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.

mc-nws-newsmaker-needle-exchange-20180314

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 (Coming Soon)

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.

CHERISH Awarded Five-year Center of Excellence Grant to Continue Substance Use Health Economics Research

The National Institute on Drug Abuse (NIDA) of the National Institutes of Health has awarded the Center for Health Economics of Treatment Interventions for Substance Use, HCV and HIV (CHERISH) a five-year grant to continue the Center’s activities as a national center of excellence. CHERISH was founded in 2015 as a multi-institutional center for health economics research in the substance use field, with an initial emphasis on addressing the needs of an integrated healthcare system and providers. The renewed funding will continue this work and will broaden the Center’s focus to evaluating intervention outcomes for individuals, systems, and communities.

While there are effective medications and interventions for substance use disorder, HCV and HIV, the cost of care and improving treatment access for people who use substances create challenges for individuals, healthcare systems, and government entities at all levels.

 

“The opioid crisis has brought a greater awareness of the investments needed to address treatment and prevention of substance use disorders, HCV and HIV among people who use substances,” said CHERISH Director Dr. Bruce Schackman, Saul P. Steinberg Distinguished Professor of Population Health Sciences at Weill Cornell Medicine. “CHERISH is eager to continue supporting investigators in the substance use field to measure the economic value of new treatments and care delivery models. During this time, it is critical to apply limited resources to the most effective strategies and ensure the sustainability of substance use care.”

 

In its first five years, CHERISH funded 16 Pilot Grant awards to support economic analyses of treatments for substance use disorder, HCV and HIV among people who use substances. CHERISH Pilot Grant Recipients received funding, mentorship and dissemination training, and several have gone on to receive career development awards from NIDA. Over the next five years, the CHERISH Pilot Grant & Training Core will continue to mentor and support health economics and health services researchers in the substance use field and will lead an enhanced diversity initiative to support the development of underrepresented minority investigators in substance use research. The Pilot Grant & Training Core also plans to sponsor peer mentorship activities for career development award recipients whose research includes topics relevant to substance use economics. The Core will be led Dr. Brandon Aden, an addiction medicine specialist and at Weill Cornell Medicine, and will take advantage of the expertise of Dr. Yuhua Bao at Weill Cornell Medicine who is an experienced behavioral health services research mentor.

CHERISH has fostered a community for health economic researchers in the substance use disorder field through its Research Affiliates program, and provided almost 90 consultations improve economic evaluations, and incorporate economic methods in substance use research. The CHERISH Methodology Core will continue these activities, and plans to develop new methods related to economic evaluation in implementation studies and adaptive interventions. The Core will be led by substance use health economists Dr. Kathryn McCollister and the University of Miami Miller School of Medicine and Dr. Sean Murphy at Weill Cornell Medicine. The Core’s activities will build on and enhance the active involvement of Dr. McCollister, Dr. Murphy, and several other CHERISH investigators in the NIH Helping to End Addiction Long-termSM (HEAL) Initiative, including translating research to practice for the treatment of opioid use disorder (OUD) and new strategies to prevent and treat OUD.

The new CHERISH Population Data & Modeling Core will promote new approaches to use state datasets for population-level economic evaluations and advance simulation modeling methods for people with substance use disorder, HCV and HIV. The Core will be led by Dr. Benjamin Linas, and infectious diseases clinician and modeling expert at Boston Medical Center, and Dr. Schackman, and will draw on complementary expertise from investigators at Weill Cornell, Boston Medical Center and the Boston University School of Public Health. The Core will continue to be actively involved in supporting collaborations among a consortium of substance use disorder modelers.

The Dissemination & Policy Core, led by Dr. Zachary Meisel and Dr. Janet Weiner at the University of Pennsylvania Leonard Davis Institute of Health Economics (LDI), will continue to engage with policy stakeholders to bridge the divide between research and policy by drawing on LDI’s unique resources. Dr. Meisel is an emergency medicine clinician and policy researcher and Dr. Weiner is the Co-Director for Health Policy at LDI. This Core will also continue to hold bi-annual Stakeholder conferences and workshops, which have brought together policymakers, researchers, providers, payers and activists, and will develop a new knowledge dissemination training curriculum for researchers in the substance use economics field.

Methodology Consultation Success: Dr. Adam Carrico

Approximately 1.6 million US adults used methamphetamine each year from 2015 to 2018, many of whom had co-occurring substance use or mental illness. Higher rates of methamphetamine use were concentrated in non-urban areas, which raises concerns due to limited substance use treatment availability in outside of urban areas. Stimulant use is associated with increased risk of HIV transmission, and lower rates of viral suppression among HIV positive men who have sex with men (MSM) due to lower rates of engagement in HIV care. Successful behavioral health interventions to improve engagement in HIV care and viral suppression have often been limited to urban centers and confined to treatment settings, but mobile health (mHealth) technologies offer the opportunity to extend reach and efficacy of these interventions.

 

The START Study Team: Dr. Adam Carrico (Left), Dr. Keith Horvath (Center), Dr. Sabina Hirshfield (Right)

Drs. Adam Carrico, Keith Horvath, and Sabina Hirshfield recently received R01 funding from the National Institute on Drug Abuse (NIDA) to conduct a randomized clinical trial of an mHealth intervention to improve HIV treatment engagement and viral suppression among MSM who use stimulants. Dr. Carrico is a Professor of Public Health Sciences and Psychology and Director of the Division of Prevention Science and Community Health at the University of Miami Miller School of Medicine. His research largely focuses on the implications of substance use on HIV transmission and disease progression. Dr. Horvath is an Associate Professor in the Department of Psychology and San Diego State University. His primary research interests are the development and testing of mHealth interventions for sexual and gender minorities. Dr. Hirshfield is a Principal Research Scientist at SUNY Downstate Health Sciences University, where she conducts video- and message-based eHealth interventions with populations at-risk for, or living with, HIV. Her research includes home collection of dried blood spots for lab-based viral load testing. Together, the study team plans to evaluate the efficacy of the Supporting Treatment Adherence for Resilience and Thriving (START) mHealth intervention in improving and maintaining viral load suppression among MSM who use stimulants. The START intervention includes individual sessions and medication self-monitoring.

 

With input from the CHERISH Consultation Service, the START study team was able to include an economic evaluation for the mHealth intervention in his research plan. CHERISH Methodology Core Co-director Kathryn McCollister provided input for the grant application on how to best capture intervention costs and potential economic benefits of the START intervention. Dr. McCollister will also serve as a co-investigator to lead the economic evaluation for the intervention. Dr. Carrico reported that he was very satisfied with the consultation and would recommend the service to other investigators. “Dr. McCollister’s input strengthened our application and we look forward to collaborating on this important and timely project that will provide valuable information on both the effectiveness and cost of this mHealth intervention,” said Dr. Carrico.