HCV in Addicted Patients: Overcoming the Barriers to Education, Treatment, and Outcomes

1. HCV in Addicted Patients:Overcoming the Barriers to Education, Treatment, and Outcomes Diana L. Sylvestre, MD Executive Director, OASIS Presented by: Amy Smith, PA-C

2. OASISOrganization to Achieve Solutions in Substance-Abuse

3. Our situation • Poverty, high rates of drug use • Heroin, crack cocaine, methamphetamine • Low rates of health insurance • Limited access to medical care • Limited access to drug treatment • Limited access to healthcare

4. Our Mission: Provide high quality medical care to drug users (or whoever shows up)

5. A Small Community Clinic • One doctor • One physician assistant (Me) • 3 peer educators • No nurses, social workers, or case managers • A lot of willing volunteers

6. A Small Community Clinic with an Evidence-based Approach • Addiction is a medical illness • Treatments are limited and relapse is characteristic • Perfection is an unrealistic expectation

8. Treatment options for hypertension • Diuretics • HCTZ, spironolactone, furosemide, amiloride, triamterene, etc. • ACE Inhibitors • Benazepril, captopril, enalapril, fosinopril, lisinopril, quinapril, ramipril, etc. • Beta Blockers • Propranolol, atenolol, metoprolol, pindolol, labetolo, carvedilol, timolol, sotalol, nadolol, etc • ARBs • Irbesartan, losartan, candesartan, valsartan, olmesartan, telmisartan, etc. • Calcium Channel Blockers • Verapamil, diltiazem, nifedipine, nicardipine, amlodipine, felodipine, etc.

9. Treatment options for diabetes • Insulins • Aspart, Glargine, Lispro, glulisine • Sulfonylureas • Chlorpropamide, tolbutamide, tolazamide • Glipizide, glyburide • Glimepriride • Biguanides • Metformin • Alpha-glucosidase inhibitors • Acarbose, miglitol • Glitazones • Pioglitazone, rosiglitazone • Megiltinides • Repaglinide

10. Treatment options for depression • Tricyclics (TCAs) • Amitriptyline, imipramine, nortriptyline, etc. • Monoamine oxidase inhibitors (MAOIs) • Phenelzine, tranylcypromine, isocarboxazid, etc. • Selective serotonin reuptake inhibitors (SSRIs) • Fluoxetine, sertraline, paroxetine, fluvoxamine, citalopram, etc. • Serotonin antagonists • Trazodone, nefazodone • Other agents • Bupropion, venlafaxine, mirtazapine, reboxetine, etc.

11. Treatment options for addiction • Alcohol • Disulfiram, acamprosate, naltrexone • Opiate • Methadone, buprenorphine, naltrexone • Stimulants • ?

12. Addiction is not a single syndrome: Heroin Cocaine Methamphetamine Alcohol Cannabis Polysubstance use Regular use Intermittent use Binge use

13. Frontal Cx Hippo DMT VTA N. Acc LC AMG The evidence for addiction as a brain disease Dopamine release in the Nucleus Accumbens is a common characteristic of virtually every drug of abuse. Koob, Trends in Pharm Sci, ,1992

14. It quickly became apparent that our little clinic had a big problem: HEPATITIS C

15. Hepatitis C in Oakland • 96% of long-term injectors • Limited access to drug treatment • Syringe exchange available on a limited basis

16. How we came to treat hepatitis C:

17. No one else would do it.

18. Remote (>15 yrs ago) Recent (<15 yrs ago) Injection Drug Use Injection Drug Use Transfusion Transfusion Unknown Other* Unknown Sexual Other* Sexual * Nosocomial, occupational, perinatal Relative Importance of Risk Factors for Hepatitis C Adapted from CDC Hepatitis Slide Kit http://www.cdc.gov/ncidod/diseases/hepatitis/slideset

19. Natural history: addiction Hser, Y. I., et al. (2001) Arch Gen Psychiatry, 58, 503-8.

20. No one else would do it.

21. We decided to try.

22. Hepatitis C Treatment in Drug Users

23. No one wants to treat drug users for hepatitis C. Why?

24. Barriers: perceived vs. real • Adherence is bad • Reinfection • Interferon can exacerbate psychiatric symptoms • Interferon is an injectable medication and may increase the risk for relapse

25. Most HCV treatment barriers are perceived or relative. The real barrier is prejudice.

26. Bridging Active Heroin Users to HCV Treatment with Buprenorphine 1 R01 DA015629-01

27. Hypothesis • Active, street-recruited heroin users can be safely and successfully treated for hepatitis C after 12-24 weeks of buprenorphine stabilization.

28. Study Design

31. Enrollment • All screened = 415 • Eligible = 275 • Ineligible = 140 (33%) • Not viremic = 94 (23%) • On methadone = 29 (7%) • No opioid addiction = 17 (4%)

32. RelevanceAll Screened: n=415 n = 188 n = 146 n = 275

33. The study sample is representative

34. The study sample is representative *Significant for the difference between screened and eligible cohorts

35. Other Characteristics • 33% homeless • Median education < high school • Median monthly income ~$550 USD • 40% on probation or parole, median weeks of prior incarceration = 156 • 64% with history of “serious depression”, 75% with history of “serious anxiety,” 22% had prior suicide attempt. 14% had been prescribed a psychiatric medication. • Median number of prior treatment attempts = 7

36. Criteria for initiating HCV treatment • Active HCV • Interested • Attendance of >75% of weekly education sessions

37. Drug Use Week 0-12

38. Treatment Retention (n=146) 58% 45%

39. Chose taper Chose HCV Tx Interest in HCV Treatment (n=146) Early Bupe termination

40. Drug Use and HCV Treatment Retention

41. Drug Use and HCV Treatment Retention

42. Drug Use and HCV Treatment Retention

43. Drug Use and HCV Treatment Retention

44. Drug Use and HCV Treatment Retention

45. HCV Treatment Outcomes • Completed treatment, n=38 • Early termination, n=18 • 3 incarcerated • 4 medical • 10 FTS • 1 side effects

46. Outcomes by Genotype 11 37 26 10 32 20 21 13 7