Syndemic of Substance Use, Infectious Disease Calls for Combined Services

Mermin said that although geography matters—it makes more sense to target areas where substance use and infectious disease are clustered rather than distribute resources and funding equally across a state—the venues where services are offered are just as important.

“If I have a substance use treatment program, what other high-priority interventions could be a standard part of services?” Mermin said. “Most people think of testing and diagnosing HIV, but what about testing for hepatitis C or giving vaccinations for hepatitis A and hepatitis B?”

Mermin emphasized the importance of harm-reduction efforts such as syringe services programs. “These programs have been associated with about a 50% reduction in the incidence of HIV and hepatitis C, but with strong linkage to substance use treatment, it becomes even more effective,” he said, citing a Cochrane review showing that syringe service programs combined with medications for opioid use disorder such as methadone or buprenorphine lower the risk of hepatitis C infection by 74%.

“It also has been shown that these programs do not increase crime or illegal drug use, which is one of the initial concerns about them,” Mermin added.

Mermin said that science-based public health policy can save a great deal of money as well as lives. For example, a study in the Journal of Acquired Immune Deficiency Syndrome found that syringe services programs in Philadelphia averted 10,592 HIV infections over 10 years and yielded estimated annual savings of $243 million.

Christopher Jones, Pharm.D., D.Ph., M.P.H., a captain in the U.S. Public Health Service and director for substance abuse prevention at SAMHSA, noted a discrepancy in the number of facilities that claim to offer multiple services and the number of facilities that actually do.

“In the National Substance Use and Mental Health Services survey, a SAMHSA survey done each year of all brick-and-mortar treatment facilities that we’re aware of, slightly more than half said they provided education, counseling, or support around HIV or AIDS, and 57% said [the same] about viral hepatitis,” Jones said. “But when we [looked at] HIV testing and testing for hepatitis C, hepatitis B, and other STIs, we see that really it’s a third or less that provide that service. It gets even lower when we talk about pharmacological interventions or medical interventions like vaccinations for hepatitis A or hepatitis B—only about 12%.”

Jones described the six pillars of SAMHSA’s harm-reduction framework, in which efforts:

“People often think of harm reduction solely as interventions, and we felt it important to think about [it] as an approach to engaging with human beings. How do we meet people where they are in empathetic, compassionate ways that [affirm] that every person has inherent dignity and value?” Jones said. “Oftentimes people who use drugs have been treated so poorly that they don’t want to engage with the health system, … so these principles are a way to think about how we show up and [work] with them in their communities.” ■