Modeling infective endocarditis mortality associated with injection opioid use

Injection-related infective endocarditis (IE) is a serious and expensive medical complication among people who inject drugs (PWID). In some states, such as North Carolina there has been a 12-fold increase in injection-related IE between 2007 and 2017. Approximately 1.3% of people who inject drugs report IE within the past year, and between 0.5% and 11.8% report IE within their lifetime. Higher injection frequency, unsterile injection practices, and injection equipment sharing are all associated with greater risk of injection-related bacterial infections, including IE.

In a recent study published in Clinical Infectious Diseases, CHERISH Research Affiliate Joshua Barocas and colleagues sought to understand the effect of injection frequency and injection behaviors such as skin cleaning or equipment sharing on IE mortality risk among PWID. They developed, calibrated, and validated a Monte Carlo micro-simulation model called the Reducing Infections Related to Drug Use Cost-Effectiveness (REDUCE) Model. Using the REDUCE model, they found that approximately 257,800 people in the United States are expected to die from injection-related IE by 2030, which equates to about 7.26 million years of potential life lost. The risk of injection-related IE death was more pronounced among people who did not use sterile injection practices such as skin cleaning or sterile injection equipment, whereas injection frequency had little effect on the risk of injection IE death.

These findings suggest that an individualized patient-centered approach to intervene with injection behaviors and increase education about sterile injection practices could significantly decrease injection-related IE deaths among PWID. The authors emphasize the importance of adopting a harm reduction approach, including expansion of syringe service programs, to decrease the mortality associated with the opioid crisis in the U.S.

Rapid versus Laboratory HIV and HCV testing for People Who Use Drugs

HIV outbreaks in Indiana, West Virginia, and Massachusetts have highlighted the need to rapidly identify and treat HIV infections among people who use drugs and their social networks in order to prevent disease transmission. Many state and local health departments have expanded their fourth generation laboratory-based HIV testing capacity that allows them to identify acute infections, and these tests are frequently employed in non-hospital settings such as drug detoxification centers. Laboratory tests can take between 3 and 5 days to process, however, leading to a delay in receipt of results or loss to follow up, and potentially continued HIV transmission. In contrast, rapid HIV antibody testing provides results within 20 minutes, although it cannot detect acute infections.

In a recent study published in the Journal of Infectious Diseases that was conducted at a drug detoxification center in Boston, CHERISH Research Affiliate Sabrina Assoumou and colleagues compared laboratory-based and rapid testing for HIV and HCV among people who use drugs in order to assess receipt of results. The single-site randomized trial found that all patients in the rapid testing arm who received their results did so in the same day. The median time to receive laboratory testing results after processing was 11 days, which included several follow up attempts to contact participants. Individuals randomized to rapid testing were more than twice as likely to receive their results within a two-week period compared with those who received laboratory-based testing (96% for HIV and 93% for HCV for rapid testing versus 42% for HIV and HCV with laboratory-based testing). Although laboratory-based testing could be helpful for HIV surveillance and to address acute HIV outbreaks, these findings highlight the distinct advantage of rapid testing in venues serving people who use drugs.

Effects of COVID-19 on Syringe Service Programs

People who use drugs (PWUD) are among the most vulnerable populations for COVID-19. They have increased prevalence of pre-existing co-morbidities that may increase their risk of a negative outcome following COVID-19 exposure, for example respiratory and cardiovascular diseases due to smoking cigarettes, marijuana, or other substances. Syringe service programs (SSPs) not only provide sterile injection equipment to PWUD, but also other health services such as HIV and hepatitis C (HCV) testing, referrals to substance use treatment, and overdose education and naloxone distribution. SSPs often serve as a primary point of healthcare access for PWUD. Recent publications by former CHERISH Pilot Grant Recipient Tyler Bartholomew and by Sara Glick from the University of Washington Department of Medicine describe the effect of COVID-19 on services provided by SSPs in the United States.

Bartholomew and colleagues conducted a national telephone survey in March of 2020 with 65 SSPs from 33 states to collect information. In this survey, SSP staff were asked to describe operational changes, changes to HIV and HCV testing services, and precautions to protect staff. Ten of the surveyed SSPs (15.4%) located across 9 states discontinued all SSP operations, sixteen (24.6%) switched to mobile delivery exclusively, and only seventeen (26.1%) continued to provide HIV and HCV testing.

These findings were consistent with those reported from a mixed methods study conducted by Sara Glick and colleagues, including CDUHR Investigator Don Des Jarlais from New York University College of Global Public Health. They found in a short survey administered by the North American Syringe Exchange Network (NASEN) conducted in the first two weeks in April 2020 that 43% of the 173 SSPs responding decreased service provision due to COVID-19, including medication for opioid use disorder and HIV and HCV testing and treatment services. They also found that approximately one quarter of SSPs closed sites due to COVID-19 related concerns such as staff safety and staff shortage.

More than a quarter of the sites also surveyed by NASEN reported conducting COVID-19 testing onsite for PWUD. This highlights the opportunity for SSPs to become a source for COVID screening and surveillance of this vulnerable population. During qualitative interviews with SSP staff in five COVID-19 hotspots, Glick and colleagues found that SSPs were not included in emergency planning in many states, and were not considered essential businesses. Qualitative interviews also confirmed that HIV and HCV testing decreased or stopped, that syringe and naloxone distribution were prioritized, and that demand for services remained high.

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Training Module 1. Cost-Effectiveness Analysis (17min)

This training was modified from a presentation for Helping to End Addiction Long-term (HEAL) Health Economics training presented at Boston University on September 6, 2019. This training module introduces participants to economic evaluation methods, with an emphasis on cost-effectiveness analysis of treatment interventions of substance use disorder. In this training we describe the purpose and significance of an economic evaluation, and describe important considerations when conducting a cost-effectiveness analysis. At the end of this module, participants should be able to understand the components of a cost-effectiveness analysis and understand how the choice of perspective affects what is included in the economic evaluation.

Training Module 2. Cost Analysis (19min)

This training was modified from a presentation for Helping to End Addiction Long-term (HEAL) Health Economics training presented at Boston University on September 6, 2019. This training module introduces participants to costing techniques and considerations as the first component of an economic evaluation. We review the different types of costing methods and categories of cost, and describe important considerations when collecting costs for an economic evaluation. At the end of this module, participants should be able to describe the difference between macro-costing methods and micro-costing methods, and should be able to understand the different types of costs collected during a cost analysis. This module builds on module 1 as it describes the role of analytic perspective in determining which costs to include and the appropriate valuation of those resources.

Training Module 3. Health Utilities and Direct Utility Assessments (10 min)

This training module introduces participants to health-related quality of life assessments as a common measure of effectiveness in economic evaluations. We review different types of direct utility assessment techniques to measure health utilities and describe the important considerations of each technique. At the end of this module, participants should be able to define a health utility, and describe three direct utility assessment methods.

Training Module 4. Health Utilities and QALYs for Cost-Effectiveness Analyses (7 min)

This training module continues to describe health-related quality of life assessments as a common measure of effectiveness in economic evaluations. In this module we introduce algorithm-based quality of life measurement tools commonly used in economic evaluations. We describe the important considerations when selecting a quality of life assessment. We then explain how these quality of life measures are used to calculate Quality-Adjusted of Life Years (QALYs), which are a common measure of effectiveness for economic evaluations. At the end of this module, participants should be able to describe the differences between preference based, non-preference based, generic, and disease specific quality of life measurement tools, and understand how these utility measures are used to calculate quality-adjusted life years as a measure of effectiveness for economic evaluations.

Training Module 5. Cost-Benefit Analysis (14 min)

This training module introduces participants to cost-benefit analyses as another type of full economic evaluation. In this training module we explain the purpose and significance of a cost-benefit analysis, and describe important considerations when conducting cost-benefit analysis. At the end of this module, participants should be able to describe the methodological differences between a cost-benefit analysis and cost-effectiveness analysis, and understand when the use of a cost-benefit analysis is most appropriate.

Training Module 6. Budget Impact Analysis (7 min)

This training module introduces participants to the techniques used in conducting a budget impact analyses. In this training we explain the purpose and significance of a budget impact analysis, and describe important considerations when conducting a budget impact analysis. At the end of this module, participants should be able to understand when to conduct a budget impact analysis, how this information is used by stakeholders, and how the intended stakeholders affects the assessment methods selected.