Adherence to Hepatitis C Treatment among Recovering Heroin Users on Methadone Maintenance  

Because hepatitis C virus (HCV) is easily transmitted via contaminated needles and other drug injection equipment, a large proportion of injection drug users (IDUs) have chronic hepatitis C.

However, IDUs are often denied treatment for hepatitis C due to concerns about adherence. This is the case despite limited and conflicting data about the impact on adherence of issues such as psychiatric conditions and concurrent illegal drug use. HCV treatment guidelines state that IDUs should not be excluded from treatment as a group, but that each individual should be evaluated for treatment on a case-by-case basis.

Some past studies have produced good sustained response rates for IDUs treated with interferon-based therapy, but results from clinical trials do not always carry over into “real world” settings.

As reported in the September 2007 issue of the European Journal of Gastroenterology and Hepatology, Diana Sylvestre, MD, from the University of California at San Francisco and colleagues evaluated the impact of mental health issues, active drug use, and other potential adherence barriers in a real-world sample of recovering drug users on methadone maintenance therapy.

The prospective observational study included 71 patients on methadone maintenance who received interferon plus ribavirin combination therapy in a community-based clinic staffed by providers with expertise in treating addiction disorders. Adherence was assessed using monthly interviews, medication counts, and urine toxicology testing.

Results

·         Overall, 48 patients (68%) were adherent to anti-HCV therapy.

·         Adherent patients were significantly more likely than non-adherent patients to achieve a sustained virological response (42% vs 4%, respectively).

·         Patients with and without a prior psychiatric history had similar rates of adherence (64% vs 72%, respectively; P > 0.5).

·         Initiation of new psychiatric medications during HCV treatment was associated with improved adherence overall (P = 0.02) and in patients that did not have a pre-existing psychiatric diagnosis (P = 0.04).

·         There was a trend towards reduced adherence in patients without a period of drug abstinence before starting HCV treatment compared with those who had been abstinent for at least 1 month (46% vs 72%; P = 0.10).

·         Although occasional drug users were similarly adherent compared with those who were completely abstinent, patients who relapsed to regular drug use showed a significantly lower level of adherence (P = 0.03).

Conclusion

“We conclude that the majority of methadone-maintained drug users can adhere to HCV treatment, even those with psychiatric illness and relatively limited pretreatment drug abstinence,” the study authors wrote.

“Lack of pre-HCV treatment drug abstinence and regular drug use during HCV treatment may be relative barriers to medication adherence, but the initiation of psychiatric medications during HCV treatment may be a helpful intervention,” they added.

They concluded that, “This report provides further evidence for an individualized approach to HCV treatment that does not categorically exclude patients with potential barriers such as mental illness and limited drug abstinence.”

    

Last year at this time,  Methadone Support Org. was among a group of organizations that supported the letter below.  We are again this year and urge other organizations to sign on and help distribute this letter.  The more they hear from us, the better chance we have of success.

If your organization would like help, the contact info is.....

Lorren Sandt
Hepatitis C Caring Ambassadors Program
Program Director
503-632-9032
lorren@hepcchallenge.org

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President George W. Bush
The White House
Washington, DC 20500

RE:   National Hepatitis Awareness Month 2007

Dear Mr. President,

We write to you today requesting a Presidential Proclamation demonstrating your administration’s support of May 2007 as National Hepatitis Awareness Month. There are more than 6 million Americans currently living with chronic hepatitis C and/or hepatitis B; that accounts for more than two percent of the U.S. population. Of the estimated 5 million Americans who have already been infected with hepatitis C, most are unaware of their infection. The number of Americans with hepatitis C or hepatitis B now outnumbers those living with HIV/AIDS 7-to-1.

Chronic hepatitis C is the leading indication for adult liver transplantation in the U.S., and the demand for liver transplants for this indication has increased by a least 12-fold since 1990. Similarly, chronic liver disease (the vast majority of which is caused by chronic infection with hepatitis C and/or hepatitis B) is now among the top ten causes of death for Americans age 25 years and older and is a leading cause of death for those infected with HIV.

In 2004, the Eleventh Report on Carcinogens issued by the National Institutes of Health added the hepatitis C and hepatitis B viruses to the list of known human carcinogens; these viruses increase the risk of liver cancer by more than 10-fold. The incidence of liver cancer among Americans more than doubled between 1975 and 1998. The number of new cases of liver cancer and the associated number of liver cancer deaths are expected to double again in the U.S. over the next 10 to 20 years.

The social and fiscal costs associated with chronic viral hepatitis are increasing exponentially. An actuarial study conducted in 2002 estimated total medical expenditures for people with HCV at $15 billion per year. Without immediate intervention, the hepatitis C epidemic in the U.S. is expected to result in 3.1 million years of life lost by 2019. The projected direct and indirect costs of the current HCV epidemic, if left unchecked, will be over $85 billion for the years 2010 through 2019.

Despite the staggering magnitude of the social, medical, and fiscal repercussions of chronic viral hepatitis on our citizens, many Americans are unaware of the personal and public health threats posed by chronic viral hepatitis. Unlike most viral illnesses, effective medical treatments are available to limit the long-term, devastating consequences of chronic viral hepatitis for many patients. But early diagnosis and medical management hinge upon increased public awareness.

The World Health Organization (WHO) is currently working with hepatitis advocates from around the world to designate May as global Hepatitis Awareness Month. The World Gastroenterology Organization is working on events to recognize World Digestive Health Day 2007: Viral Hepatitis on May 28, 2007. Here in the U.S. at least 18 states have already issued or are working on proclamations recognizing May 2007 as Hepatitis Awareness Month. This is a public health issue that is being recognized in all corners of the globe. As such, we respectfully request and urge you to help us educate the American public and thereby begin the process of turning the tide on chronic viral hepatitis in our country by issuing a Presidential Proclamation recognizing May 2007 as National Hepatitis Awareness Month.

**Some excellent articles from the Hepatitis C Association website**

Treating Methadone Patients
http://www.hepcassoc.org/news/article77.html

Is Treatment of Chronic Hepatitis C Feasible in Patients on Methadone
http://www.hepcassoc.org/news/article73.html

Pharmacokinetics, Pharmacodynamics and Antiviral Response in Patients with Chronic Hepatitis C Infection on Methadone Maintenance Therapy Receiving Pegasys (peginterferon alfa-2a)
http://www.hepcassoc.org/news/article68.html

Liver transplantation for patients on methadone maintenance
http://www.hepcassoc.org/news/article55.html

Treating the Methadone Patient
http://www.hepcassoc.org/news/article34.html

Although injection drug users comprise the majority of cases of infection with hepatitis, most of these individuals do not undergo treatment because of physician concerns about adherence, treatment efficacy and reinfection.

Still, based on growing evidence that injection drug users can successfully undergo treatment for chronic hepatitis C, the 2002 National Institutes of Health Consensus Statement on Hepatitis C  recommended that substance users, even those with ongoing drug use, should be considered for treatment for HCV infection on a case-by-case basis.

[ READ MORE ]

I received the information below in an email from hcvadvocate.org. We know that any person with HCV (or other liver diseases) should not eat raw or undercooked shellfish, but it seems like the message is not getting out to the HCV or liver communities. Please feel free to forward to anyone interested...Carol

The following is from the Arizona Health Department - (602) 364-3199 fax hurstc@azdhs.gov

*FYI* - We have had two deaths in AZ from raw oysters. Both people Hepatitis C (HCV) positive.

Here are the details on our two deaths related to Vibrio Vulnificus in Arizona. The first one was a 45 year old male that resided in Pima County and became ill 05/02/2006, and passed away 05/06/2006. He had a history of HCV, hepatic cirrhosis, and alcohol abuse. He was seen in the ER on 05/05/2006 due to SOB, fluid retention in chest, 2-3 day history of increasing edema and jaundice. Per family, case consumed oysters always. Oysters were purchased from unlicensed vendor in Tucson.

The second death was a case that resided in Maricopa County. He was a 58 year old man that became ill on 06/17/2006 and passed away on 06/19/2006. His only pre-existing condition was Hepatitis C. Per family, this case had eaten raw oysters at a restaurant while visiting Memphis, TN on 06/15-06/16/2006. The Tennessee Department of Health has been notified of the case's exposure and they will follow-up. The wife of this man is a nurse and was very concerned that she had never heard people with Hepatitis should avoid eating raw oysters. While this is thought to be general knowledge, eating raw oysters can be harmful to your health, I am not sure that the specific fact of having HCV and the increased risk of dying when infected with Vibrio may not be presented to HCV carriers.

If you have any questions or need more details, please let me know.

Thank you,

Laura Nathan
Christina L. Hurst, MSW
Arizona Department of Health Services
Office of Infectious Diseases
150 N. 18th Ave, Suite 140
Phoenix, AZ 85007
602 364-3662 office