“Twelve weeks into treatment they checked my viral count and it was undetectable. I knew I was going to make it through this.”
— a patient, quoted in Tip 53: Addressing Viral Hepatitis in People With Substance Use Disorders
Tip 53—the new publication from the Substance Abuse and Mental Health Services Administration (SAMHSA)—is full of great information about hepatitis C virus (HCV)—the new rapid diagnostic test, the two new drugs that have advanced the treatment of HCV infection, and everything staffers and patients at opioid treatment programs (OTPs) need to know. (See Resources to find out about a free download or paper copy.)
Why Hepatitis C Is So Important to OTPs
The prevalence of HCV infections in the U.S. is about 3 million to more than 5 million, and at least half are related to injection drug use. Because HCV afflicts between 67 percent and 96 percent of methadone patients, those who aren’t infected need to know how to prevent it, and those who already have it need to know about tests and treatment options, and how to avoid spreading the infection.
Hepatitis C begins as a silent disease. It goes away in about 15 percent to 25 percent of people; otherwise it can persist for decades, without symptoms, until there is severe liver damage that can lead to liver failure or cancer, a liver transplant, or death.
A New Test and New Treatment Options
The new 20-minute screening test can detect HCV antibodies in a blood sample while the patient is waiting. If a patient tests positive on screening and follow-up testing, further workup entails finding out which of six types of HCV—called genotypes—the patient has. Most methadone patients have genotype 1. Workup could also include a liver panel, other blood tests, a viral load test to determine the amount of virus present, and maybe a liver biopsy.
If a caregiver and patient decide treatment is best, two newly approved oral drugs greatly improve the odds for those with genotype 1: telaprevir (Incivek) or boceprevir (Victrelis). When either—never both—is added to the current two-drug therapy—weekly peg-interferon injections, plus daily oral ribavirin, 68 percent to 80 percent of patients respond, vs. 40 percent to 55 percent that responded to the previous two-drug therapy. Treatment time for many patients has been cut in half, to about six months. (The methadone dose may need to be modified, because of interactions with the new drugs.) Patients with genotype 2 or 3 tend to respond well to the earlier two-drug treatment.
When the virus can no longer be detected in the blood for six months, the patient is said to have a “sustained viral response”—an SVR. The virus doesn’t return in up to 99 percent of patients, but reinfection can occur, so preventive steps are important.
In another few years, a new two-drug oral therapy (without peg-interferon injections) may be available. Many oral drugs are in clinical trials, and a regimen now in experimental use in humans has achieved very high cure rates. By then, a hepatitis C vaccine may even be on the horizon.
What OTP Patients Can Do
HCV is highly contagious—much more so than HIV. But it’s a blood-borne disease, rarely spread through sexual contact. Patients need to avoid contact with blood that has been contaminated with the virus. This means not sharing injection needles, or rinse water, even a razor or toothbrush that may harbor invisible traces of blood.
Also, OTP patients should get vaccinated against hepatitis A and B, to help shield the liver from damage caused by those viruses. A damaged liver is less able to withstand hepatitis C infection. OTPs may have these vaccines, or can refer patients elsewhere.
Also important is avoiding alcohol, for it contributes to and often speeds liver damage in people with hepatitis. The same is true of acetaminophen and other drugs that can damage the liver.
Focus groups of OTP patients interviewed in Beyond Methadone (see Resources) called for at least one onsite OTP specialist for hepatitis C—but that’s a difficult goal for a small OTP, and trained staff can fill many roles. The survey noted that about one-fourth of OTP patients didn’t know their HCV status, and didn’t recall ever being offered a test. The survey also found that more than half who tested positive said they weren’t referred for follow-up tests or medical care, nor were they aware of any support groups or educational materials at their program. Based on these focus findings, OTPs can provide more HCV education, testing, support, and treatment, either onsite or by referral.
How OTP Staff Can Help
OTPs are being called upon to help patients deal with a deadly illness. According to the Centers for Disease Control and Prevention (CDC), more people in the U.S. now die each year from hepatitis C than from AIDS—almost 5 per 100,000 from hepatitis C, vs. about 4 per 100,000 from AIDS. Clearly, early diagnosis, treatment, and support services would save much suffering and many lives. This is a great opportunity for OTPs to make a difference in the lives of their patients.
VOCAL-NY and other patient advocacy groups have long urged OTPs to provide better intervention and care for patients with HCV. Many OTPs—67 percent, according to the National Survey of Substance Abuse Treatment Services—already test patients for HCV infection, and that’s very encouraging, but it leaves a sizeable percentage untested, therefore untreated. Some OTPs that test haven’t the resources to provide follow-up care for patients who test positive—additional tests, education, counseling, and medical care. Those OTPs will need a strong referral system to send patients elsewhere, and to make sure they follow up.
Sometimes the side effects of HCV therapy may feel similar to withdrawal symptoms. Staff can encourage peers and patients in treatment to share experiences, support each other, and help each other access care and adhere to treatment.
Many OTPs offer testing only, but staff can still help immensely by being supportive of patients and providing information about HCV in a nonjudgmental, compassionate way, referring patients to outside sources, and making sure they follow up. VOCAL-NY recommends that OTPs with limited services “establish a concrete referral system for HCV patients, and enter into memoranda of understanding (MOUs) with medical providers for follow-up care.”
Among the many wonderful resources for OTP staff in Tip 53 are leads for patients seeking financial help. Treating hepatitis C is costly and can take many months. Yearly medical expenses can easily top $60,000—and that’s before a liver transplant, which can add $100,000 to $250,000 for the procedure alone.
Hepatitis is inflammation of the liver. It can be caused by viruses, substance or alcohol use, certain diseases, or exposure to toxins. The term viral hepatitis refers to liver inflammation caused by any of several viruses; A, B, and C are the most common in the U.S. Acute hepatitis lasts six months. If acute hepatitis doesn’t go away—through treatment, or on its own—it becomes chronic hepatitis, and can last indefinitely, whether treated or not.
Substance Abuse and Mental Health Services Administration. Addressing Viral Hepatitis in People With Substance Use Disorders. Treatment Improvement Protocol (TIP) Series 53. HHS Publication No. (SMA)11-4546. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2011. http://store.samhsa.gov/shin/content//SMA11-4656/SMA11-4656.pdf
Beyond Methadone: Improving Health and Empowering Patients in Opioid Treatment Programs. VOCAL-NY and Community Development Project of the Urban Justice Center (CDP). ebook. By Alexa Kasdan, Phil Marotta, Alison Hamburg, VOCAL New York; and the Urban Justice Center. Brooklyn, NY. VOCAL New York, New York, N.Y. October 6, 2011. http://www.vocal-ny.org/wp-content/uploads/2011/10/Methadone-Report-Cover1.jpg