WELCOME TO THE CLINICAL CENTER GRAND ROUNDS,
A WEEKLY SERIES OF EDUCATIONAL LECTURES FOR PHYSICIANS AND
HEALTH CARE PROFESSIONALS BROADCAST FROM THE CLINICAL
CENTER AT THE NATIONAL INSTITUTES OF HEALTH IN
BETHESDA, MD.
THE NIH CLINICAL CENTER IS THE WORLD'S LARGEST HOSPITAL TOTALLY
DEDICATED TO INVESTIGATIONAL RESEARCH AND LEADS THE GLOBAL
EFFORT IN TRAINING TODAY'S INVESTIGATORS AND DISCOVERING
TOMORROW'S CURES.
LEARN MORE BY VISITING US ONLINE AT HTTP://CLINICALCENTER.NIH.GOV
>> SO IN THE TRADITION OF GRAND
ROUNDS AS THE CLOCK STRIKES
EXACTLY 12, WE WILL START.
TODAY I AM PLEASED TO INTRODUCE
ELANA ROSENTHALL, AS OUR
SPEAKER.
BEFORE I TELL YOU ABOUT HER, I
THINK YOU KNOW FROM BEING HERE
BEFORE HOW TO GET YOUR CMEs
AND I THINK ALSO AWARE THAT
THOSE OF YOU ONLINE CAN SUBMIT
YOUR QUESTIONS AND TOM WILL READ
THOSE AT THE END IF WE HAVE TIME
AND OF COURSE, WE ENCOURAGE ALL
OF YOU HERE TO ASK SPEAKERS AT
THE MICROPHONE.
FIFTEEN YEARS AGO BEING WE
STARTED AS AN INTRAMURAL PROGRAM
LOOKING AT HIV IN THE DISTRICT
OF COLUMBIA TO SEA WHAT WE COULD
DO TO TRY TO REDUCE THE IMPACT
OF HIV IN THE CITY AND 1 OF THE
THINGS THAT OUR STAFF HAVE
RECOGNIZED OVER THE YEARS AND
WHAT LARGE IMPACT SUBSTANCE USE
AND OPIOID USE DISORDER HASOT
ABILITY OF PATIENTS TO EITHER
AVOID GETTING HIV OR TO TAKE
THEIR MEDICATIONS.
TODAY, ELANA, IS GOING TO SPEAK
ABOUT THE INTERSECTION BETWEEN
OPIOIDS AND INFECTIOUS DISEASE
BOTH VIRAL AND BACTERIAL
DISEASES AND I THINK THIS IS 1
OF MANY INITIATIVES THAT NIH IS
SPONSORING NOW TO TRY TO DEAL
WITH THE OPIOID EPIDEMIC IN THE
UNITED STATES.
WE APPRECIATE THE FACT THAT
THESE PROGRAMS ARE SUPPORTED BY
NIAID, BY NIDA, BILET NATIONAL
INSTITUTE OF MENTAL HEALTH, BY
THE OFFICE OF AIDS RESEARCH AND
BY A NUMBER OF YOU WHO ARE HERE
SO THESE PROGRAMS COULD NOT
EXIST WITHOUT THIS KIND OF
SUPPORT.
SO ELANA CAME TO OUR PROGRAM
ALMOST 10 YEARS AGO FROM HER
INTERNAL MEDICINE AND INFECTIOUS
DISEASE TRAINING AT BETH ISRAEL
DECONNIST, SHE CAME HERE BECAUSE
SHE REALLY HAS A PASSION FOR
DEALING WITH PATIENTS WITH
INFECTIOUS DISEASE AND SUBSTANCE
USE DISORDER.
SHE HAS BEEN A MAJOR ARCHITECT
IN THE DIRECTION OF OUR PROGRAM
HAS TAKEN AND SHE'S GOING TO
TELL YOU ABOUT WHERE OUR PROGRAM
IS NOW, WHAT WE'RE DOING AND
WHAT SHE SEES IS THE FUTURE.
ELANA?
>> THANK YOU, DOCTOR.
HE DIDN'T MENTION MY HIGHEST
ACCOLADE WHICH THAT I WAS A
SUMMER INTERN HERE FOR 3 YEARS
IN I THINK 2000, 2001, AND 2003,
SO, IT FEELS VERY MUCH LIKE A
HOME COMING TO ME, OVER HERE
SITTING IN THE SEATS, LESS
STRESSFUL BUT THANK YOU EVERYONE
FOR COMING TO HEAR MY TALK TODAY
ABOUT ACHIEVING SOURCE CONTROL,
ADDRESSING ADDICTION IN PATIENTS
WITH INFECTIOUS COMPLICATIONS OF
SUBSTANCE USE.
THESE ARE MY DISCLOSURES.
AND THE LEARNING POINT.
SO WHAT IS SOURCE CONTROL?
I WANT TO TART OFF BY EXPLAINING
THAT ID PHYSICIANS ARE OBSESSED
WITH THE CONCEPT OF IDENTIFYING
THE SOURCE OF INFECTION, CALL US
PERSISTENT, PERHAPS CALL US NOSY
BUT I. DOCTORS ARE NOTERIOUS FOR
EXHAUSTING ASKING QUESTIONS
ABOUT ALL ASPECTS OF THEIR
LIECHS, PETS, HOBBIES, HABITS,
TRAVEL, TRAVEL FROM 40 YEARS
AGO, EVERYTHING IS RELEVANT TO
OUR HISTORIES ON OUR CERTIFYING
EXAMS AND FAIR WELL IN OUR
CLINICS WE SEE ALL SORTS OF
PATIENTS WHO HAVE FALLEN ILL WHO
INADVERTENTLY BECOME ILWHETHER
IT'S MOWING OVER A RABBIT,
HIKING IN A CAVE WITH BATS OR
ANYONE WHO HAS TAKEN THE
DOCTOR'S INFECTIOUS DISEASE
COURSE KNOWS WHAT I'M TALKING
ABOUT.
AND ONCE WE IDENTIFY A SOURCE,
WE ARE DOGGED IN OUR PURSUIT TO
ERADICATE IT.
DOES THE PATIENT HAVE ROTTEN
TEETH, TAKE THEM ALL OUT.
DO THEY HAVE OLD HARDWARE
EMBEDDED IN THE MYOCARDIUM THAT
COULD BE INFECTED, GET RID OF
IT.
I ONCE WENT SO FAR TO PRESCRIBE
A PROTOCOL FOR A DOG ONCE FOR A
PATIENT.
AUDACIOUS DEMANDS, WE KNOW
TREEING THE INFECTION IS NOT
ENOUGH, ACHIEVING SOURCE CONTROL
IS CRITICAL TO LONG-TERM HEALTH
OF THE PATIENT.
AND YET, THIS SAME FOCUS IS NOT
APPLIED TO PATIENTS WITH
INFECTIONS DUE TO ADICK,
SOMETHING WE ENCOUNTER FAR TOO
OFTEN.
SO I WILL TELL YOU A STORY,
2ATORYS ABOUT PATIENTS OF MINE,
AND I WILL TELL YOU IN ADVANCE,
NEITHER HAVE HAPPY ENDINGS.
THE FIRST WAS A 37 YEAR-OLD JAZZ
MUSICIAN I MET AS A FELLOW IN
BOSTON YEARS AGO.
HE WAS HOSPITALIZED WITH OPIOID
USE DISORDER THAT WAS
COMPLICATED BY INFECTIVE
ENDOCARTITEIS.
HE GOT EXCEPTIONAL CARE FOR HIS
INFECTION.
CT SURGERY, EXCISED AND REPLACED
HIS INFECTED VALVE, I.D.
SELECTED THE PERFECT REGIMEN FOR
HIS ANTIBIOTICS BUT NO 1
ADDRESSED HIS ADDICTION.
HE WAS DISCHARGED TO A MEDICAL
REHAB, COMPLOATED HIS ANTIBIOTIC
THERAPY, WENT HOME, CURED OF HIS
ENDOCARTITEIS.
BUT NOT SURPRISINGLY A FEW
MONTHS HE RETURNED WITH AN
INFECTION ON HIS PROSTHETIC
VALVE, AND THIS TIME, CT SURGERY
CAME, ACTUALLY DON'T THINK THEY
EVEN SAW THE PATIENT AND THEY
JUST WENT STRAIGHT TO HIS CHART,
WROTE 6 WORDS.
NO SURGERY, FETAL CARE,
INTRACTABLE ADDICTION.
I DON'T KNOW HOW THEY KNEW THAT
BECAUSE NO 1 HAD ACTUALLY CARED
ENOUGH TO TRY TO TREAT HIS
ADDICTION BUT THAT WAS IT.
A DEATH SENTENCE BECAUSE WE ALL
KNEW THAT WITHOUT THE SURGERY HE
WAS NOT GOING TO SURVIVE AND HE
DIED.
HE DIED A MISERABLE PAINFUL
PREVENTIBLE DEATH.
AFTER AN ADDICTION THAT WAS
PERFECTLY TREATED BUT COMPLETELY
DEVOID OF SOURCE CONTROL.
WOULD HE BE ALIVE TODAY IF WE
TREATED HIS ADDICTION, I
HONESTLY DON'T KNOW, BUT I KNOW
THAT WE DIDN'T EVEN TRY AND
THAT'S A TRAGEDY.
LATER IN MY CAREER, I
ENCOUNTERED A LOVELY PATIENT WHO
HAD HEPATITIS C THAT WAS A
RESULT OF INJECTING OPIOIDS.
HE WAS REALLY EXCITED TO GET HIS
HEPC, FULLY ADHERED TO HIS
REGIMEN, AND WAS CURED HE DID
NOT DIE OF HEPATITIS E ATULAR
CELLULAROSEIS, HE DID NOT
CONTRACT LIVER DISEASE, BUT A
YEAR AFTER I CURED HIS DISEASE,
HE WAS FOUND IN HIS BATH TUB
WITH RIGOR MORTIS WITH A NEEDLE
IN HIS ARM.
WHY AM I TELLING YOU THESE
STORIES?
BECAUSE INCREASINGLY WE'RE
SEEING YOUNG PATIENTS THAT ARE
DYING BECAUSE WE'RE TREATING
THEIR INFECTIONS WITH LITTLE
REGARD FOR THE ADDICTION THAT
CAUSED THEM AND IF WE HOPE TO
SAVE THEIR LIVES WE NEED TO
COMMIT TO TRULY ACHIEVING SOURCE
CONTROL FOR INFECTIONS DUE TO
SUBSTANCE USE.
HOW DO WE DO THAT?
LET'S DISCUSS.
SO THE FIRST STEP IN ACHIEVING
SOURCE CONTROL FOR INFECTIONS
DUE TO SUBSTANCE USE IS TO
LOCALIZE WHERE THE INFECTIONS
ARE HAPPENING AND GO THERE.
TO EXPLAIN THIS, I WANT TO
HIGHLIGHT THE ORIGINS OF OUR
CLINICAL RESEARCH PROGRAM THAT
THE DOCTOR WAS MENTIONING, THE
D. C. PARTNERSHIP FOR HIV/AIDS
PROGRESS.
IT ALL BEGAN IN 2007 WHEN THE D.
C. DEPARTMENT OF HEALTH
CONDUCTED ITS FIRST ASSESSMENT
OF HIV PREVALENCE, AND FOUND
THAT D. C. HAD EPIDEMIC LEVELS
OF HIV, 3% OF THE POPULATION HAD
HIV, WITH NEW DIAGNOSIS EVERY
YEAR IN A CITY WITH FEWER THAN
600,000 RESIDENTS.
UPON THIS REALIZATION, A TEAM
FROM NIH, INCLUDING
[INDISCERNIBLE], [INDISCERNIBLE]
AND DR. TONY FAUCI, RESOLVED TO
BRING THE RESOURCES OF NIH TO
THIS NEARBY EPIDEMIC WITH THE
GOAL OF APPLYING STRATEGY IN HOW
TO REDUCE THE BURDEN OF HIV IN
URBAN AREAS WITH D. C. AS A
NATIONAL MODEL.
IN CONJUNCTION WITH D. C.
[INDISCERNIBLE], THE OFFICE OF
AIDS RESEARCH AND THE SCHOOL OF
PUBLIC HEALTH, THE D. C.
PARTNERSHIP FOR HIV/AIDS
PROGRESS WAS BORN.
AN INITIAL NEEDS ASSESSMENT
INVOLVING COMMUNITY BASED
ORGANIZATIONS, PROVIDERS AND
PATIENTS WAS CONDUCTED.
AND WITHIN NIH THOUGHT THE
COMMUNITY WOULD IDENTIFY AS AN
UNMET NEED WAS SUPPORT FOR
TREATMENT OF HIV.
THEY THOUGHT THEY WERE GOING TO
GO IN AND DO A. R. T. BUT WHAT
THEY ACTUALLY FOUND OUT WAS THAT
THE COMMUNITY WAS MUCH MORE
INTERESTED IN SUPPORT FOR
SPECIALIST CARE FOR
CO-MORBIDITIES INFECTION,
SPECIFICALLY MENTAL HEALTH,
HEPATITIS C AND SUBSTANCE USE
DISORDER.
DR. MARYLAND POWELL AND
DR. [INDISCERNIBLE] AND THEIR
TEAM AT NIMH SET OUT TO ADDRESS
MENTAL HEALTH.
WHILE UNDER THE SUPPORT OF
DR. MIKE [INDISCERNIBLE], AND
DR. [INDISCERNIBLE] THEY PUT
THEIR FOCUS ON HEPATITIS C.
THIS ALIGNED WITH THE TIMING OF
THE REVOLUTION OF HEPATITIS C
TREME.
FOR THOSE WHO DON'T KNOW OR
CHOOSE TO FORGET, THE MAIN STAY
OF HEPC TREATMENT WAS INTERFERON
BASE.
IT WAS A TERRIBLE MEDICATION, IT
MODULATED THE IMMUNE SYSTEM TO
HELP GET RID OF HEPATITIS C, BUT
IT HAD ENORM AUSSIDE EFFECTS, IT
WAS TOLERATED THERE WERE
COMPLICATIONS TO TREATMENT AND
IF YOU DID SOMEHOW MAKE YOUR WAY
THROUGH 12 MONTHS OF TREATMENT,
THE CARE RATES WERE NOT VERY
GOOD, AND HIV.
SETHE FIRST STEP WAS TO BRING
THE SPECIALIST CARE TO THE D. C.
COMMUNITY TO PROVIDE THEM WITH
HEP C TREATMENT BECAUSE AT THE
TIME YOU COULD ONLY GET IT FROM
A SPECIALIST.
EARLY ON THE DOCTOR AND HIS TEAM
RECOGNIZE THAD THOUGH THE
DISTANCE BETWEEN D. C. AND
BETHESDA IS FAIRLY SHORT, I MADE
IT TODAY, IT WAS NONETHELESS
INSURMOUNTABLE FOR MANY PATIENTS
WITH THE GREATEST NEED, EVEN THE
MAJOR ACADEMIC MEDICAL CENTERS
IN D. C. WHICH ARE LOCATED IN
THE NORTH AND WEST OF THE CITY,
WERE LARGELY INACCESSIBLE TO THE
PATIENT'S MOST IMPACTED BY HIV
AND HEP C WHO WERE CLUSTERED IN
THE SOUTHEAST.
HE RECOGNIZED THAT IF WE WANTED
TO ACCESS THE PATIENTS WE HAD TO
BRING OURSELVES TO THEM.
RATHER THAN ASKING THEM TO COME
TO US.
SO THE FIRST STEP TO ENGAGING
THIS POPULATION WAS TO EMBED A
TEAM AT UNITY HEALTH CENTER AND
FAMILY MEDICAL AND COUNSELING
SERVICES TO FEDERALLY QUALIFIED
HEALTH CENTERS THAT WERE
ACCESSING PATIENTS EMBEDDED IN
WARDS 7 AND 8, REGIONS THAT ARE
PREDOMINANTLY RACIAL MINORITY,
DISPROPORTIONATELY SERVED AND
LOW ACCESS TO CARE AND HIGH
RATES OF HIV AND HEP C.
SO IN THE STANDARD, THEY STARTED
BUILDING TRUST AND ENGAGEMENT
WITH PATIENTS AND PROVIDERS IN
THE COMMUNITY.
NOT LONG AFTER P-FAB WAS
DEVELOPED, THE OPPORTUNITY AROSE
TO BRING NOVEL THERAPEUTICS TO
THE D. C. PATIENTS.
DUE TO PREVIOUS COLLABORATIONS
RELATED TO TREATMENTS FOR
PNEUMOCYSTIS IN HIV, THE TEAM
WAS APPROACHED BY A SMALL
PHARMACEUTICAL COMPANY CALL TEST
SET TO HELP TEST FOR HEPATITIS E
C.
THE NIH TEAM WAS ABLE TO ACCESS
DONATED DRUG TO CONDUCT
INVESTIGATOR INITIATED SICKLE
SITE STUDIES AND WANTED TO
PROVIDE THE D. C. COMMUNITY WITH
ACCESS TO THIS PROMISE ARE
THERAPEUTIC.
INITIALLY, PATIENTS WERE
RECRUITED BY THE NIH TEAM AT OUR
COMMUNITY BASED SITES AND
STUDIES WERE CONDUCTED ENTIRELY
AT THE NIH.
BUT THIS MODEL EVOLVED TO BRING
PATIENTS TO THE NEYE H FOR THEIR
FIRST ENROLLMENT VISIT BUTAR LOW
THEM TO COMPLETE L FOLLOW UP
VISITS IN THE COMMUNITY BASED
SITES.
AND THE FINAL ITERATION OF THIS
MODEL WAS THAT THE NIH THROW A
FOOTBALL WENT TO THE COMMUNITY
BASED--STAFF WENT TO THE
COMMUNITY BASED SITES FOR ACCESS
OF COMMUNITY CARE.
THIS MODEL WAS ABLE TO RESULT IN
THE FIRST STUDY OF INTERFERON
FREE HEPATITIS C TREATMENT IN
THE UNITED STATES, FIRST STUDY
OF INTERFERON IN RIBOFLAVORIN
FOR HEPATITIS E C INFECTED
PATIENTS AND SHORT DURATION OF
HEPATITIS C TREATMENT, LARGEST
STUDY OF DIRECT ANTIVIRALS IN
BLACK PATIENT ANDS THE FIRST
STUDY OF NONSPECIALIST LED
HEPATITIS C TREATMENT IN HEP-C
AND CO INFECTED PATIENTS.
OVER 800 PREDOMINANTLY PLAQUE
PATIENTS WERE TREATED FOR
HEPATITIS C THROUGH THESE EARLY
STUDIES INSURING REPRESENTATION
IN THE RESEARCH BY PEOPLE CO
INFECTED WITH HIV, AND RACIAL
MINORITIES WHO ARE TRADITIONALLY
UNDERREPRESENTED IN
INVESTIGATIONAL DRUG STUDIES.
THESE STUDIES HELPED CONTRIBUTE
TO THE FDA APPROVAL AND
GUIDELINES RECOMMENDATIONS FOR
DIRECT AND ANTIVIRALS WHICH ARE
INCREDIBLY SAFE, TOLERABLE AND
OVER 90% EFFECTIVE AFTER 2-3
MONTHS OF USE.
NONE OF THIS WOULD HAVE BEEN
POSSIBLE IF WE HADN'T LOCALIZED
TD EPICENTER OF HEPATITIS C
INFECTION IN DC AND GONE THERE.
A SLIGHT INCONVENIENCE FOR THE
TEAM, LED TO MASSIVE
CONTRIBUTIONS TO SCIENCE, AND
THE COMMUNITY.
AS D. A.s WERE COMING DOWN THE
PIPELINE, A NEW EPIDEMIC WAS
GAINING TRACTION, THE MODERN
OPIOID EPIDEMIC.
WHILE OPIOIDS HAVE BEEN AROUND
SINCE THE TIME OF HIPIECE OF
CONTENT RATEASE, THE MODERN
OPIDDOID ERA IS CATEGORIZED IN 3
WAVES.
FIRST WAVE TART NOTHING THE LATE
1990S WAS RELATED TO OPIOID
PILLS, THERE WAS A DRAMATIC RISE
OF OPIOID PILLS FOLLOWED BY
RECOMMENDATIONS BY MEDICAL
SOCIETIES TO FOCUS ON PAIN
CONTROL ACCOMPANIED BY MARKETING
BY PHARMACEUTICAL COMPANIES
EMPLOY AFTER THE OPIOID PILL
PRESCRIBING SO SAW A WAVE OF
OVERDOSE DEATH WITH A
PARAILLUMINATE RISE IN
INRECYCLINGING DRUG USE, THIS
INCREASE IN HEROIN USE WAS IN
PART DUE TO THE FACT THAT PEOPLE
WHO HAD DEVELOPED OPIOID USE
DISORDER THROUGH PILL USE, WERE
FINDING IT DIFFICULT TO OBTAIN
OR AFFORD SUFFICIENT QUANTITIES
OF PILLS TO MEET THEIR NEEDS.
SO THE NATURAL TRANSITION WAS TO
HEROIN WHICH WAS CHEAPER AND
MORE READILY AVAILABLE.
THE THIRD WAVE, IS DUE TO
SYNTHETIC OPIOIDS SUCH AS FENT
NILE VIRUS AND FENTAFYL AN LOGS,
AS YOU CAN SEE THE INTRODUCTION
OF SYNTHETIC OPIOIDS WHICH ARE
MUCH MORE POTENT THAN HEROIN
WHICH HAS LED TO RISING
OVERDOSES IN 2013.
THE DRAMATIC REDUCTIONTIC SPREAD
OF OPIOID USE ACROSSLET COUNTRY
AND INTO THE DRUG SUPPLY AS
RESULT INDEED A PRECIPITOUS RISE
IN OVERDOSE RELATED DEATHS.
CLIMAXING IN 2022, OUR MOST
RECENT DATA WHEN OVER 109,000
PEOPLE DIED OF OVERDOSE.
TO PUT THIS IN PERSPECTIVE, THE
CURRENT ANNUAL RATE OF OVERDOSE
DEATH SYSTEM OVER DOUBLE THE
NUMBER OF ANNUAL DEATHS AT THE
PEAK OF THE HIV EPIDEMIC.
CLEARLY THIS IS A BIG PROBLEM.
ALONG WITH THE RISKS OF OVERLOAD
DEATH, THE MODES OF INJECTION
CAN BE OFTEN FATAL, AND THE
ACQUISITION OF BLOOD BORN
TRANSITIONS DUE TO SHARING OR
INJEKING EQUIM, OF NOTE,
TRANSMISSION OF SOME INFECTIONS
ESPECIALLY HEPATITIS C CAN OCCUR
WITH THE SHARING OF EQUIPMENT
USED FOR INTRA NAIS AT DRUG USE,
INFECTIONS ACQUIRED VIA
TRANSMISSION INCLUDE HIV,
HEPATITIS B, C, AND D.
THE SECOND CONTAMINATION IS
DURING THE PROCESS WHICH RESULTS
IN INOCULATION DUE TO NONSTERILE
INJECTING PROCESSES, THIS
RESULTS IN KIN AND SOFT TISSUE
INFECTIONS, BACTERIAEMIA AND
SEPSIS AND SUCH WITH THE RISE OF
THE OPIOID EPIDIMMIC WE'VE SEEN
A RISE IN CONTAMINATIONS.
FROM 2004-2014 THERE WAS A 300%
INCREASE IN HEPATITIS C INDENTS
THAT PARALLELLED 134% INCREASE
FOR OPIOID INJECTION.
THESE REENFORCE THAT IN THE
UNITED STATES HEPATITIS C AND
OPIOID USE DISORDER ARE ENDEMIC.
JUF AS WE'VE SEEN A RISE IN
TRANSMISSION RELATED INFECS,
BOTH HAVE WE SEEN A RISE OF
INFECTIONS ASSOCIATE WIDE INYEKS
USE OVER THE PAST DECADE EMPLOY
AS WE CAN SEE FROM THIS FIGURE
HOSPITAL DISCHARGE DATA IN OARG
ORGFROM 2008-2018, THERE HAS
BEEN A DRAMATIC REDUCTIONTIC
INCREASE FOR HOSPITALIZATIONS
FOR DRUG RELATED BACTERIAL
INFECTIONS.
SO WHAT CAN WE DO TO HELP PEOPLE
WITH OPIOID USE DISORDER.
1 THING IS WE CAN TREAT THEM.
THE GOLD STANDARD USE FOR OPIOID
DISORDER IS MEDICATION BASED
THERAPY AND THERE ARE CURRENTLY
3 FDA APPROVED THERAPIES TO
TREAT DISORDER.
METHADONE, BUPRENORPH AND
THEY'RE BOTH AGONIST OF THE
OPIOID RECEPTOR AND WHILE
NALTREKS OWN IS THE ANTAGONIST.
THE REASON WE USE HAD IS BECAUSE
IT WORKS, IT REDUCES DRUG USE
WHILE IN TREATMENT.
HERE YOU CAN SEE PEOPLE WHO
INJECT DRUGS USING METHADONE,
THE PERCENT STEADILY DECREASED
IN THE COURSE OF TREATMENT.
HOWEVER IN THOSE THORS SET
MAINTENANCE THERE WAS A STUDY
INYECTING DRUG USE OVER TIME.
FURTHER, OPIOID AGONIST THERAPY
REDUCES MORTALITY.
HERE DATA FROM A TODAY IN
MASSACHUSETTS EVALUATED
MORTALITY AS SEEN ON THE Y-AXIS
IN PATIENTS WITH A RECENT
NONFATAL OVERDOSE.
WHAT THEY FOUND WAS THAT
PATIENTS NOT ON MEDICATION FOR
OPIOID USE DISORDER HAD THE
HIGHEST RATES OF MORTALITY,
WHILE ENGAGEMENT AND OPIOID
AGONIST THERAPY WAS
SIGNIFICANTLY ASSOCIATED WITH
DECREASE MORTALITY FOR A YEAR
AFTER OVERDOSE.
ENIMAIJMENT IN M. O. D. REDUCES
HEPATITIS C TRANSMISSION BY
CREASING INYEKS, FREQUENCY AND
REDUCING RISK TAKING BEHAVIORS.
IN THIS STUDY OF PEOPLE WHO
INJECT DRUGS UNDER THE AGE OF
30, BEING ON MAINTENANCE OPIOID
AGONIST THERAPY SEEN IN GREEN IS
ASSOCIATED WITH SIGNIFICANTLY
LOWER INCIDENCE OF HEPATITIS C
COMPARED TO NO DRUG TREATMENT IN
PURPLE, NONMEDICATION BASED
TREATMENT IN BLUE AND DETOX
ALONE IN YELLOW.
FURTHER, M. O. U. D. IMPROVES
HIV OUTCOMES BY INCREASING
UPTAKE OF A. R. T. AND IMPROVING
ADHERENCE AND RETEPGZ TO A. R.
T. AND RESULT NOTHING A HIGHER
LIKELIHOOD OF HIV VIRAL
SUPPRESSION.
THOUGH M. O. U. D. HAS BEEN
PROVEN FOR DECADES TO IMPROVE
OPIOID USE DISORDER OUTCOMES,
ACCESSIBILITY REMAINS POOR.
IN THE U.S. THERE WERE
6.1 MILLION PEOPLE IN OPIOID USE
DISORDER AND ONLY 1 IN 4
RECEIVED MEDICATION EMPLOY AS
THERE ARE ONLY 144 MEDICATION
ADDICTION SPECIALISTS IN THE
UNITED STATES, WHO CANNOT
POSSIBLY MEET THE NEEDINGS OF
THIS ENTIRE POPULATION, IT IS I
PERRATIVE THAT THE NONADDICTION
SPECIALISTS, AND PRIMARY CARE
PROVIDERS TAKE ON THE CHALLENGE
IN PROVIDING ACCESS TO M. O. U.
D. FOR PATIENTS AND ESPECIALRY
THOSE WITH COMORBID INFECTIONS.
I ALSO WANT TO HIGHLIGHT A CORE
PRESENCE PEL WITH THE MANAGEMENT
AND SUBSTANCE USE DISORDERS,
THAT PRINCIPLE IS HARM
REDUCTION, THE PRACTICE OF
RIDUCING THE NEGATIVE
CONSEQUENCES OF DRUG USE
INCLUDING IN PEOPLE WHO ARE NOT
READY OR NOT ABLE TO ABSTAIN
FROM KRUG USE COMPLETELY.
THIS IS SAVING EVEN IF SOMEONE
CONTINUES TO USE DRUGS THERE ARE
THINGS WE CAN DO TO HELP THEM
STAY SAFER TO HELP THEM STAY
ALIVE.
IN MEDICINE WE ARE CONSTABTLY
EMPLOYING THE PRACTICE OF HARM
REDUCTION, WHETHER IT'S
CELEBRATING A PATIENT WITH
DIABETES WHO A1C IS NOT AT GOAL
DID YOU SIGNIFICANTLY IMPROVED
OR USING A ANTIHYPER TENSIVE TO
CONTROL BLOOD PRESSURE WHEN DIET
AND EXERCISE ARE NOT SUFFICIENT
AND DOING IT WITHOUT SHAME OR
STIGMA.
FOR A MULTITUDE OF REASONS
INCLUDING STIGMA, AND STRUCTURAL
INIQUITIES, THE TRIEWMENT OF
SUBSTANCE USE DISORDERS HAS
ALWAYS BEEN APPROACHED
DIFFERENTLY.
RATHER THAN FOCUSING ON
PROGRESS, ABSENCE IS CONSIDERED
THE ONLY SUCCESSFUL OUTCOME AND
RATHER THAN OFFERING
EVIDENCE-BASED MEDICATION FOR
THE TREATMENT OF OPIOID USE
DISORDER, PATIENTS ARE EXPECTED
TO KICK THEIR ADDICTION WITH
SHEER FORCE OF WILL.
SOMETHING WE DON'T EXPECT FOR
ANY OTHER CHRONIC DISEASE.
INSTEAD WHEN WE THINK ABOUT
GOALS FOR TREATING SUBSTANCE
USE, WE NEED TO THINK ABOUT SOME
OF THE HARMFUL CONSEQUENCES THAT
WE WOULD LIKE TO ALLEVIATE, SUCH
AS OVERDOSE DEATH AND
ACQUISITION OF INFECTIOUS
COMPLICATIONS.
WOULD ABSTINENCE BE BE A GOOD
WAY TO ACHIEVE THESE GOALS?
ABSOLUTELY.
BUT IT'S NOT THE ONLY WAY.
AND THE REALITY IS FOR PATIENT
WHO IS DESIRE ABSTINENCE, THE
IDEA THAT PEOPLE GO FROM
COMPLETE USE TO COMPLETE
ABSTINENCE IS UNREALISTIC
THEREFORE FOCUSING ON HARM
REDUCTION IS A WAY TO REDUCE USE
AND DEATH IN FOLKS USING THE
DRUG AND IT'S ALSO A WAY TO
HONOR THE DIGNITY AND AUTONOMY
WITH THESE PATIENTS WHILE
BUILDING RAPPORT WITH THIS
POPULATION.
SO USING MEDICATION FOR DISORDER
IS 1 WAY TO REDUCE HARM, OTHER
WAYS INCLUDE ENGAGING THEM TO
NEEDLE AND SYRINGE PROGRAMS THAT
IF THEY'RE INJECTING THEY'RE
INYECTING WITH SAFE EQUIPMENT,
TO PROVIDE SAFE INJECTION
PRACTICE COUNSELING, OVERDOSE
EDUCATION ANDINAL OX OWN USE AND
MAKURE SURE THEY DON'T DIE FROM
OVERDOSE AND ACCESS TO SAFE
COMSUMPTION SITES.
SO GETTING BACK TO OUR PROGRAM,
AROUND 2015 I WAS FORTUNATE TO
JOIN DCP, AND WE EXPANDED TO THE
UNIVERSITY OF AND NOW UNDER THE
DAY-TO-DAY LEADERSHIP OF MY CO
DIRECTOR SARAH AND MYSELF AS
WELL AS PROGRAM MANAGER RACHEL
[INDISCERNIBLE], 1 OF THE
ORIGINAL DCPFAPP PROGRAM, THIS
ALLOWS US TO INTERNATIONAL
CLASSIFICATION DPRAIT INTO THE
BALTIMORE COMMUNITY AT THAT
TIME, DA STUDIES AND SO WE'RE
FOCUSED SHIFTED TO
IMPLEMENTATION.
MORE SPECIFICALLY HOW TO INSURE
THAT MARGINALIZED POPULATIONS
WERE ABLE TO ACCESS DAAs AND
SUCCESSFULLY ACHIEVE HEPATITIS C
CARE.
WHAT OUR EXPERIENCES IN THE
COMMUNITY LED US TO UNDERSTAND
WAS THAT FINDING WAYS TO
EFFECTIVELY IMPLEMENT HEPATITIS
C TREATMENT IN PEOPLE WHO INYECT
DRUGS WAS CRITICAL TO
INTERRUPTING HEPC TRANSMISSION.
HOE WE WERE EMBEDDED IN HQFCs,
WE WERE TO INJECT PEOPLE WITH
DRUGS WHO WERE NOT ENGAGE INDEED
MEDICAL CARE SO WE HAD TO AGAIN
EXPAND OUR CLINICAL OPERATIONS
AND GO AND SEARCH FOR ADDITIONAL
COMMUNITY PARTNERS.
SO WE ESTABLISHED SITES AND
COMMUNITY BASED SETTINGS IN
WASHINGTON D. C. AND BALTIMORE
WHERE PEOPLE WERE INYECTING
DRUGS WERE ALMOST COMFORTABLE,
INCLUDING SYRINGE CENTERS,
DROP-IN PROGRAMS, AND CLINICS
AND HAVE WORKED THEIR WAY TO THE
EASTERN SHORE AS WELL.
TO HIGHLIGHT 1 OF OUR MAIN
SITES, HIPS, THIS IS AN
ORGANIZATION THAT HAS BEEN
PROVIDING HARM REDUCTION
SERVICES IN THE DISTRICT OF
COLUMBIA SINCE 1993 WITH A
SPECIAL EMPHASIS ON PEOPLE WHO
INJECT DRUGS AND SEX WORKERS.
WHILE HIPS OFFERED SAFE TESTING
SUPPLIES, AND DROP HAD-IN
CENTER, THE POPULATION THEY
SERVED HAD DIFFICULTY
ESTABLISHING AND REMAIN NOTHING
HEALTHCARE AND SO 3 OUR
COLLABORATION, ONSET CLAINICAL
SERVICES WERE INTRODUCED IN 2016
TO MEET THAT NEED.
HERE YOU CAN SEE SOME OF THE
SPACES THAT WE TURNED FROM
LITERAL CLOSETS INTO A FLEBOT ME
SUITE, DOWN IN THE MIDDLE YOU
CAN SEE DANA 1 OF OUR COMMUNITY
OUTREACH WORKERS DOING PARKS
OUTREACH IN PLACES WHERE PEOPLE
INYECT AND CONGREGATE, ALSO SOME
PARKING SPOTS DURING THE HOT
SUMMER AND COLD WINTER WE
CONTINUE TO BE THERE PROVIDING
CLINICAL SERVICES IN THE
COMMUNITY TO OUR PATIENTS.
SO I HOPE YOU TRUST ME FROM THE
PICTURES WHEN I SAY WE BROUGHT
OURSELVES TO THE COMMUNITY, AND
WE SET UP IN TENTS, PARKING
LOTS, PATIENT ACTIVE PORTA
POTTYS BUT HOW DO WE GET THE
PATIENTS TO MEET WITH US,
BECAUSE MEETING WITH THEM IS
JUST THE FIRST STEP.
OUR MODELS OF ENDPAIJMENT IS NOT
ONLY TO LEVERAGE THE TRUSTED
RELATIONSHIPS OF THE COMMUNITY
ORGANIZATIONS MAZATIONS WITH
WHICH WE'RE PARTNERING, BUT ALSO
TO PROVIDE A SPECTRUM OF CO
LOCATED CLINICAL SERVICES
INCLUDING INFECTIOUS DEC
TREATMENT THAT INCOMPASSES HIV
TREATMENT IS PREVENTION,
HEPATITIS C, B, TEST XG
TREATMENT, SUBITANCE USE
DISORDER TREATMENT, MENTAL
HEALTH AND GENDER AFFIRMING
CARE.
BECAUSE WHILE WE FOUND THAT MANY
PATIENTS ARE INTERESTED IN
TREATMENT OF HEP C AND HIV, SOME
ARE INTERESTED THIS ENGAGE
NOTHING OTHER MEDICAL PRIORITIES
OR M. O. U. D. OR GENDER
AFFIRMING CARE.
THEREFORE CO LOCATION OF THESE
SERVES ALLOWS US TO PRIORITIZE
THE PATIENT'S INTEREST AND LAY
ON OTHER PRIORITIES LIKE
TREATMENT AND CARE OF HEPATITIS
C.
ONCE WE ESTABLISHED CLINICAL
SERVICES THAT ARE ACCEPTABLE AND
SUSTAINABLE, WE THEN LAYER ON
RESEARCH ALONGSIDE CLINICAL
CARE.
IN THIS WAY, RESEARCH IS BEING
OFFERED BY A TRUSTED TEAM WITHIN
THE COMMUNITY SITE, AND THE
PATIENTS ARE ABLE TO RECEIVE
CLINICAL CARE WITHOUT RESEARCH,
CLINICAL WITH RESEARCH OR
RESEARCH ALONE.
INSURING THAT THE INVOLVEMENT IN
STUDIES IS COMPLETELY
NONCOERCIVE.
THAT BRINGS US TO THE NEXT
POINT.
DON'T JUST TREAT THE INFECTION,
TREAT THE SOURCE OF THE
INFECTION.
TO HIGHLIGHT THIS PRINCIPLE, I
WANT TO DISCUSS THE ANCHOR
STUDY, THIS WAS A TODAY TO TREAT
EPITITIS C IN PEOPLE WITH OPIOID
USE DISORDER ACTIVELY INJEKING
OPIOIDS.
AT THE TIME THE STUDY WAS
INITIATED IN 2017, PEOPLE WHO US
DRUGS WERE DENIED HEPC TREATMENT
UNLESS THEY WERE ABNORMALITIES
STINNENT, SOMETIMES FOR A YEAR
AND BEING TOLD THEY BEING NOT
GET HEP C TREATMENT UNTIL THEY
OBTAINED TREATMENT FOR THEIR
OPIOID USE DISORDER.
THIS WAS NOT EFS BASED BUT THERE
WAS VERY LITTLE EVIDENCE FOR THE
TIME AND VERY LITTLE ACCESS TO
M. O. U. D.
SO WE DECIDE THE STUDY TO OFFER
TREATMENT TO PEOPLE WHO INJECT
OPIOID USE DISORDER WITH ACTIVE
ONGOING DRUG INYEKS USE
REGARDLESS OF WHETHER OR NOT
THEY WERE ON M. O. U. D. WE
WANTED TO ACCESS PATIENTS WITH
CHAOTIC LIFE FACTORS WHO ARE
UNIVERSALLY BEING EXCLUDED FOR
TREATMENT BUT INVOFFED IN
ONGOING TRANSMISSION.
IN THE FIRST PART OF THE STUDY,
PATIENTS WERE INITIATED ON 12
WEEKS OF HEPATITIS C TREATMENT
THAT WAS DONATED BY GILLIAD
SCIENCES AND MONITORED FOR CARE
AND REINFECTION.
IN ADDITION WE OFFERED OPTIONAL
UPTAKE OF CO LOCATED OPIOID
AGONIST WITH BUPRENORPH TO ALL
ENROLLED PATIENTSA WELL AS
OPTIONAL PREP FOR HIV
PREVENTION.
WE MONITOR PATIENTS OVER THE
COURSE OF A 2 YEAR PERIOD FOR
CHANGE IN DRUG USE FACTORS AND
OTHER OUTCOMES WITH THE ULTIMATE
GOAL BEING TO NOT ONLY CURE HEP
CONSIDER BUT TO USE IT AS AN
OPPORTUNITY TO REDUCE OVERALL
HARM ASSOCIATE WIDE OPIOID USE.
PARTICIPANTS WERE DEDOMINANTLY
BLACK MEN, THIRD ON CIRRHOSIS,
OVER HALF UNSTABLY HOUSED AND
ALMOST ALL WITH PREVIOUS
INCARCERATE AND ALMOST ALL WITH
NO OR GOVERNMENT BENEFITS ONLY.
OUR PATIENTS HAD LIMITED ACCESS
TO M. O. U. D., AND COCO 8ED,
AND OF A HUNDRED PEOPLE WHO
INJECT DRUGS WITH STARTED ON
HEPATITIS E C TREATMENT, 2/3RDS
WERE NOT ON BASE LINE, OF THOSE
4 OUT OF 5, TARTED M. O. U. D.
DURING TREATMENT AND 70% WERE
RETAINED AT WEEK 24.
THE RESULT IS THAT THE LARGE
MAJORITY OF PATIENTS WERE CURED,
82%, WITH 88% CURE RATE WHEN
EXCLUDING THE FOLLOW UP OR DEAD
PATIENTS, THIS WAS THE SUCCESS
THROUGH THE LENS OF HEP C
TREATMENT.
WE ALSO FOUND THAT M. O. U. D.
IMPACTED THAT CURE, IT WAS
ASSOCIATE WIDE HIGHER RATES OF
HEPATITIS E C CARE.
WHILE BEING ON M. O. U. D. AT
BASE LINE WAS NOT RELEVANT TO
THE HEPATITIS E C OUTCOMES,
PATIENTS ON M. O. U. D. BY THE
EPPED OF TREATMENT WERE MORE
SIGNIFICANTLY LIKELY TO ACHIEVE
CARE, REINFORCING THAT PATIENTS
DIDN'T NEED TO BE ON M. O. U. D.
FOR HEPATITIS E C TREATMENT BUT
CAN USE IT AS AN OPPORTUNITY TO
ENGAGE THEM IN M. O. U. D. AND
IMPROVE, THEREBY IMPROVE THE HEP
C OUTCOMES.
WE ALSO LOOKED AT NONHEP C
OUTCOMES SO USING THE DARK RISK
TAKING BEHAVIOR KALE TO,A
ASSESSES PREVIOUS MONTH RISK
BEHAVIORS AND WE FOUND A
SIGNIFICANT DECLINE IN RISK
BEHAVIOR FROM DAY 0 TO WEEK 24
SEEN IN PATIENTS STARTED AND
RETAIN ON O. A. T. BUT NO
SIGNIFICANT EXCHANGES OF
PATIENTS ON BASE LINE OR NOT ON
OAT.
FURTHER WE FOUND THAT M. O. U.
D. AND SBR WERE ASSOCIATE WIDE
QUALITY OF LIFE.
USING THE HCBC QUALITY OF LIFE,
ASSESSED AT DAY 0 AND 24, WE SAW
THAT ACHIEVING SVR, IN BLUE AT
THE TOP AND BEING AT THE BOTTOM
LINE, WERE BOTH ASSOCIATE WIDE
IMPROVED QUALITY OF LCH.
HOWEVER PEOPLE NOT ON M. O. U.
D. OR DID NOT KARKS CHIEF SCVR
DID NOT ACHIEVE THESE
IMPROVEMENTS.
SO THIS IS AN OPPORTUNITY TO NOT
ONLY IMPROVE HEP C CURE RATES IN
THOSE WHO INJECT DRUGS BUT TO
REDUCE HARM DURING THE COURSE OF
THE HEP C TREATMENT.
BUT WHAT ABOUT LONG-TERM?
I WANT TO HIGHLIGHT 2-POINTS.
THE FIRST IS THAT 82% OF OUR
PARTICIPANTS COMPLETED THE FINAL
STUDY VISIT.
OF OUR OVERALL STUDY OF 198
PATIENTS, THAT'S 82% OF PEOPLE
WHO WERE ACTIVELY USING DRUGS AT
THE TIME OF ENROLL AM,
MAINTAINED ENGAGEMENT FOR 2
YEARS.
WHEN LOOKING AT ONLY THE SUBSET
WHO ARE ALIVE AT THE END OF THE
STUDY OR HAD NOT REALLY
TERMINATED AT THAT TIME POINT,
IT WAS 94%.
AND OF THOSE, OVER HALF ENROLLED
IN A 2 YEAR EXTENSION STUDY.
THERE IS NO QUESTION IN MY MIND
THAT THIS LONGITUDIAL ENGAGEMENT
AND M. O. U. D. CARE IS ONLY
POSSIBLE BECAUSE OF OUR
COMMUNITY BASED RESEARCH MODEL
EMPLOY WE COULD NOT HAVE GOTTEN
MOST OF THESE PATIENTS THROUGH
THE GATES AT NIH EVEN IF THEY
SHOWED UP.
THEY DON'T HAVE IDs, THEY
COULDN'T HAVE COME IN BUT THEY
WERE HAPPY AND EAGER TO SEE US
AT SITES THAT FELT CULTURAL AND
CONFIDENT.
I ALSO WANT TO HIGHLIGHT THAT
OVER THE COURSE OF THE ANCHOR
STUDY, 3-QUARTERS OF THE
PARTICIPANTS WERE EVER ON M. O.
U. D. THROUGH 1 OF OUR SITES.
AND HERE'S WHY IT MATTERS?
WE HAD A STAGGERING AMOUNT OF
DEATH AMONG OUR PATIENTS.
TWENTY-SIX PARTICIPANTS DIED OF
WHOM 77% DIED OF OVERDOSE.
I KNEW THEM ALL.
I WONDER WHAT WE COULD HAVE DONE
FOR THEM TO KEEP THEM ALIVE.
BUT I AM LIGHTLY COMFORTED BY
THE UNDERSTANDING THAT M. O. U.
D. WAS ASSOCIATED WITH A 62%
REDUCTION IN MORTALITY.
WE SAVED SOME LIVES, NOT ALL,
BUT WE SAVED SOME, BECAUSE WE
ENGAGE THEM IN HEPC CARE BUT
IT'S NOT ACTUALLY BECAUSE WE
CURED THEIR HEP C THAT THEIR
LIVES WERE SAVED.
IT'S BECAUSE IN THE PROCESS OF
TREATING THEIR HEP C, WE ALSO
CHOSE TO ADDRESS THE SOURCE OF
THEIR INFECTION AND THEIR OPILOT
PROJECT IDENTITY USE DID ORDER,
IN RESEARCH WE SPENT A LOT OF
TIME THINKING ABOUTEN POINTS AND
I CAN SAY WITH CONFIDENCE IF
YOUR GELLERT IS TO REDUCE
MORTAILITY OF PEOPLE WHO USE
DRUGS AND HAVE HEP C, BUT YOU
HAVE TO TREAT THEIR OPIOID USE
DISORDER.
SO WE FOCUSED ON INFECTIONS
RELATED TO OPIOID USE DISORDER
THAT ARE SEEN IN THE OUTPATIENT
SETTING.
BUT IT'S ALSO CRITICAL THAT
EVERY TOUCH POINT WITH THE
HEALTHCARE SYSTEM BE AN
OPPORTUNITY TO ENGAGE PEEMENT
WITH OPIOID USE DISORDER AND
TREATMENT.
SO WE ALSO WANT TO FOCUS FOR A
FEW MINUTES ON INFECTIONS THAT
BRING PEOPLE TO THE HOSPITAL.
AS I MENTIONED BEFORE, THERE'S
BEEN A PRECIPITOUS RISE IN
BACTERIAL FUNGAL INFECS
ASSOCIATED WITH CONTAMINATION
DURING INJECTION, LEAVING SOFT
TISSUE INRECYCLINGS,
ENDOCARTITIS, YOU NAME IT.
UNLIKE CHRONIC VIRAL INFECTIONS
LIKE HIV AND HEPATITIS C WHICH
WILL KILL PEOPLE OVER YEARS TO
DECK'SS THESE INFECS CAN MAKE
YOUNG PEOPLE ACUTELY ILL ASK
RESULT IN SIGNIFICANT MORBIDITY
OR EVEN MORTALITY IN A VERY
SHORT PERIOD OF TIME.
IN ORDER TO BETTER UNDERSTAND
HOW TO IMPACT CHANGE IN THESE
PATIENTS WE HAD TO FIRST
UNDERSTAND THE STATUS QUO AND WE
WERE VERY FORTUNATE AS ALWAYS TO
RECEIVE SUPPORT FROM DR. BOB
[INDISCERNIBLE] TO CREATE A
CONSORTIUM BETWEEN THE
UNIVERSITY OF MARYLAND, GW,
UNIVERSITY OF ALABAMA BIRMINGHAM
AND EMORY UNIVERSITY TO CONDUCT
A RETROSPECTIVE REVIEW OF
PATIENTS HOSPITALIZED IN 2018
WITH INFECTIONS DUE TO INYECTING
OPIOIDS.
WE SAW 322 PATIENTS WHO MET THE
CRITERIA AND THERE WAS ACROSS
THE BOARD SUBOPTIMAL M. O. U. D.
ENGAGEMENT DURING THE
HOSPITALIZATION.
HERE WE SEE THAT 29 RS --29% OF
THE PATIENTS WERE ON BASE LINE
M. O. U. D.
SO THE MINORITY.
THE REST WERE CONTINUED ON M. O.
U. D. DURING HOSPITALIZATION.
WHEREAS THE 71%, NOT AT BASE
LINE, ONLY 29% WERE PUT ON M. O.
U. D., AND IF WE LOOK AT THE
OVERALL CONTINUUM OF M. O. U. D.
CARE, WE CAN ALSO SEE THAT ONLY
41% HAVE M. O. U. D. ON THEIR
DISCHARGE PRESCRIPTION, 40% HAD
AN M. O. U. D. REFERRAL AND ONLY
8 AND HALF% WERE LINKED TO M. O.
U. D. IN THE YEAR FOLLOWING
DISCHARGE AND REMEMBER, THESE
ARE ALL PATIENTS WHO HAVE OPIOID
USE DISORDER AND WERE
HOSPITALIZED FOR A COMPLICATION
OF THEIR OPIOID USE DISORDER.
WE ALSO FOUND DRAMATICALLY HIGH
RATES OF PREMATURE DISCHARGE, 1
IN MY PATIENTS LEFT PREMATURELY,
PREMATURE DISCHARGE WAS
ASSOCIATE WIDE NOT TREATING
THEIR ARK DICTION, NOT BEING ON
PATIENT M. O. U. D., NOT BEING
INITIATE OFFICE OF DIVERSITY M.
O. U. D. AND NOT HAVING AN
ADDICTION CONSOLE.
THAL IS PARTICULARLY CONCERNING
BECAUSE OF THE 1 IN 5 PATIENT
WHO IS LEFT PREMATURELY, 80% OF
THEM HAD NO PLAN FOR ANTIBIOTIC
TREATMENT COMPLETION, OKAY,
THEY'RE HOSPITALIZED FOR AN
INFECTION, THEY LEFT WITH AN
ANTIBIOTIC PLAN.
WE'RE NOT TREATING THEIR
INFECTION OR ADICK AT THAT
POINT.
OF THE 316 PATIENTS DISCHARGED
ALIVE, HALF WERE READMITTED IN
THE FOLLOWING YEAR FOLLOWING
SENTINAL ADMISSION.
READMISSION WAS NOT ASSOCIATED
WITH M. O. U. D. RECEIVED OR
CONSULTATION WHICH WAS A
DISAPPOINTING FINDING FOR US BUT
I THINK REFLECTIVE OF THE FACT
THAT WE HAD VERY POOR RATES OF
LINKAGE AND RETENTION IN THE
COMMUNITY.
BUT WE WANTED TO BETTER
UNDERSTAND WHAT WAS HAPPENING,
WHY PEOPLE WERE GETTING
READMITTED SO OFTEN, WHAT WAS
HAPPENING DURING THE
READMISSIONS AND WHAT WERE THEY
FOR.
SO WE'RE IN THE PROCESS OF
EXPANDING A RETROSPECTIVE
ANALYSIS, WE'RE NOT DONE YET,
WE'RE LOOKING AT PATIENTS
HOSPITALIZED OVER A 4 YEAR
PERIOD AND SO FAR WE HAVE
IDENTIFIED 964 PATIENTS ALIVE.
MEDIAN TIME OF READMISSION WAS A
MONTH AND A HALF.
WHEN LOOKING AT THE CAUSE OF THE
FIRST READMISSION, 2/3RDS CAME
BACK FOR AN INFECTION, MORE
SPECIFICALLY, A THIRD WERE
RELATED TO PERSISTENT SENTINAL
INFECTION, AND A QUAURTER HAD
ACTUALLY RESOLVED THEIR INITIAL
INFECTION AND WERE BACK FOR A
NEW INFECTION RELATED TO
INYECTING DRUGS.
WHICH RAISES THE QUESTION, WHAT
ISHT VENTIONS CAN WE IMPLEMENT
FOR PEOPLE HOSPITALIZED WITH
INYEKS RELATED INFECTION TO
REDUCE REHOSPITALIZATION DUE TO
REDUCING INFECTION AND PREVENT
NEW INJECTION DRUG USE
INFECTIONS.
WE ARE VERY FORTUNATE THAT THE
HEAL INITIATIVE RECOGNIZED
IMPORTANCE OF THIS QUESTION AND
IS FUNDING A STUDY WHICH WILL BE
CONDUCTED OVER THE NEXT 4 YEARS
WHICH BRINGS US TO OUR NEXT
POINT.
IN ORDER TO ACHIEVE SOURCE
CONTROL FOR INFECTIONS DUE TO
SUBSTANCE USE, WE HAVE TO
CONDUCT PATIENT CENTERED
RESEARCH TO BETTER UNDERSTAND
HOW TO ACHIEVE SOURCE CONTROL.
THIS IS CRITICAL.
WE KNOW VERY LITTLE ABOUT
SPECIFIC ISHT VENTIONS TO REDUCE
RISKS OF INFECTION AMONG PEOPLE
WITH OPIOID USE DISORDER.
WE HAVE VERY LITTLE EVIDENT TO
INFORM CLINICIANS, GUIDELINES OR
PAYERS.
PRETTY MUCH WHAT WE DO KNOW IS
THAT M. O. U. D. IS IMPORTANT,
WE KNOW M. O. U. D. IS UPDATER
UTILIZE EXCLUDE WE THEED TO KNOW
HOW TO GET BETTER ACCESS TO M.
O. U. D. BUT WE ALSO KNOW
MEDICATION IS OFTEN NOT A
PANACEA.
WE NEED MORE WAYS TO HELP OUR
PATIENTS THEREFORE WE NEED
RESEARCH, ESPECIALLY WITH THE
FOCUS ON IMPLEMENTATION, TO
BETTER UNDERSTAND HOW TO
EFFECTIVELY AND SUSTAINABLY
TREAT THE SOURCE OF THESE
INFECTIONS.
TO TRY TO ENDEAVOR TO ANSWER
THESE QUESTIONS, WE'VE AGAIN
CREATED THE CONSORTIUM LED BY
DR. [INDISCERNIBLE] AT
INTRAMURAL WITH OUR TEAM AT
UNIVERSITY OF MARYLAND LED BY
SARAH, MYSELF AND ED
[INDISCERNIBLE], AND GW AND WEST
EMORY, AND THESE REPRESENT THE
SPECTRUM FOR ARK DICTION,
PRIMARY CARE, GENERAL MEDICINE,
EMERGENCY MEDICINE, ALL THE
PEOPLE WHO INTERFACE WITH THIS
PATIENT POPULATION.
AND THE FIRST THING WE DID,
WELL, PROBABLY THE SECOND THING
WE DID WAS TAKE THE DATA THAT WE
HAD ALREADY ACCUMULATED AND WE
WANTED TO MEET WITH OUR KEY
STAKEHOLDERS AT OUR INSTITUTIONS
TO REALLY SEE WHAT THEY THOUGHT
WERE THE REASONS THAT THESE
PATIENTS WERE GETTING
REHOSPITALIZED.
AND THE ANSWERS REALLY FELL INTO
2 BUCKETS.
THE FIRST WAS THAT THERE'S
LIMITATIONS OF I.D. AND M. O. U.
D. MEDICAL CARE DURING
HOSPITALIZATION.
THIS IDEA THAT THEY'RE NOT
GETTING ACCESS TO THE MEDICATION
THEY NEED, THEY'RE NOT GETTING
THE MEDICATION FOR OPIOID USE
DISORDER, THEY'RE NOT GETTING
ANTIBIOTICS WE NEED A BETTER WAY
TO INSURE THEY'RE GETTING THE
RIGHT MEDICAL CARE.
THE OTHER BUCKET WAS CHALLENGING
SOCIAL DETERMINE NABTS OF HEALTH
AND PSYCHOSOCIAL CIRCUMSTANCES.
HOW CAN WE EXPECT PEOPLE TO
PRIORITIZE ADDICTION AND
TREATMENT OF INFECTION WHEN
THEY'RE HOMELESS, WHEN THEY'RE
BEING TRAUMATIZED, WHEN THEY
DON'T HAVE ANY MONEY, RIGHT IN
SO THESE WERE REALLY THE MAIN
CHALLENGES AND AMONGST OUR GROUP
WE REALLY DEBATED WHICH OF THESE
CHALLENGES WERE MORE SALIENT AND
WE COULDN'T AGREEN CELLS OR
DECIDE SO WE THOUGHT THEY WERE
BOTH SO WE CAME UP WITH 2 TO
ADDRESS THESE ISSUES.
THE FIRST IS AN M. O. U. DAND ID
MEDICAL CLINIC WITH CARE AND
CARE COORDINATION BETWEEN THE
OUTPATIENT AND M. O. U. D. AND
D. D. PROVIDERS.
SO THE WHYED THAT THIS
INFORMATION WILL BE LINK FRIDAY
THE HOSPITAL INTO THE INTEGRATED
CLINIC WILL IMMEDIATELY HAVE
ACCESS TO A PROVIDER WHO CAN
PRESCRIBE MEDICATION FOR THE
OPIOID USE DID ORDER AND TREAT
THEIR ARK DICTION AS WELL AS
DOCTORS WHO WERE TREAT THEIR
DISEASES WHETHER IT'S SENTINAL
INFECTIONS, NEW INFECTIONS,
PREP, HIV TREME, HEAP TITIS C
TREME, WHATEVER THE NEEDS ARE,
THEY WILL BE SEEN BY THIS
COORDINATED CARE TEAM WITHIN THE
FIRST 14 DAYS AFTER DISCHARGE
AND MONTHLY THEREAFTER IF NOT
MORE.
AND THE MOPE IS THAT THIS
WILL--HOPE IS THAT THIS WILL
HELP TO ADDRESS THEIR ADICK,
RESOLVE INFECTION AND EITHER
PREVEBT OR RAPIDLY ADDRESS ANY
NEW INFECTIONS SOPHISTICATEDY
THAT THEY DON'T HAVE TO BE
HOSPITALIZED.
THE OTHER ARM, THE OTHER BUCKET
IS A SOCIAL SUPPORT ARM, AIMED
AT ADDRESSING SOCIAL
DETERMINANTS OF HEALTH AND
BARRIERS TO CARE THROUGH CASE
MANAGE AM, ADVOCACY, SERVICE
LINKAGE AND MOTIVATIONAL
INTERVIEWING AND THIS IS DONE IN
COLLABORATION WITH THE FRIENDS
RESEARCH AND HEAVILY DEVELOPED
BASED ON THEIR NAV-STAR MODEL,
IN 2021, WHICH SHOWED THAT AN
AGGRESSIVE CASE MANAGEMENT
NAVIGATION INTERVENTION CAN
REDUCE THE NUMBER OF ADMISSIONS
OVER 1 YEAR AND INCREASE ENTRY
INTO SUBSTANCE USE TREATMENT, SO
WE'RE WORKING VERY CLOSELY WITH
THEM TO,A DATA PROTECTION THIS
MODEL FOR OW SPECIFIC PATIENT
POPULATION
POPULATION.
SO WHAT THIS WILL LOOK LIKE
START NOTHINGAUK, WE ARE GOING
TO HOUSE PATIENTS AND WE'RE
GOING TO ENROLL 600 AND THEY
WILL BE RANDOMIZED TO RECEIVE
THIS INTEGRATED I.D. M. O. U. D.
OR THE TROAMENT OR OR TREATMENT
AS USUAL.
THE TREATMENT WILL LAST FOR 6
MONTHS, AT THE END WE WILL REARK
ASSESSES FOR THE PRIMARY
OUTCOME.
BUT WE WILL THEM OVER THE COURSE
OF A YEAR AND LOOK AT A NUMBER
OF SECONDARY OUTCOMES INCLUDING
IMPACT ON DRUG USE, SOCIAL
DETERMINANTS OF HEALTH BUT I
WANT TO DRAW SPECIFIC FOCUS TO
THE BOTTOM, TOO WHICH IS
IMPLEMENTATION IS COST
EFFECTIVENESS.
BECAUSE IT'S BECOME REALLY CLEAR
THAT IF WE CREATE AN
INTERVENTION THAT'S EFFECTIVE,
BUT THAT WE CAN'T--IS NOT
FEASIBLE OR ACCEPTABLE, IT
DOESN'T MATTER.
IF WE CREATE AN INTERVENTION
THAT'S ACCEPTABLE, BUT NOT COST
EFFECTIVE FOR THE HEALTH SYSTEM,
IT DOESN'T MATTER.
WE NEED TO BOTH CREATE
INTERVENTIONS THAT WORK AS WELL
AS THAT ARE FEASIBLE AND
SUSTAINABLE.
OKAY AND IN THE LAST FEW MINUTES
I WANT TO LIGHT 1 LAST POINT
WHICH IS THAT IT WE'RE TRYING TO
ACHIEVE SOURCE CONTROL FOR
INFECTIONS DUE TO SUBSTANCE USE,
WE CAN'T ANCHOR ON A SINGLE
SOURCE WOORKS HAVE TO EXPAND OUR
FOCUS.
AND THIS IS A LITTLE BIT OF A
BITTER PILL TO SWALLOW BECAUSE
OVER THE LAST DECADE WE'VE
REALLY BEEN LASER FOCUSED ON
OPIOIDS BUT THE REALITY IS, THAT
THE MAJORITY OF OUR PATIENTS ARE
USING MULTIPLE TYPES OF
SUBSTANCES, THEY HAVE
POLYSUBSTANCE USE.
AND IF YOU LOOK AT THIS OVERDOSE
GRAPHIC, YOU CAN SEE YES, THE
MAJORITY OF OVERDOSES ARE
RELATED TO OPIOIDS BUT THERE'S A
SIGNIFICANT PORTION OF PATIENTS
FROM DRUGS OTHER THAN OPIOIDS.
I WANT TO BRING YOUR ATTENTION
PARTICULARLY TO STIMULANT WHICH
IS ARE ARE PREVALENT AND
PROBLEMATIC FOR AT RISK HIV USE.
METHAMILLIO FET MINE IS
ASSOCIATE WIDE HIGH RATE OF
SEXUAL ACQUISITION, FOR MSM, FOR
USE WITH CHEM SEX AND COCAINE
USE IS ASSOCIATED WITH INCREASED
CARDIOVASCULAR RISK,
INFLAMMATION, MORTALITY AND
PEOPLE WITH HIV WHO ARE
DISPROPORTIONATELY LIKELY TO BE
USING COCAINE.
UNFORTUNATELY, THERE ARE NOT FDA
APPROVED MEDICATIONS FOR THE
TREATMENT OF METHAMPHETAMINE USE
DISORDER OR COCAINE USE
DISORDER.
BUT WE HAVE BEEN FORTUNATE TO
FIND OUT JUST LAST WEEK THAT WE
GOT SOME FUNDING PRACTICES O. A.
R. TO 1 DUCT 2 PILOT STUDIES.
THE FIRST IS TO LOOK AT THE USE
OF LONG ACTING STIMULANTS FOR
METHAMILLIO FET MINE USE
DISORDER WITH THE IDEA OF
REDUCING HARM TO HIV RISK
BEHAVIOR, PREP ENGAGEMENT, ART
ENGAGEMENT, VIRAL SUPPRESSION.
SO WE'RE SEEING IF WE CAN USE
LONG ACTING STIMULANTS TO REDUCE
HARM IN THE HIV POPULATION.
AND THE OTHER IS TO LOOK AT
COCAINE USE DISORDER IN
COLLABORATION WITH
[INDISCERNIBLE] AT NIDA, AND SEE
IF WE CAN USE SEMIGLUE TIDE FOR
PEOPLE WITH COAIN USE TO SAFELY
AND EFFECTIVELY BOTH REDUCE
COCAINE USE AS WELL AS IMPROVE
CARDIOVASCULAR HEALTH IN PEOPLE
WITH AND WITHOUT HIV.
SO WE'RE REALLY EXCITED FOR THE
OPPORTUNITY TO BE ABLE TO EXPAND
OUR FOCUS A BIT BEYOND OPIOID
USE DISORDER AND SEE IF WE CAN
CONTINUE TO BENEFIT THIS PATIENT
POPULATION.
SO IN CONCLUSION, JUST TO REMIND
YOU, HOPEFULLY I HAVE CONVINCED
YOU THAT IT IS CRITICAL IN
PEOPLE WHO USE DRUGS TO NOT ONLY
TREAT THEIR INFECTIONS ABOUT YOU
REALLY TO ADDRESS THEIR
ADDICTION IN ORDER TO ACHIEVE
SOURCE CONTROL.
AND THE WAY TO DO THIS IS TO
LOCALIZE WHERE THEIR INFECTIONS
ARE HAPPENING AND GO THERE, TO
TREAT THE SOURCE OF THE
INFECTION, NOT JUST THE
INFECTION ITSELF.
TO CONDUCT PATIENT CENTERED
RESEARCH TO BETTER UNDERSTAND
HOW TO ACHIEVE SOURCE CONTROL,
AND TO EXPAND OUR FOCUS AND NOT
ANCHOR ON A SINGLE SOURCE, I
ALSO WANT TO SAY THANK YOU TO
ALL THE MANY, MANY PEOPLE WHO
HAVE CHAMPIONED THIS PROGRAM
OVER THE LAST SEVERAL YEARS,
FACILITATED ALL THE ASPECTS OF
THIS PROGRAM TO MAKE IT WORK AND
COLLABORATED WITH US WHO HAVE
HELPED IN CLINICS AND THE
COMMUNITY AND OUR AMAZING TEAM
ON THE RIGHT THAT MAKES THIS ALL
HAPPEN.
SO THANK YOU.
[ APPLAUSE ]
>> AGAIN, WE'RE HAPPY TO ANSWER
QUESTIONS BUT LOOKING AROUND THE
AUDIENCE, IT'S WORTH POINTING
OUT A FEW PEOPLE HERE THAT MAKE
THIS POSSIBLE, I MEAN MARY
Mc LAUGH LYNN PROBABLY SAW ALL
THE PATIENTS WE SAW UP IN THE
CLINIC OR PROBABLY MOST OF THEM.
JIM WE APPRECIATE THE FACT THIS
IT GIVES US THE FLEXIBILITY TO
HAVE THIS KIND OF PROGRAM AND
THERE ARE PROBABLY OTHER PEOPLE
I'M MISSING BUT THE PERSON WHO
IS REALLY KEY IS ROB PALMER IS
THE 1 WHO IS NOT THE SCIENTIST,
BUT MAKES ALL THE MONEY FLOW SO
THESE THINGS CAN HAPPEN.
THIS CERTAIN LE WOULDN'T HAPPEN
WITHOUT ROB PALMER AND SEAN
[INDISCERNIBLE] IS THE CHIEF OF
INFECTIOUS DISEASE AT MARYLAND
WHO STARTED OUT IN THE FAUCI LAB
AND ALSO THE SCIENTIFIC AND
CLINICAL BRAINS BEHIND THAT.
SO THERE ARE A LOT PEOPLE HERE
WHO MADE THIS POSSIBLE.
BUT ARE THERE ANY QUESTIONS OR
COMMENTS OR TOM?
I DON'T KNOW IF YOU HAVE NONE
THERE?
ONE OF THE ISSUES ELANA, BEING
IN THE COMMUNITY, SOME OF THE
IDEAS ABOUT WHAT I THOUGHT WERE
IMPORTANT HERE WERE NOT THE
WHYEDS THAT YOU AND SARAH AND
SEAN THOUGHT WERE IMPORTANT FROM
BEING IN THE COMMUNITY TALKING
TO STAKEHOLDERS AND TALKS TO
PATIENTS BUT YOU WANT TO SAY HOW
THAT CHANGES YOUR PERSPECTIVE ON
WHAT RESEARCH QUESTIONS ARE
IMPORTANT?
NYEAH, I THINK IT'S CRITICAL,
WE'RE INCREDIBLE LOAMACYY
FORTUNATE TO GET THE INSIGHT OF
OUR PATIENTS AND COMMUNITY
STAKEHOLDERS WHEN WE WERE
DESEENING RESEARCH, 1 OF THE
LAST STUDIES I MENTION, THE
METHAMPHETAMINE STUDY WAS NOT
OUR IDEA.
IT WAS BROUGHT TO US BY THE
PATIENTS BECAUSE THEY IMU WE
WERE PROVIDING LOW BARRIER HARM
REDUCTION OPIOID USE DISORDER
TREATMENT AND THEY WANTED TO
KNOW IF WE COULD DO THE SAME
WITH METHAMPHETAMINE DISORDER
AND IF YOU DID THROUGH REDIT AND
TALK TO PATIENTS, THIS IS
SOMETHING THEY'RE DOING IN THE
COMMUNITY, THEY'RE ACCESSING
LONGAC BEING STIMULANTS AND
THEY'RE USING IT TO REDUCE HARM
THEMSELVES BUT THEY CAN'T FIND
PROVIDER WHO IS WILL DO IT ARE
FOR THEM BECAUSE THERE'S NOT AN
EVIDENT BASE FOR IT SO WE REALLY
DESIGNED AND TRIED TO GET THE
STUDY FUNDED FOR 5 YEARS NOW
BECAUSE THE PATIENTS WERE ASKING
FOR IT, AND EVERY TIME WE SEE
THEM, WE HAVE NOTHING TO DO FOR
THEM.
AND WE'RE JUST SCARED AND I
THINK THE OTHER HING IS THAT,
YOU KNOW UNFORTUNATELY I DIDN'T
HAVE TIME TO MENTION BUT WE'VE
BEEN ABLE TO REEL KEEPSAKESLY
EXPAND INTO THE GENDER AND
SEXUAL MINORITY POPULATION.
WE HAVE A COHORT OF TRANSGENDER
PATIENTS WHO WE STARTED DOING
CLINICAL CARE WITH OVER COVID
BECAUSE HIPS THE HARM REDUCTION
ORGANIZATION WHERE WE'RE
OPERATING BASICALLY KACCT
IMPEDIMENTS TO US AND SAID WE
HAVE ALL THESE PATIENT WHO IS
ARE LOSING ACCESS TO CARE
BECAUSE OF COVID, WHAT CAN WE
DO?
WE'RE LIKE WE WILL LEARN HOW TO
DO GEBDER AFFIRMING CARE, WHY
NOT AND THROUGH THAT
COLLABORATION, WE HAVE DEVELOPED
AN HPV PROGRAM AND WE'VE REALLY
BEEN ABLE TO DO ANNAL APPLIEDS
ON ALL OF OUR PATIENTS AND WE
HAVE HRA CLINIC IN CONJUNCTION
WITH ANDREA HERE AND THAT WAS
BORN OUT OF A NEED THAT WAS
IDENTIFIED TO US IN THE
COMMUNITY, 1 OF OUR COMMUNITY
HEALTH WORKERRED HAD ANALL
CANCER AND THIS IS A HUGE KIND
OF UNMET NEED THAT HE'S
IDENTIFIED TO US AS WELL AND I
THINK WITHOUT THE PERSPECTIVE OF
MY PATIENTS I WOULD BE VERY OUT
MUCH TOUCH AND SO THE WAY THAT
WE'RE ABLE TO ENGAGE THEM IS
BECAUSE THEY WANT TO DO THIS
WERE WITH US, THEY'RE EXCITED,
AI LOT OF THESE THINGS ARE THEIR
IDEAS SO IT'S WHAT MAKES IT
MEANINGFUL TO US TO DO WHEN
WE'RE DEALING WITH IRB
CHALLENGES AND YOU KNOW THE
CONCERN ABOUT RETENTION IN
PATIENTS WHO ARE ACTIVELY USING
AND THINGS LIKE THAT.
BUT IT'S ALSO HOW WE DO THE WORK
THAT WE DO THAT'S IMPACTFUL
NBEFORE WE GET TO YOUR QUESTION,
BUT THE FIRST MONEY WE GOT FROM
THE PROGRAM WAS FROM NIMH WHICH
REALLY GOT US STARTED AND THE
PSYCHIATRIC SUPPORT THAT WE GOT
AND THE COLLABORATION WITH
MARILYN, DIANE AND OTHER PEOPLE
HAS BEEN ESSENTIAL BECAUSE IT'S
HARD TO DO THIS KIND OF PROGRAM
OR IMPOSSIBLE SOILY AS
INFECTIOUS DEC PEOPLE IF YOU
TONIGHT HAVE MORE OF A SENSE OF
ADDICTION IN MEDICINE AND
PSYCHIATRIST, BUT I DON'T KNOW
IF MARYLAND WANTS TO SAY
ANYTHING, BUT AGAIN, WE WILL GET
TO YOUR QUESTION IN 30-SECONDS
BUT NIH IS THE LAND OF
OPPORTUNITY IN THAT IF YOU CAN'T
GET WHAT YOU WANT OUT OF YOUR
INSTITUTE OR ANOTHER INSTITUTE,
YOU CAN ALWAYS GO TO OTHER
PEOPLE IN THE OFFICE OF AIDS
RESEARCH, THE HEAL INITIATIVE,
LOTS OF PLACES WE GO AND LOOK
FOR MONEY.
YOU'RE NOT ALWAYS SUCCESSFUL BUT
IF YOU LOOK OFTEN ENOUGH, CAN
YOU BE SUCCESSFUL AND THERE ARE
LOTS OF PEOPLE WHO LIKE ANDREA
WHO WILL EXPAND THE KIND OF
PROGRAMS YOU DO, I DON'T THINK
WE THOUGHT ABOUT DOING HPV
INITIALLY BUT CERTAINLY AN
INIMPORTANT INITTIAIVE IT NOW,
BUT OKAY, YOU HAVE A QUESTION
NSORRY, I'M DEANNA CANNED WHAT,
I AM AT--
>> HI.
>> AND I'M ALSO THE ACTING
DIRECTOR OF THE OFFICE OF AIDS
RESEARCH WHICH YOU JUST
MENTIONED AND SPEAKING OF MONEY,
MY QUESTION IS ABOUT THE COSTS
ASSOCIATED WITH THIS KIND OF
CARE.
SO I LOVE THIS STUFF, YOU
TOUCHED ON IT AND ACTUALLY EARLY
ON I WAS VERY INTERESTED IN THE
ECONOMICS, I STUDIED THE
ECONOMICS OF HEALTHCARE AND THEN
RAN INTO THE STRUGGLE OF THE
POLITICAL PROBLEM OF WHO PAYS
FOR THESE SORTS OF, THIS SORT OF
CARE AND HOW CAN YOU MAKE IT
REALLY SHOW THAT IT IS COST
EECTIVE BOTH ECONOMICALLY AND
POLITICALLY.
SO HOW CAN WE TURN IT INTO
SOMETHING THAT IS REALLY
APPEALING ECONOMICALLY WHEN THE
COSTS ARE USUALLY BORN BY THAT
HOMELESS PERSON OR EEIVET
CRULLLY IT'S BORNE BY SOCIETY.
BUT HOW DO WE DO THAT BETTER?
>> YEAH THAT'S A GREAT QUESTION
AND I THINK AT THE CRUX OF HOW
WE CAN GET ANYTHING DONE.
FOR THE CHOICE STUDY WE ARE
COLLABORATING WITH PEOPLE AT
CORNELL WHO THAT'S THEIR WHOLE
FOCUS IS ECONOMIC FEASIBILITY
AND COST EFFECTIVENESS SO THEY
LOOK AT THINGS NOT JUST IN
[INDISCERNIBLE] BUT WHAT IS THE
COST TO THE SYSTEM AND THEY ALSO
ELECTRIC AT OUTCOMES BEYOND JUST
YOU KNOW LIVES SAVED BUT ALSO
ARE THEY GOING TO BE
INCARCERATED?
WHAT'S THEIR UTILIZATION?
HOW OFTEN ARE THEY GOING TO THE
EMERGENCY DEPARTMENT?
HOW OFTEN ARE THEY GOING TO
PRIMARY CARE AND THINGS LIKE
THAT SO WE CAN TAKE THIS TO THE
HELT SYSTEM AND SAY LOOK AT ALL
THE WAYS WE'VE SAVED YOU MONEY
EVEN THOUGH YOU HAVE TO PAY FOR
THIS PEER TO HELP WITH THIS
NAVIGATION.
IT WAS--I DIDN'T MENTION IT BUT
1 OF THE BIG PARTS OF OUR DEBATE
ABOUT WHAT INTERVENTION TO DO
WAS THAT TECHNICALLY, YOU KNOW
HAVING NAVIGATORS HELP SUPPORT
PATIENTS IS A LOW COST
INTERVENTION BUT IT'S NOT A
REIMBURSABLE INTERVENTION.
WHEREAS TAKING TOO DOCTORS AND
INTEGRATING THEM IN THE CLINIC,
IS WE CAN DO THAT, THAT'S
SOMETHING WE CAN BILL FOR.
SO I THINK THE OTHER CHALLENGE
WE'VE RUN INTO BECAUSE WE'RE
DOING THESE INTERVENTIONS IN 4
DIFFERENT ESTATE STATES, D. C.
IS NOT EXACTLY A STATE BUT
ENCOUNTERING DIFFERENT UPON
ISSUES IN TERMS OF MEDICAID
EXPANSION AND SOME PLACES
PEERINGS ARE REIMBURSABLE AND
SOME PLACES THEY'RE NOT SO I
DEFINITELY DEMONSTRATION HAVE
THE ANSWERS BUT I THINK
INCREASINGLY WE'RE UNDERSTANDING
THAT IT'S CRITICAL TO
INCORPORATE INTO OUR ALL OF OUR
STUDIES THIS ABILITY TO ASSESS
THE COST EFFECTIVENESS AND
ECONOMIC FEASIBILITY SO THAT AT
THE END AND IMPLEMENTATION
ASSPEBTS RIGHT IS IT FEASIBLE,
ACCEPTABLE?
SUSTAINABLE?
BECAUSE WE'VE SEEN TIME AND TIME
AGAIN THAT WE DO THESE GREAT
STUDY ANDS THEN NOTHING HAPPENS
FOR 10 YEARS, RIGHT IN AND SO,
WE ACTUALLY WANT TO BE ABLE TO
NOT ONLY PUSH FORWARD THE
SCIENCE BUT TAKE SCIENCE AND
CHANGE CLINICAL PRACTICE VERY
RAPIDLY IF WE HOPE TO IMPACT
CHANGE IN THESE PATIENTS.
SO, I'M NOT AN EXPERT IN HOW TO
DO IT BUT WE'RE FORTUNATE TO BE
ABLE TO COLLABORATE WITH EX
PERS AT THIS POINT WHO I AM
CONTIARAS DEPT CAN FIGURE IT
OUT.
>> AND AS I LOOK AT THE BRIGHT
LIGHT, RECOGNIZE DEANNA BEFORE
BECAUSE WE'VE GONE NOW 15
CONSECUTIVE YEARS OF FUNDING FOR
THE OFFICE OF AIDS RESEARCH AND
THEY'VE BEEN VERY FLEXIBLE ABOUT
ALLOWING US TO GET INTO AREAS
THAT WE DIDN'T KNOW THAT MUCH
ABOUT LIKE IMPLEMENTATION
RESEARCH WHICH I DIDN'T KNOW
ANYTHING ABOUT 6 OR 7 YEARS AGO,
AND THEN AGAIN TO OPIOID AND
ADDICTION MEDICINE WHICH ELANA
WILL TELL YOU I DIDN'T KNOW
ANYTHING ABOUT 6 OR 7 YEARS AGO
BUT WE GOT INTO THAT AND AGAIN,
THE KIND OF FUNDING YOU CAN GET
IF SOMEBODY LIKE THE OFFICE OF
AIDS RESEARCH, NIMH HAS
CONFIDENCE THAT YOU CAN
SUCCESSFULLY OPERATIONALIZE YOUR
PROGRAM HAS BEEN REALLY
ESSENTIAL FOR THIS PROGRAM.
SO WE APPRECIATE THAT AND WE'RE
ALSO VERY EXCITED ABOUT THESE 2
INMODEL CITIZENIVATION GRANTS
FOR AMPHETAMINE ANDS COCAINE.
WE ACTUALLY HAVE 1 QUESTION
ABOUT HPV.
>> NO, I'M NOT GOING TO ASK YOU
ABOUT HPV.
>> YOU WOULD HAVE TO ANSWER IT.
[LAUGHTER]
>> WELL IS AN INTERNAL DEBATE IN
OUR DIVISION ABOUT HOW OUT OF
TOUCH WE ARE WITH THE COMMUNITY
AND THIS IS A GREAT TALK IN THAT
SENSE.
THE CURRENT DEBATE IS WHETHER TO
INCORPORATE IN OUR SCIENTIFIC
REVIEW AND WHEN WE DESIGN
STUDIES INSIDE THE NIH,
COMMUNITY ADVISORS AND OTHER
WAYS IN WHICH WE CAN UNDERSTAND
BETTER THE NEEDS IN THE
COMMUNITY, DO YOU HAVE ANY
EXPERIENCE IN THAT FIELD IN
OTHER ACADEMIC INSTITUTIONS.
I FEEL LIKE WE'RE LATE TO THIS
AND DO HAVE YOU ANY SUGGESTION
HOW TO IMPLEMENT THAT?
>> YEAH, I THINK WE USED TO HAVE
A COMMUNITY ADVISORY BOARD AND
THEN IT LAPSED FOR A TIME AND
NOW WE'RE GOING BACK TO
IMPLEMENTING THAT AGAIN AND I
THINK THAT CABS ARE SOMETHING
THAT HAVE BECOME INCREASINGLY
UNDERSTOOD TO BE VERY IMPORTANT
IN THE CONDUCT OF RESEARCH, BOTH
FOR IDENTIFYING THE NEEDS OF THE
COMMUNITY AND ALSO FOR REVIEWING
THE RESEARCH THAT IS PLANNED AND
MAKING SURE THAT IT'S BEING DONE
IN A WAY THAT IS MEANINGFUL AND
RESPECTFUL OF THE POPULATIONS
AND TAKES INTO ACCOUNT THE NEEDS
OF THE PATIENTS AS WELL.
IT'S OBVIOUSLY EVERYTHING'S
EASIER SAID THAN DONE.
YOU KNOW, FINDING THE RIGHT
PEOPLE, ENGAGING THEM, FINDING A
WAI TO HAVE A MEANINGFUL
CONVERSATION WHERE YOU WILL GET
APPROPRIATE FEEDBACK AND WORK,
BUT IT'S WORK WORTH DOING AND I
THINK 1 OF THE KEY THING SYSTEM
VALUING THE TIME OF THE PEOPLE
THAT ARE DOING IT, THEY HAVE TO
BE COMPENSATED, YOU HAVE TO
SUPPORT THE TIME AND EFFORT OF
WHAT THEY'RE DOING BUT WE FOWBD
IN RECRUITING PEOPLE FOR THIS,
IS PEOPLE ARE REALLY EAGER TO
CONTRIBUTE AND SO I THINK IT
WOULD BE AMAZING TO HAVE THAT BE
SOMETHING THAT NIH TAKES ON
BECAUSE IT IS--IT IS REALLY A
WAY FOR US TO GET INSIGHT FROM
THE COMMUNITY AND ALSO FOR THEM
TO UNDERSTAND THAT OUR AIMS CAN
CONDUCTING RESEARCH ARE TO HELP
THE PASHT POPULATION AND
SOMETIMES IT'S HARD TO BELIEVE
THAT IF WE DON'T TAKE THEIR
PERSPECTIVE INTO,A COUNT AT ALL.
I THINK YOU KNOW, WE'RE VERY
FORTUNATE IN THE COMMUNITY DAY
IN AND DAY OUT, AND SO THEY JUST
COME UP AND TELL US, BUT EVEN
THEN WHEN WE DEVELOP NEW
PROTOCOLS, WE MAKE SURE THAT YOU
KNOW OUR COMMUNITY PARTNERS IN
OUR STUDIES OF TRANSGENDER
PEOPLE, OUR TRANSIMENDER
COMMUNITY HEALTH WORKERS ARE
VIEWING BOTH WHEN WE'RE DON
DUCTING AND THE LANGUAGE OF THE
SURVEYS AND THINGS LIKE THAT TO
MAKE SURE THAT IT ALIGNS WITH
THE INTEREST OF THE COMMUNITY.
>> LET ME JUST EXPAND ON THAT
FOR A MOMENT.
I THINK THAT MOST OF THE PEOPLE
IN THIS ROOM ARE HEALTHCARE
PROFESSIONAL ANDS I THINK THAT
WE ALL REMEMBER PATIENTS WHO
REALLY CHANGED OUR LIFE, SO
HEARING SOMETHING FROM THE
COMMUNITY ADVISORY BOARD ASK
HELPFUL BUT ACTUALLY SEEING A
PATIENT WITH A PROBLEM AND
DEALING WITH THEM, I THINK GIVES
YOU A MUCH DIFFERENT PERSPECTIVE
AND I THINK SOME OF THE ISSUES
WITH THE INTRAMURAL RESEARCH
PROGRAM, I THINK WE ARE ALL
GUILTY OF THAT, IS THAT THE MORE
WE'RE UPHERE IN BETHESDA IN THE
FENCE, THE MORE WE DON'T SEE
EXACTLY WHAT'S HAPPENING.
THE LONGER WE'RE HERE, THE THING
I WORRY ABOUT IS THAT WE'RE
GETTING OUT OF TOUCH WITH WHAT
SOME OF THE REAL PROGRAMS ARE,
SO COMMUNITY ADVOICERY BOARDS
ARE GREAT, BUT BEING OUT IN THE
COMMUNITY AND SEEING PEASHT
SYSTEM ALSO IMPORTANT AND I
THINK THAT YOU KNOW SEAN AND
ELANA, AND SARAH, DESERVE A LOT
OF CREDIT FOR SPENDING A LOT OF
TIME MANAGING THE PATIENTS AND
BEFORE WE CAME HERE ELANA WAS
TAKING A CALL FROM A PATIENT WHO
JUST GOTTEN OUT OF PRISON AND
HAD TO GET HIS--BUT THIS GIVES
YOUA SENSE OF WHAT THE REAL
PROBLEMS ARE.
NOT JUST IMPLEMENTATION,
SOMETIMES IT LEADS TO SPECIFIC
ISSUES ALSO, SO, AGAIN, IT'S
12:58 AND A HALF UNLESS TOM HAS
A FINAL QUESTION, AGAIN, WE
ALWAYS APPRECIATE THE FEW HARDY
PEOPLE WHO ACTUALLY COME IN
PERSON AND WE HOPE THAT MORE
PEOPLE IN GRAND ROUNDS IN THE
FUTURE WILL COME IN PERSON SO
THEY CAN ASK QUESTIONS SO THANK
YOU TO ALL OF YOU FOR ATTENDING. 1821 00:59:16,552 [ APPLAUSE ]