Public substance abuse treatment services have largely operated as an independent part of the overall health care system, with unique methods of administration, funding, and service delivery. The Affordable Care Act of 2010 and other recent health care reforms, coupled with declines in state general revenue spending, will change this. Overall funding for these substance abuse services should increase, and they should be better integrated into the mainstream of general health care. Reform provisions are also likely to expand the variety of substance abuse treatment providers and shift services away from residential and stand-alone programs toward outpatient programs and more integrated programs or care systems. As a result, patients should have better access to care that is more medically based and person-centered.

The Looming Expansion And Transformation Of Public Substance Abuse Treatment Under The Affordable Care Act

Background 
People who inject drugs (PWID) have increased risk of morbidity and mortality. We update and present estimates and trends of the prevalence of current PWID and PWID subpopulations in 96 US metropolitan statistical areas (MSAs) for 1992–2007. Current estimates of PWID and PWID subpopulations will help target services and help to understand long-term health trends among PWID populations.


Methodology 
We calculated the number of PWID in the US annually from 1992–2007 and apportioned estimates to MSAs using multiplier methods. We used four types of data indicating drug injection to allocate national annual totals to MSAs, creating four distinct series of component estimates of PWID in each MSA and year. The four component estimates are averaged to create the best estimate of PWID for each MSA and year. We estimated PWID prevalence rates for three subpopulations defined by gender, age, and race/ethnicity. We evaluated trends using multi-level polynomial models.


Results 
PWID per 10,000 persons aged 15–64 years varied across MSAs from 31 to 345 in 1992 (median 104.4) to 34 to 324 in 2007 (median 91.5). Trend analysis indicates that this rate declined during the early period and then was relatively stable in 2002–2007. Overall prevalence rates for non-Hispanic black PWID increased in 2005 as compared to other racial/ethnic groups. Hispanic prevalence, in contrast, declined across time. Importantly, results show a worrisome trend in young PWID prevalence since HAART was initiated – the mean prevalence was 90 to 100 per 10,000 youth in 1992–1996, but increased to >120 PWID per 10,000 youth in 2006–2007.


Conclusions 
Overall, PWID rates remained constant since 2002, but increased for two subpopulations: non-Hispanic black PWID and young PWID. Estimates of PWID are important for planning and evaluating public health programs to reduce harm among PWID and for understanding related trends in social and health outcomes.

/pdf/trends-in-the-population-prevalence-of-people-who-inject-4bwemnvtlc.pdf

Trends in the population prevalence of people who inject drugs in US metropolitan areas 1992-2007.

The longitudinal association between homelessness, injection drug use, and injection-related risk behavior among persons with a history of injection drug use in Baltimore, MD.

Drug use continues to be a major factor fueling the global epidemic of HIV infection. This article reviews the current literature on the ability of drug treatment programs to reduce HIV transmission among injection and noninjection drug users. Most data come from research on the treatment of opiate dependence and provide strong evidence on the effectiveness of medication-assisted treatment for reducing the frequency of drug use, risk behaviors, and HIV infections. This has been a consistent finding since the epidemic began among diverse populations and cultural settings. Use of medications other than methadone (such as buprenorphine/naloxone and naltrexone) has increased in recent years with promising data on their effectiveness as HIV prevention and as new treatment options for communities heavily affected by opiate use and HIV infection. However, few treatment interventions for stimulant abuse and dependence have shown efficacy in reducing HIV risk. The cumulative literature provides strong support of drug treatment programs for improving access and adherence to antiretroviral treatment. Drug users in substance abuse treatment are significantly more likely to achieve sustained viral suppression, making viral transmission less likely. Although there are challenges to implementing drug treatment programs for maximum impact, the scientific literature leaves no doubt about the effectiveness of drug treatment as an HIV prevention strategy.

/pdf/drug-treatment-as-hiv-prevention-a-research-update-1sn24mvmze.pdf

Drug treatment as HIV prevention: a research update.

OBJECTIVE To examine temporal trends and predictors of linkage to HIV care, longitudinal retention in care and viral suppression among injection drug users (IDUs) infected with HIV. DESIGN Community-based, prospective cohort study. METHODS We prospectively studied 790 HIV-infected IDUs participating in the AIDS Linked to the Intravenous Experience (ALIVE) study from 1998 through 2011. IDUs were considered linked to care if they attended any HIV care visit during follow-up and retained in care if they reported HIV clinic attendance at every semi-annual study visit. We used logistic regression to identify predictors of poor retention in care and failure to achieve sustained viral suppression in response to ART. RESULTS Of 790 HIV-infected IDUs studied, 740 (93.6%) were ever linked to care. The majority of IDUs (76.7%) received ART at some point during observation and of these, most (85.4%) achieved viral suppression. However, over a median of 8.7 years of follow-up, only 241 (30.5%) IDUs were continuously retained with no 6-month lapses in HIV care and only 63 (10.2%) had sustained viral suppression at every study visit after first receiving ART. Suboptimal engagement in care was associated with poor access to medical care, active drug use, and incarceration. CONCLUSION Compared with national estimates of retention in care and virologic suppression in the United States, IDUs are substantially less likely to remain fully engaged in HIV care. Strategies to optimize HIV care should acknowledge the elevated risk of poor engagement in care among IDUs.

Longitudinal changes in engagement in care and viral suppression for HIV-infected injection drug users.

Injection-drug users (IDUs) acquire human immunodeficiency virus (HIV) infection by sharing drug equipment with HIV-infected persons and by engaging in risky sexual behavior. In 2007, injection-drug use was the third most frequently reported risk factor for HIV infection in the United States, after male-to-male sexual contact and high-risk heterosexual contact. To characterize HIV-infected IDUs aged >or=13 years in the United States, CDC analyzed data from the national notifiable disease reporting system for 2004-2007 from the 34 states that had conducted confidential, name-based HIV surveillance since at least 2003. The results of that analysis indicated that, during 2004-2007, 62.2% of IDUs with a new diagnosis of HIV infection were males, 57.5% were blacks or African Americans, and 74.8% lived in urban areas at the time of their HIV diagnosis. In addition, during 2004-2006, approximately 40% of HIV-infected IDUs received late HIV diagnoses (i.e., diagnosis of acquired immunodeficiency syndrome [AIDS] <12 months after the date of HIV diagnosis). To reduce the prevalence of HIV infection and late HIV diagnosis among IDUs, HIV prevention programs serving IDUs should have comprehensive approaches that incorporate access to HIV testing as part of community-based outreach, drug abuse treatment, and syringe exchange programs.

HIV infection among injection-drug users - 34 states, 2004-2007.

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HIV infection among injection-drug users - 34 states, 2004-2007.