use?
40
Changes in availability and price of heroin and meth
“I’d rather do heroin, but meth is so much cheaper and easier to get.”
Adding meth for beneficial effects, e.g., to improve functioning
“I work in [timber industry job]. My job is super fast-paced…I use [meth] as a tool so that I can work my 10-and-a-half-hour day with it and go home and still be a husband and do what I need to do all day long… I have a family I have to look after.”
What are the reasons for
increased meth use?
Continued
41
Shifting to meth use as a harm reduction from heroin, e.g., to reduce withdrawal or dependence
“So that’s why I guess I do heroin less now, is because I do methamphetamine… I’ve toned down the heroin use because I’ve lost… A lot of my friends have died, and the endocarditis heart condition…I’ve known 30 people that have gotten that.
Implications of Meth Co-Use
42
▪ Need for treatment tailoring, provider education and support
▪ Some participants report being discharged from medications for opioid use disorder due to meth use
▪ Need for overdose education
▪ Some participants perceived meth as conveying overdose prevention or reversal benefits.
▪ Participant reports and fentanyl test strip results show fentanyl adulteration of methamphetamine
43
Access barriers
“I gave her my whole spiel, and so then she gave me a whole resource booklet to then look through... [multiple phone calls, lack of response or availability]… and I never did get in yet. So I started going to church.”
Experience of mistreatment
“…in the hospital, the doctor purposefully spoke very, very loud so everyone out in the hall could hear that I was a drug addict and stuff. It really violated my confidentiality because there are other people out there, not just healthcare workers.”
“They just look down at me like I’m less than human, and it messes with me.”
What barriers do PWID report in
engaging in healthcare services?
Healthcare Barriers
Continued
44
Fear of arrest
“[Hospital staff] call the freaking police on you if you have a warrant. If you’re on probation and you piss a dirty UA, they’ll call the cops, call your PO. I thought that was against the law, like doctor-patient confidentiality.”
“Because I had a warrant, and I don’t know why the hospital here… If you have a warrant, the hospital calls the cops. But they’re not supposed to do that, because I think that’s against the law. Isn’t it?”
What barriers do PWID report in
engaging in SUD Treatment?
45
Access barriers
“I wish that there were more doctors around here who did the methadone or Suboxone programs and stuff. There are hardly any here in town, and there are waiting lists and it’s hard to get in. It’s really hard to wait.”
Criminal justice system barriers
“Jail is mostly the number one thing that gets in the way, in and out of jail…I am supposed to be on Suboxone Tuesday, and if I go to jail, I’ll miss that. I can’t miss that; I’ve been waiting on that for four weeks.”
SUD Treatment Barriers
Continued
46
“There was nothing [residential] here, and every time I would find a bed in a treatment facility—you’ve got to call every day to see if your bed’s available or not—well, a bed became available, and my PO would have me in jail and wouldn’t let me out. You can’t make the phone call every day from jail to see if your bed’s available. I lost like eight or nine different beds before finally I absconded. I just left. I told [my PO], “You know what? Screw you. I’m not staying in this county. I’m going to leave.” I went to Portland… I completed the treatment and then I came back here. It was the next day I came in and reported to [my PO], and [my PO] took me to jail for 20 days for going to rehab.”
SUD Treatment Barriers
Continued
47
Lack of supportive housing
“I shouldn’t be out here like this. If I can make it to a clinic every day and take medicine [MOUD] while I’m homeless, living on the sidewalk, don’t they think that they could put me somewhere?...if I was in a place, it would be so much easier for me. I probably wouldn’t use meth or heroin anymore. I would just take my medicine and go home, but I don’t have a home.”
What barriers do PWID report in
accessing sterile syringes?
48
Access barriers
“If I have transportation, I would use clean syringes all the time, either by buying them at the pharmacy or coming [to syringe exchange].”
Pharmacy barriers
“Walgreens, which is close, they won’t even sell them to you if you don’t have ID.”
Stigma/fear of discovery
“I would be afraid that family would see my car parked out front, or I would run into somebody with a bag in my hand. I take a huge risk by going into Walmart and asking for them, too.”
DISCUSSION
Thoughts?
50
How can rural communities
collaborate effectively across
sectors (including criminal justice,
treatment, health care, and harm
reduction services)?
What policy and infrastructure
changes are needed to reduce
harm and increase treatment
access?
How can we use existing resources
to make each contact an open door
to treatment?
Principal Investigator, Todd Korthuis
Co-Investigator, Ann Thomas
Project Manager, Gillian Leichtling
Viral Hepatitis Coordinator, Jude Leahy
Contact Oregon HOPE
