Indiana is grappling with an outbreak of HIV that local health officials say is connected to prescription drug abuse.
Since mid-December, there have been 27 confirmed and 10 preliminary -- meaning they need to be confirmed with further testing -- HIV-positive cases in the state, according to an announcement from Indiana health officials on Friday. The infections are largely concentrated in the southeast corner of the state, and in all cases, the patients had reported injecting the prescription opioid oxymorphone hydrochloride, known by the brand name Opana. For local health officials, this raises concern about addiction in the area.
“It’s very concerning to me that most of the individuals who have tested HIV positive have only recently contracted the virus,” said State Health Commissioner Jerome Adams in a statement released Feb. 25 about the HIV outbreak. “Because prescription drug abuse is at the heart of this outbreak, we are not only working to identify, contact and test individuals who may have been exposed, but also to connect community members to resources for substance abuse treatment and recovery.”
Opana comes in either injection or pill form and contains the active ingredient oxymorphone. The opioid painkiller is usually prescribed to treat back pain or pain related to cancer or osteoarthritis. It’s also more potent per milligram than OxyContin, another commonly prescribed and abused opioid painkiller.
Opana's manufacturer, Endo Pharmaceuticals, did not respond to requests for comment.
In response to reported cases of Opana misuse and abuse, Endo Pharmaceuticals reformulated the pill in 2012. The company made the pill difficult to crush and made it so that it took on a sticky feel when combined with liquid.
Nabarun Dasgupta, an epidemiologist who studies the abuse of prescription painkillers, told The Huffington Post that this abuse-avoidance strategy may have led some people to turn to riskier methods of taking the drug, such as injecting it. He said he was not surprised to learn that Opana has been linked to the spread of HIV.
"If the pills are harder to crush and inject, the amount of active ingredient in each preparation will be lower, and the nasty [fillers] will be be greater," Dasgupta, who is the chief data scientist at public health data company Epidemico, wrote in an email. "So, to achieve the same high or stave off withdrawal, there has to be more injection events. More events are more opportunities for HIV and hepatitis transmission."
To illustrate this theory, Dasgupta pointed to a 2009 study of 41 people who injected the drug Suboxone. The study showed that when abuse-deterrent formulations of the drug hit the market in 2006, 44 percent of participants actually increased their number of daily injections, while 54 percent continued to inject the same amount of drugs as before.
To help stem the outbreak of HIV, Dasgupta encouraged separating the issue of drug abuse from HIV transmission, in order to tackle the more immediate threat first. He suggested a variety of tactics, from connecting people to substance abuse treatment -- which is Indiana’s official approach -- to programs that would distribute clean needles.
“Basically, anything that helps people inject less often is part of the solution,” Dasgupta said.
Adam Carrico, an assistant professor at the University of California, San Francisco, who focuses on the intersection of drug abuse and HIV, pointed out that “harm reduction” strategies like needle exchange programs can also act as a hook to draw drug abusers into services that will eventually lead them to drug treatment programs like opiate replacement or self-help groups.
“People don’t want to get HIV, but maybe they’re not motivated at that point to abstain from drugs or pursue drug treatment,” he said. “We can use needle exchanges almost like a net to move them into more comprehensive approaches, so that they hopefully become abstinent through biomedical and behavioral approaches that we know work."
Opioid painkillers like Opana connect with reward centers in the brain, which creates a sense of pleasure and euphoria. However, drug users can build up a tolerance to opioids, which means it takes more of the drug to achieve the same sense of satisfaction over time. This, in addition to accidental combinations with alcohol or other drugs, can lead to overdose and death.
A 2013 report by Trust for America’s Health, a nonprofit organization focused on disease prevention, showed that overdose deaths had quadrupled in Indiana since 1999, and that most of them were caused by prescription drugs like the opioids oxycodone (known as OxyContin or Percocet), hydrocodone (Vicodin), fentanyl, morphine and methadone. Indiana is hardly alone when it comes to prescription drug abuse. Deaths from drug overdose are rising in the U.S., and prescription painkillers are largely to blame, according to the Centers for Disease Control and Prevention. It is estimated that there were 2.1 million people in the U.S. addicted to prescription painkillers in 2012, while about 467,000 were addicted to heroin.
Other professionals suggest a different approach to treating opioid addiction. In her 2014 testimony before Congress, Nora Volkow, the director of the National Institute on Drug Abuse at the National Institutes of Health, said that medications like methadone, which act to block opioid receptors in the brain, can help people beat opioid addictions. These medications can ease withdrawal symptoms that may trigger a relapse, which in turn helps people regain control of their lives.
However, as Jason Cherkis of HuffPost showed in a investigative report on heroin addiction published in January, there is a cultural reluctance to kick drug addiction with the help of another drug. Instead of working off evidence-based recommendations that show methadone helps people gain control over their opioid addiction, he writes, many publicly funded drug abuse treatment centers are "driven instead by a philosophy of abstinence that condemns medical assistance as not true recovery.”
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