@CDCgov researchers report increases in HCV infection and #opioid admissions in @AMJPublicHealth

Friday, January 12, 2018

Just before Christmas, researchers from the CDC's Division of Viral Hepatitis published an article in the American Journal of Public Health reporting an increase in both acute hepatitis C (HCV) cases and admissions for injection drug use in substance abuse treatment centers:
The annual incidence rate of acute HCV infection increased more than 2-fold (from 0.3 to 0.7 cases/100 000) from 2004 to 2014, with significant increases among select demographic subgroups. Admissions for substance use disorder attributed to injection of heroin and prescription opioid analgesics increased significantly, with an almost 4-fold increase in prescription opioid analgesic injection. Significant increases in opioid injection mirrored those for reported cases of acute HCV infection among demographic subgroups.
CDC featured the article, along with several related graphics, in a press release. As a side note, HCV infection is considered a highly reliable proxy for injection drug use, although I would advise caution when looking at "acute" HCV figures. HCV infection is frequently asymptomatic (i.e., not acute), and surveillance for acute cases is spotty in some states. Overall HCV infection rates are most likely much higher, however, meaning that these numbers point to what is most likely a much larger overall infection rate.

The authors used national surveillance data for HCV infection and substance use treatment data from SAMHSA for IDU admissions:
We obtained confirmed cases of acute HCV infection and associated demographic and risk characteristics from the National Notifiable Disease Surveillance System (NNDSS) for 2004 to 2014.
...
TEDS is a national data system administered by SAMHSA. It collects information on annual admissions to SUD treatment facilities in the United States. TEDS contains data on admissions to publicly funded and state-certified SUD treatment facilities by year and by state of treatment facility for all persons aged 12 years or older. By state law, treatment facilities provide data to TEDS. TEDS is estimated to include 67% of all SUD treatment admissions and 83% of TEDS-eligible admissions in the United States.
Despite limitations of the data, this should add to the list of rather loud alarm bells that we have a serious injection drug use problem. HIV looms.

Interestingly, the same issue of AJPH featured a commentary on the national opioid crisis, co-authored by HIV/IDU heavyweight Daniel Ciccarone at UCF. After a brief historical overview that separates the crisis into three phases, the piece criticizes what it calls the "vector model" - the focus on supply of opioid prescription drugs as the root of the crisis - and argues that appropriate policy responses should instead consider the reasons behind the demand for such drugs. The authors present several related possiblities to explain demand, including "diseases of despair" and the structural aspects of poverty:
The “reversal of fortunes” in life expectancy saw rapid diffusion, going from largely limited to Appalachia and the Southwest in 2000 to nationwide by 2015. The unprecedented 20-year difference in life expectancy between the healthiest and least healthy counties is largely explained by socioeconomic factors correlated with race/ethnicity, behavioral and metabolic risk, and health care access. These indicators are the most recent evidence of a long-term process of decline: a multidecade rise in income inequality and economic shocks stemming from deindustrialization and social safety net cuts. The 2008 financial crisis along with austerity measures and other neoliberal policies have further eroded physical and mental well-being.
It's an excellent piece that looks at the data on structural factors behind other forms of substance use (e.g., alcoholism), issues of racism, and the inability of the current U.S. health care system to adequately address the problem. It urges a human-centered approach to the problem and says that we should "focus on suffering."

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