Oregon's Syndemic

Oregon’s Syndemic: Substance Use, Overdose, STIs, associated conditions and IDU-related infections Framework and Response Models Oregon HIV, Hepatitis and Opioid Prevention and Engagement (OR-HOPE) Study

• Aim 1: Conduct community assessments in two high-risk rural Oregon counties to inform development of a community-based program to increase HIV/HCV testing among PWUDs and linkage to accessible treatment services. • Aim 2: Develop and evaluate feasibility of a rural community-based service plan comprising (1) Peer Care Coordinators for HIV/HCV testing and linkage to HIV, HCV, and OUD services and (2) telehealth support of rural primary care providers for office-based treatment of HIV, HCV, and OUD. Oregon HIV, Hepatitis and Opioid Prevention and Engagement (OR-HOPE) Study

• Aim 3: Refine and evaluate the impact of rural PCCs and telehealth provider support on rural PWID’s HIV testing rates, engagement in appropriate HIV, HCV, and OUD treatment. ▪ Peer care coordinator intervention to enroll 800 PWID in 8 rural counties ▪ Use State Medicaid and epi data used to assess HIV/HCV testing & treatment and OUD treatment, compared with matched controls What is a Syndemic? A • Population-level cluster of health conditions or issues C • Syndemic ≠ co-morbidity B • Each condition or issue has its own epidemiologic trajectory B • Conditions or Issues interact at the level of • Cause A • Consequence, or C • Needed response • The burden from the interaction is greater than the sum A B C Syndemic Approaches and Responses

• Align with Health Equity and Social Determinants of Health

More information on SDOH Neighborhood and Built Environment

Economic Health and Stability Health Care Social Determinants of Health

Social and Education Community Context Source: Beyond Health Care: The role of SDH in Promoting Health and Health Equity

• Recognize the realities that social inequalities, environments and political climates affect people’s vulnerability to and capacity for effectively dealing with health conditions and issues. Using a Syndemic Lens A C • Identifies diverse stakeholders and allies B • Aids effective • Policy analysis and planning A B C • Program planning and evaluation • Surveillance and monitoring of epidemiologic and B programmatic indicators A • Leverages action across systems and social determinant levels to address conditions and C issues, including root causes to improve health and address health disparities Oregon’s Syndemic: Substance Use, Overdose, STIs, associated conditions and IDU-related infections

Alcohol, prescription and OTC drugs with Overdose Sexually Transmitted misuse potential Morbidity and Mortality Infections (STIs): Syphilis, Suicidality chlamydia, gonorrhea, genital herpes, HIV, HBV and HCV Substance Use Disorder Substance Use Substance Misuse (SUD), including Opioid Use Disorder (OUD) HBV HIV HCV Transition to IDU Neonatal Abstinence Injection Drug Use (IDU) Injection Drug Use Syndrome (opioids) related infections such as Fetal Alcohol skin and soft tissue Illegal drugs with Spectrum Disorders infections, bacteremia/sepsis, misuse potential Note: 1. Substance misuse is defined as the use of a substance for a purpose not endocarditis, osteomyelitis, consistent with legal or medical guidelines. HIV, HBV, and HCV Condition or 2. Root social and economic issues underlie the model, including Adverse Childhood Input Link Issue Experiences (ACEs) and toxic stress that - Affect the access to and availability of resources to prevent, respond and recover - Influence experience of risk or protective factors, and - Shape individual level physical and emotional health, resilience and risk behaviors Supported by grant number UG3DA044831 (PI: P. Todd Korthuis, MD MPH) from the National Institute on Drug Abuse Contact [email protected] for model questions An Integrated Community Response • Comprehensive – NOT disease or issue specific Health Impact Pyramid Counseling • Cross-sector and public/private partnerships & Education • Based on key or core strategies Clinical Interventi • Uses systems based thinking and evidence-based ons Long-lasting and evidence-informed approaches Protective Interventions Change the Context Meikirch Model of Health to make individual’s default decisions Environment healthy Environmental Determinants of health Address Socioeconomic factors Society Social determinants of health More information on the Health Impact Pyramid Individual Individual determinants of health Personally Biologically acquired given potential potential Demands of More information on the life Meikirch Model of Health Levels of Community Response and Approaches to address the Syndemic: Acronyms Substance Use, Overdose, associated conditions and IDU-related infections ACEs = Adverse Childhood Key Strategies Experiences AUD = Alcohol Use Disorder Reduce stigma HAV = Hepatitis A Virus Prevent acute life-threatening HBV = Hepatitis B Virus outcomes HIV nPEP = HIV Non-medical Improve community infrastructure Naloxone Overdose (OD) and Suicide Post Exposure Prophylaxis Drug checking HIV PrEP = HIV Pre-Exposure Collaborate across sectors IDU-related infections: skin and soft Sterile syringes Prophylaxis tissue infections, sepsis, endocarditis IDU = Injection Drug Use Use evidence and data HAV/HBV Vaccine Exposure of unborn infants to drugs, MAT = Medication Assisted to make decisions Safe injection supplies Treatment alcohol, syphilis, hepatitis B, Condoms and HIV nPEP OD = Overdose Increase protective factors hepatitis C and HIV OD and suicide survivor response OTP = Opioid Treatment 3 Program Reduce risk factors and Diagnose and treat conditions Opioid Treatment Programs (OTP) PDMP = Prescription Drug Use support harm reduction and infections Monitoring Program Integrated screenings in primary care STI = Sexually Transmitted Infection Substance Use Disorders (SUD) Integrated, peer-based rapid HIV, HCV and syphilis SUD = Substance Use Disorder screening and linkage to care Alcohol Use Disorders (AUD) MAT, HIV PrEP, hepatitis C, HIV and STI treatment in primary care Hepatitis C, HIV and syphilis Primary Care Provider SUD/AUD, Buprenorphine, HIV and HCV training, 2 IDU-related infections mentoring and support network Policy, environment and Reduce stigma, change social norms and strengthen social supports social determinants Prevent and address Adverse Childhood Events (ACEs) trauma and toxic stress Community safety and resilience Peer-based substance use and disease prevention, risk and harm reduction programs Laws and policies protect health Laws and policies promote safety and decrease overdose, suicide and infection risk Insurance coverage and parity for Effective use of PDMP and overdose reporting data, persistent pain management and prescribing 1 OTP, SUD and mental health Community and cross-sector provider training about SUD and infectious disease risk reduction Model adapted from the Association of State and Territorial Health Officers (ASTHO) Opioid Framework, a combination of the Health Impact Pyramid , the Social Determinants of Health and the Meikirch Model of Health . Contact [email protected] questions. Supported by NIDA grant number UG3DA044831 (PI: P. Todd Korthuis, MD MPH). Using the Syndemic and Community Response Models • Increased communication and collaboration across programs, sections and divisions • Public Health Modernization efforts • Integrated information for local planning and response efforts Rates of Chronic HCV cases in persons < 30, Oregon, 2012-2016

70 N=813 cases statewide 60 50 N=520 cases statewide 40 30

20 Cases Cases per 100,000 10 0 2012 2013 2014 2015 2016 Lane and Douglas PDX Area Rest of Oregon

• 53% increase in cases under 30 years of age statewide Data slides just in case Rates of new HIV diagnoses in Oregon 2012-2016

14 N=270 cases statewide 12

10 N=221 cases statewide 8

Cases Cases per 100,000 2

0 2012 2013 2014 2015 2016 Lane and Douglas PDX Area Rest of Oregon

• 18% drop in cases statewide between 2012 and 2016 Rates of syphilis, Oregon, 2012-2016

25 Year Congenital Syphilis 20 Cases

15 2013 0 2014 2 10

Cases Cases per 100,000 2015 6 5 2016 6 0 2017 8 2012 2013 2014 2015 2016 Lane and Douglas PDX Area Rest of Oregon

• 32% increase statewide, from 310 cases to 408 cases Proportion of cases reporting injection drug use, Oregon, 2012-2016

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% HIV Diagnosis HIV Death Syphilis Chronic HCV, <30 Years Old* Lane and Douglas PDX Area Rest of Oregon

* 84% of cases with missing data Inpatient admissions for severe bacterial infections among PWIDS, Oregon, 2008-2015

By Drug Class By Infection 1.0% 0.9% Opioids 0.9% 0.8% Endocarditis Cocaine 0.8% 0.7% Bacteremia Sepsis Amphetamines 0.7% 0.6% 0.6% Sedatives Osteomyelitis 0.5% 0.5% Other drug 0.4% Skin\Soft Tissue Infection 0.4% 0.3% 0.3%

0.2% 0.2% Drug visits among all inpatient visits inpatient all among visits Drug Drug visits among all inpatient visits allinpatient among visits Drug 0.1% 0.1% 0.0% 0.0% 2008 2009 2010 2011 2012 2013 2014 2015 2008 2009 2010 2011 2012 2013 2014 2015

• Number of cases rose from 975 in 2008 to 5,257 in 2015 Rate of women who are HCV+, as reported on birth certificate (per 1,000 live births), Oregon 2012-2016 Highest risk of HCV in mothers: 5.0 • American Indian • less than a high school education 4.0 • Medicaid N=184 cases 3.0 • lack of prenatal care N=137 cases • history of alcohol and tobacco use 2.0 during pregnancy 1.0 Study matching birth certificates with 0.0 Oregon HCV surveillance database 2012 2013 2014 2015 2016 identified additional 113 women who were HCV+ and gave birth in 2015 • 34% increase between 2012 and 2016

20 Rates of Neonatal Abstinence Syndrome (NAS) per 1,000 live births, Oregon, 2012-2016

9.00 N=294 cases 8.00 7.00 N=214 cases 6.00 Lane County Infants

5.00 PDX Area Infants 4.00 3.00 Oregon Infants, Excluding Lane & PDX

2.00 Rate per 1,000 per births 1,000 live Rate 1.00 0.00 2012 2013 2014 2015 2016

• 37% increase in rates between 2012 and 2016