Opioid Epidemic Stigma Mirrors Early Rise of HIV

SAN FRANCISCO -- The current opioid epidemic in the U.S. is associated with the same stigma as the HIV epidemic was in the past, an expert said here.

While HIV is now treated as a "disease," and patients are immediately ushered into treatment, patients with opioid user disorder are framed as making a "choice." Yet, there is a significant intersection between patients acquiring infectious diseases who also have opioid use disorder.

"I tell [younger doctors] the opioid epidemic is going to be like the HIV epidemic was [when I was younger]," said Carlos Del Rio, MD, of Emory University in Atlanta, at a talk at ASM Microbe. "We're going to be here for a while."

He noted that a patient with HIV receives treatment in the hospital, is connected to outpatient care, given access to life-saving medications, and then the HIV is always addressed during medical encounters.

But Del Rio added that in the same patient with opioid use disorder, treatment is rarely addressed in the hospital, the patient is given a list of treatment programs, faces numerous barriers to medication, their addiction is ignored, and they often leave against medical advice.

Del Rio cited three waves of the opioid epidemic, starting with a rise in prescription opioid overdose deaths, followed by a rise in heroin overdose deaths, and finally a rise in synthetic opioid overdose deaths (from drugs such as fentanyl). And the opioid epidemic is linked with a rise in certain infectious diseases, he noted.

As the opioid epidemic goes, so goes an increase in hepatitis C (HCV) infections. With the link between HCV and injection drug use is well-known, Del Rio added that areas of the U.S. with significant opioid use have also experienced more HCV infections. In fact, compared with HIV, HCV is much more transmissible through sexual contact, such as receptive anal intercourse, Del Rio said.

But he also touched upon HIV and its link to opioid use, citing arguably the most famous recent HIV outbreak in the U.S. in Scott County, Indiana. This outbreak was linked to the injectable opioid Opana, and needle sharing. In what has become a too-familiar refrain throughout the opioid epidemic -- Scott County had a 9% unemployment rate, with 19% of its citizens living below the poverty line.

"In 2015, the HIV rate in this single Indiana county was [higher] than any country in sub-Saharan Africa," Del Rio noted.

Research may also be pointing to an increased risk of invasive pneumococcal disease thanks to the opioid epidemic, he said. People living with HIV also were linked with a higher risk of community-acquired pneumonia if they were currently prescribed opioids. Del Rio cited a "huge increase" in drug use-associated infective endocarditis from 2007 to 2017.

He gave an example from a colleague in Portland, who said that in the internal medicine service, they are seeing more hospitalizations for endocarditis in injection drug users than hospitalizations for uncontrolled diabetes.

The problem has caught the attention of the National Academies of Sciences, Engineering and Medicine, Del Rio said, where a committee that he is chairing is examining the "intersection of opioids and infectious disease," with the next meeting scheduled this month.

Del Rio characterized the opioid epidemic as a "public health emergency," and said that addressing it could take some lessons from the early days of the HIV epidemic, where the initial response was to blame the patients.

He also recommended standard-of-care treatment models, educating the medical community, employing community activism, and recognizing that much of the opioid epidemic is linked to poverty, so it's important to avoid stigmatizing language in reference to opioid users.

"We need a public health approach to prevention, diagnosis and treatment, [but] we need to go beyond the epidemic and address stigma," Del Rio said.