Approaching Public Health Issues Among People Who Use Drugs Through a Syndemic Lens

Introduction Syndemics occur when two or more disease epidemics or clusters occur at the same time and interact (ie, biologically, socially, environmentally, etc), and are often exacerbated by inequities in social determinants of health. A syndemic approach considers interactions between diseases and social determinants of health that may hinder an individual from reaching optimal health. The traditional public health approach has been to divide funding by disease-state, with funding and programs assigned to a single topic. By taking a holistic, cross-cutting approach, public health agencies can better address syndemic conditions on the individual and population level. A primary example of this phenomenon is the syndemic of substance misuse, viral hepatitis, sexually transmitted infections (STIs), and mental health conditions. Substance misuse is an urgent epidemic in the United States, with over 8% of people aged 12 and older having a drug use disorder.1 People who use substances face numerous barriers in society, including stigma, barriers to care and treatment, and unmet basic needs.2,i Additionally, these individuals face an increased risk of infectious diseases (including HIV, viral hepatitis, and STIs),3 a high rate of comorbidity with mental health disorders,4 and among those with co-occurring substance use and mental health disorders, they are significantly more likely to be arrested.5 Additionally, using substances can have a major impact on the health of an individual, even if they do not have a formal substance use disorder diagnosis. This technical package describes how a syndemic approach allows public health programs to address the basic needs and health of people who use drugs and provides specific interventions that can be effective. The Association of State and Territorial Health Officials (ASTHO) outlines evidence-based policies on specific public health topics in technical packages. The objective of ASTHO’s technical packages is to provide discrete policy objectives for state and territorial health officials to address public health issues. Technical packages include both policies that can be addressed legislatively and internal policies that state health officials can implement or influence within the health department. Health officials can provide support to the objectives outlined in the technical package through policy change efforts, increasing awareness of policy options, and/or funding (if available). Methods The Syndemic Technical Package was developed through an iterative process with a multidisciplinary team of subject matter experts at ASTHO. Subject matter expertise included infectious disease, behavioral health, substance use, and Medicaid. After identifying the focus area of the technical package as people who use substances, team members shared evidence-based best practices that could help to achieve the stated objectives. A summary of ASTHO’s Syndemic Technical Package, with a focus on people who use substances, is outlined in Table. TABLE - Syndemic Technical Package Objectives Potential Indicators Mechanisms Levels of Influence Improved health outcomes and access to treatment and services among persons who use substances living with or at risk for syndemic-related conditions Number of jurisdictions that have reduced barriers to establishing or running syringe service programs (SSPs), which support opioid overdose prevention, education, and treatment, and linkage to other community and social services Number of jurisdictions that support training and education for fentanyl test strip use and distribution Number of jurisdictions that have increased community access to naloxone Access to care, including status neutral care (providers and services) Access to substance use disorder (SUD) treatment Number of infectious disease tests at traditional and nontraditional infectious disease testing settings Number of pre-exposure prophylaxis prescriptions administered through community organizations that serve people who use drugs (PWUD) Review access to harm reduction services in your jurisdiction Consult legal counsel to determine 1) barriers to harm reduction service provision (ie, billing for services) and 2) facilitators Assess feasibility (eg, legal mechanisms and interactions, etc.) to provide harm reduction services Assess scope of legal issues: policies related to drug checking equipment and drug paraphernalia; drug decriminalization Support laws that cover mental health and substance use treatment in health insurance policies, regardless of insurance type and where someone lives, and no matter the reason for accessing carea Support health care payment and delivery models that increase access to comprehensive support of health-related social needsb Implement Ryan White Services in correctional facilities (PCN 18-02) Implement a holistic case management approach for pregnant people using substances with syphilis, HIV, hepatitis B, and hepatitis Cc Increase community distribution of naloxone, particularly through overdose education and naloxone distribution groups Consider legislation and approaches to treating substance use during pregnancy as an opportunity for child welfare services, rather than a mandatory child abuse reportd Integrate housing support into comprehensive HIV programse Support peer-led initiatives related to drug use and associated infectious diseases Support evidence-based overdose reversal policies Support flexible funding for health agencies to implement housing-based pilot programs Partner with community-based organizations (CBOs) working with unstably housed populations to identify unmet needs Support efforts to engage community members in policy processes Encourage partnerships between settings that may work with people who are using substances (eg, SSPs, correctional facilities, and substance use treatment centers) and infectious disease organizations (eg, disease intervention specialists) Disease reporting laws and policies Data confidentiality laws and policies Expedited Partner Therapy laws Laws and policies related to accessing prophylaxis for pre- and post- exposure to HIV and STIs State Medicaid partners and experts State departments of correction and municipal correctional facilities State child welfare agencies Jurisdictional behavioral and mental health experts and partner organizations Single - State Agencies for substance abuse services Positive relationships between the community and public health providersf Positive public perceptions of public health institutions at state and local levels Number of community engagement events and community members that attend community engagement events Number of jurisdictions that have conducted focus groups with community leaders in the last three years Percentage of local health departments that collaborate with CBOsg Number of CBOs with unique focus areas that partner with the health department Number of case investigator and contact tracing Disease Intervention Specialists that have lived experiences Number of jurisdictions who include lived experience in position descriptions and job postings for leadership positions Number of community peer support programs for PWUD Number of nontraditional partners reimbursed by Medicaidh Number of programs that exist to reduce disparities among PWUD Number of PWUD that engage with support services Increase community outreach competence of public health employeesi Evaluate leaders’ involvement with communities impacted by syndemic conditions by including this measurement in performance management reviews Increase use of the Public Health Accreditation Board’s community engagement standards Require that community outreach training be available for public health employeesj Hire and train culturally competent case investigation and contact tracing staff Remove hiring policies that discriminate against individuals with a criminal record related to substance use Enhance peer support programs for PWUD Embed peer support specialists in Federally Qualified Health Centers Credential peer support programs Partner with and expand the number of nontraditional providers (eg, birth doulas, community health workers, peer support specialists, and SSP employees) covered by Medicaid and other payers Hire individuals with lived experiences (including experience with substance use and/or infectious diseases) Follow best practices for working with people with lived experiencek Communicate with policymakers—Governor’s Office, legislature, etc—about the need for long-term systemic change to support PWUD Engage with law enforcement to foster supportive environments between law enforcement and people who use substances Community and state health needs assessments Share the community’s priorities with the governor, encouraging long-term systemic changel Department of Health hiring policies State Medicaid office State behavioral health, mental health, and substance abuse directors Carefully crafted data sharing agreements (DSAs) between programs and jurisdictions (as appropriate) to improve identification of individuals in need of services and improve continuity of care Percentage of health departments using data platforms that allow data sharing between internal teams Percentage of health departments using data platforms that allow data sharing between neighboring jurisdictions Number of health departments supporting data access and use of syndemics-related data across internal HD programs through established agreements (eg, DSAs) Number of jurisdictions using modern health IT standards to support approved sharing of syndemics-related data Increase the proportion of vital records/health statistics (VRHS) programs that are nationally accreditedm Increase the number of DSAs between local health departments and local institutions (eg, hospitals)n,o Promote the VRHS Accreditation Program for local health departments (recommended by CDC) Work with legal counsel to review data sharing laws and policies to assess the feasibility of data sharing across systems relating to HIV, STD, substance use, and behavioral health to improve service delivery for persons impacted by or at risk for syndemic conditions Support data sharing and linkages across key datasets and systems, including PRAMS supplements on substance use and vital records, to better understand substance use during pregnancy Explore establishing inter-jurisdictional DSAs Review and/or develop DSAs and standard patient consent forms used by SUD treatment facilities Modernize core public health data systems to support timely, complete data sharing for public health actionp Disease reporting laws and policies Data confidentiality laws and policies Statewide health data advisory council or Health IT group Abbreviations: CDC, Centers for Disease Control and Prevention; PCN, Policy Clarification Notice; PRAMS, Pregnancy Risk Assessment Monitoring Systems; STIs, sexually transmitted infections.aASTHO’s Suicide Prevention Policy Statement.bASTHO’s Adverse Childhood Experiences Policy Statement.cPerinatal Case Management at the Louisiana Department of Health.dIn Washington State, infants with prenatal substance exposure who have no other safety concerns do not prompt a mandated report to Child Protective Services.eIssue Brief: The Role of Housing in Ending the HIV Epidemic (https://www.cdc.gov/hiv/policies/data/role-of-housing-in-ending-the-hiv-epidemic.html), Access to housing subsidies, housing status, drug use and HIV risk among low-income U.S. urban residents (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3283493/), Housing Status and HIV Risk Behaviors: Implications for Prevention and Policy (https://link.springer.com/article/10.1007/s10461-005-9000-7).fLessons From the Mpox Response.gIndicator is tracked by the National Association of County and City Health Officials.hASTHO’s Congenital Syphilis Technical package.iMechanism is tracked by Public Health Workforce Interests and Needs Survey (PH WINS).jMechanism is tracked by Public Health Workforce Interests and Needs Survey (PH WINS).kBuilding community relationships.lASTHO shares Indiana’s Success Story.mHealthy People 2030.nConnecting the Dots: A Data Sharing Framework for the Local Public Health System.oCross-Jurisdictional Data Sharing.pASTHO’s Public Health Data Modernization Policy Statement. Improved health outcomes among persons who use substances living with or at risk for syndemic-related conditions Substance use may be just one component of an individual’s complex health landscape. As health issues among people who use substances may be multifaceted and related, a syndemic approach can more effectively improve health outcomes.ii Some policies to support these individuals may directly relate to substance use—such as ensuring access to syringe service programs (SSPs) and increasing community distribution of naloxone—but a syndemic lens also addresses infectious disease outcomes, employment, housing, and mental health care. For example, status neutral care aims to engage an individual in care through a whole person perspective, regardless of an individual’s infectious disease status. This approach and increased engagement with the medical system may allow for an individual to address other medical or social determinants of health-related needs. As this is an area where best practices continue to evolve (especially with regard to evidence-based overdose reversal policies and the tools available to support it), it is recommended that state health officials consult their overdose prevention colleagues for the most recent evidence and information on promising practices. In addition to partners within the health department, there is the potential for working with numerous external partners to improve health outcomes using a syndemic approach, including state Medicaid offices, state departments of corrections, and state child welfare agencies. For example, the Louisiana Department of Health takes a syndemic approach with its Perinatal Case Management program, which engages pregnant people who have syphilis in care and links them with medical and nonmedical resources. While not designed specifically for individuals using substances, substance use does not exclude someone from participating in the Perinatal Case Management program. Foster Positive Relationships Between the Community and Public Health While public health aims to improve the well-being of individuals and a jurisdiction’s population, there may not be many opportunities to directly engage with the community. Promoting a culture of trust and ensuring a positive impression of public health among a specific population can make public health work more effective and impactful. When addressing syndemics, improving community relations can play an important role. As syndemic work is inherently intertwined, engaging a community on one health topic may have a ripple effect. For example, by focusing on indicators and mechanisms that improve relationships with people who use substances, there will be overlap and engagement with people who are unstably housed or unhoused or at higher risk for sexually transmitted infections or behavioral health conditions. State health officials can promote better community relationships within the health department, and with other state agencies, payers, and other organizations. Within the health department, ensuring a diverse workforce with relevant lived experience is crucial. Lived experience refers to the direct experiences of an individual, whether this is demographic (eg, age, race/ethnicity, or gender identity) or related to health status or social determinants of health (eg, infectious disease status, substance use experience, or history of being unstably housed). For example, a program that is working to support racial and ethnic minority individuals with a history of substance use who are experiencing food insecurity should make efforts to ensure their staff reflect the populations they serve. Hiring practices should aim to be inclusive and promote lived experience. Beyond the health department, state health officials can also improve community relationships by engaging with agencies such as Medicaid and other payers. Nontraditional providers, such as birth doulas, community health workers, peer support specialists, and SSP employees, can connect with populations that may be impacted by syndemic conditions. A lack of reliable payment mechanisms for health and social services can present a barrier for these providers, so payment through Medicaid and other payers supports nontraditional providers and allows them to reach additional vulnerable clients. Outside organizations also play an important role in helping public health agencies engage individuals. While community-based organizations tend to have a narrow focus area, working with a large and diverse network of organizations increases the likelihood of engaging with individuals impacted by syndemic conditions. SSPs provide a natural connection point for people who use substances and infectious disease prevention. However, homeless shelters and job training support organizations may also work with these populations. Working relationships with a variety of community-based organizations and national organizations can improve community relationships and reach a larger target audience. Carefully Crafted Data Sharing Agreements Between Programs and Jurisdiction to Improve Identification of Individuals in Need of Services and Improve Continuity of Care Data sharing agreements (DSAs) help to coordinate care for many health issues, including substance use and infectious disease. Timely, secure, and appropriate data sharing can maximize health outcomes by ensuring continuity of care and minimizing unnecessary, repetitive medical tests and treatment. Jurisdictions can explore DSAs between several different entities in their state, including within the state health department, between the state health department and local health department, and with hospitals. Data sharing within the health department can make it easier for HIV, STI, behavioral health, and substance use teams to prioritize and reach those at highest risk for syndemic conditions. While DSAs provide public health benefits, it is important to ensure that an individual’s data are protected to ensure privacy and respect for all citizens. Many of the medical outcomes and social determinants of health that impact people who use substances may be stigmatized or illegal in neighboring jurisdictions; therefore, additional potential privacy concerns should be considered when sharing data across state lines. State health officials should partner with their health department legal counsel to guarantee that DSAs effectively achieve the program’s goals, respect patient preference, do not stand as a barrier to care, appropriately protect individual health data, and comply with other relevant state and federal laws. Conclusion Jurisdictions can begin to address syndemic conditions that impact people who use substances by reviewing and implementing policies outlined in ASTHO’s Syndemic Technical Package. These interventions aim to improve health outcomes for people who use substances, promote positive relationships between public health and the community, and support DSAs. By taking a syndemic approach, jurisdictions can build partnerships and positively impact social determinants of health while supporting the health of people who use substances.