Archive for the ‘snorting drugs’ Category

Hepatitis C: What’s New?

A fair number of my patients screen positive for the Hepatitis C virus. Obviously, they want to know what a positive screening test means, and what they should do next. Since a positive screen doesn’t necessarily mean an infection with Hep C, I’d like to explain more about this test, about the virus, and what’s new in the treatment of Hep C.

Hepatitis C is a virus that mainly affects the liver, as its name implies. There are other viruses that affect the liver, creatively named Hepatitis A, Hepatitis B, and so on. But Hepatitis C is the biggie, with an estimated 3.4 million people in the U.S. with the infection. In fact, it’s the most common chronic blood-borne viral infection in the U.S.  Around the world, 180 million people are estimated to be infected with Hep C.

Anyone with a history of intravenous drug use should be screened for hepatitis C. In the U.S., this is the most common way of contracting the virus. Even if you didn’t share needles, if you shared cookers, water, spoons or other material, you may have contracted the virus. Even people who shared straws to snort drugs appear to be at risk, and should be tested.

It’s a blood-borne illness, so it can also be transmitted through tattoos with unclean needles, re-used medical supplies, and blood transfusion with tainted blood. However, risks of infection through transfusion in the U.S. are very low since testing for the virus became available in 1992.

Most people who have hepatitis C got it from another person’s blood, but it can be transmitted through sex. In monogamous couples with one infected partner, the virus is transmitted to the uninfected partner in only about 1 – 5% of cases. However, multiple sexual partners and high risk sexual activities result in higher transmission rates. You can’t transmit Hep C by hugging, kissing, sharing eating utensils or ordinary household contact, though a person with Hep C shouldn’t share razors or toothbrushes.

In May of this year, the Centers for Disease Control and Prevention recommended one-time testing for Hepatitis C in all baby boomers, meaning people born between 1945 and 1965. About one in thirty baby boomers have hepatitis C, according to the CDC. Because newer treatments can cure chronic Hep C infection, the CDC hopes to save an estimated 120,000 lives by uncovering infections in people who don’t know they’re infected.

The screening test for Hep C is relatively inexpensive, and screens only for antibodies to the Hepatitis C virus. If you screen positive with this test, it means you have been exposed to the Hep C virus. It does not tell us if you have chronic Hepatitis C infection. Up to 20% of people who contract Hepatitis C infections are able to clear the virus on their own, and will not have chronic infection. However, they will remain positive on this screening test, because they will carry antibodies against the virus for the rest of their lives. Patients diagnosed, treated, and cured of Hep C infection will also remain positive for Hep C on this antibody screening test, so it’s not helpful to screen these patients again. In fact, it may be confusing if the provider doesn’t understand what this antibody test means, and explain it adequately to patients.

There are six specific types, called genotypes, of Hepatitis C. Even if you clear the infection to one genotype, you can be re-infected with another genotype of hepatitis C. If you have active Hep C and continue to share needles, it’s possible to become infected with more than one subtype.

There’s no vaccine available for Hep C like there is for Hep A and B. Much like HIV, the Hep C virus undergoes frequent changes, so it’s like making a vaccine against a moving target.

If you test positive on screening for Hep C, you need to have further testing to see if you have Hepatitis C infection. The next step is a qualitative test for hepatitis C. At around $100 at the cheapest, it’s difficult for patients without insurance to afford the proper testing.  If this qualitative test is positive, you should then see a specialist to see if you need a liver biopsy. Most specialists base the decision to treat on a liver biopsy. There are other tests, but biopsy is still the gold standard.

If treatment is contemplated, it will be necessary to have genotype testing, to find out what specific type of Hep C you have. Treatments are different for different subtypes. Two new medications are used in the treatment of type 1, the most frequent type in the U.S., and give cure rates up to 75%. On the other hand, genotypes 2 and 3 are more easily treated and don’t require treatment to be as long as type 1. Quantitative Hep C testing, called viral counts, isn’t needed unless treatment is going to be done, when it is used to follow the response to treatment. Outside of that, the viral count provides little information.

Liver function tests, called LFT’s, are relatively cheap, and are often done at the same time as the first Hep C screening test. If they are elevated, it usually means there’s inflammation in the liver. Many things can cause an increase in LFTs. Alcohol is the most common cause, but all viral hepatitis infections can cause elevations too. However, it’s possible to have normal LFT’s and still have active Hepatitis C. We can’t assume you don’t have Hep C infection even if your LFT’s are normal.

If you have Hepatitis C, you should NEVER drink alcohol. Even patients infected with Hep C but with no problems on liver biopsy will go downhill fast if they drink alcohol. The dangers of alcohol in patients with Hep C cannot be overstated. Don’t. Drink. Ever. Not even a cold beer after mowing the lawn.

In my next blog post, I’ll talk about the exciting new treatment developments.

Advertisements

Am I Addicted to Prescription Pain Pills?

I am a guest blogger on addictionblog.org, and recently had a well-received article published on that site about how to know if you are addicted. I thought I’d repeat a version of that column here.

 There’s so much confusion about the differences between the disease of addiction to opioid pain pills and mere physical dependency on pain pills. Even some doctors don’t understand the differences, regretfully. Any person who regularly takes opioid pain pills for a period of weeks to months, for whatever reason, will develop a physical dependency to these drugs. That’s a biologic event. But addiction is much more than just the physical process. With addiction, there’s also a psychological component. People with addiction think about the drug often, spend time using and recovering from the drug, and continue to use the drug even though bad things happen. In physical dependency alone, this doesn’t happen.

 Here are a few specific questions that I ask patients, that help me decide if they have the disease of addiction:

  • Do I take more medication than prescribed? Do I take early doses, or extra doses?
  • Do I take medication in ways it’s not intended? For example, do I snort it, or chew it for faster onset? Do I inject it?
  • Do I get medication from friends, family, or acquaintances because I run out of my prescription pills early?
  • Do I become intoxicated, or high, from my medication? Without telling my doctor?
  • Do I drink alcohol with medication, even though the pharmacist advised against this?
  • Do I look forward to my next dose of medication?
  • Do I get impaired from my medication, to the point I’m unable to function normally?
  • Do I take pain medication to treat bad moods, anxiety, or to get to sleep?
  • Do I use street drugs like cocaine, marijuana, or others?
  • Have I driven when under the influence of pills, when I know I shouldn’t be driving?
  • Do I get prescriptions from more than one doctor, without telling them about each other?
  • Do I spend a great deal of time worrying about running out of medication?
  • Do I spend a great deal of time thinking about my medication, and how it makes me feel? 

One “yes” answer to any of these questions is worrisome, though not necessarily diagnostic of addiction. I think of addiction as a continuum, and it’s easier to diagnose with multiple “yes” answers. For example, people taking prescriptions may have a few worrisome symptoms, like taking an extra pill occasionally. Perhaps they did this because of a temporary increase in pain. Without any other symptoms, I probably wouldn’t diagnose addiction. At the other end of the spectrum, if a patient is crushing pills to inject or snort, I feel confident making the diagnosis of addiction.

 Sometimes addiction only becomes apparent over time. This is why doctors need to see patients frequently who are prescribed potentially addicting medication, like pain pill, stimulant, and benzodiazepines.

 If you had one or more “yes” answers to the above questions, please see a doctor who knows something about addiction, because untreated addiction usually gets worse. In fact, it can even be fatal.

The New OxyContin Formulation

Over the last three weeks, at least five of the opioid addicts I’ve admitted to treatment said they wanted help because they couldn’t abuse the new form of OxyContin.

 And I say: Hallelujah! It’s about time!!

 This new tablet, approved by the FDA in April of this year, appeared recently on the black markets of this area, replacing the older, more easily abused OxyContin. The new tablet is bioequivalent to the older tablet, meaning the same amount of oxycodone, the active ingredient, is available to the body when swallowed whole, as it’s meant to be. In other words, the same amount of pain reliever is given to the body. However, it’s more difficult to crush for the purpose of snorting or injecting, because it turns into a gummy ball.

Purdue Pharma, the drug company that makes OxyContin, admits this new formulation isn’t abuse-proof, but hopes it will be more resistant to abuse.

The patients I’ve talked to say the new tablet is a big disappointment. One patient, who usually chews her pill to get a faster high, said it was like trying to chew a jelly bean. Other patients said they could crush the tablet, but got a kind of gelatinous mess that was impossible to snort or inject.

 For pain relief, the opioid in OxyContin lasts much longer when it’s taken as directed and swallowed whole. Addicts prefer to crush and snort or inject because of the quick high they feel with this route of administration. But when used in this way, it leaves the body faster, and the addict usually needs to find more opioid within six to eight hours to avoid withdrawal.

Before I applaud Purdue Pharma for this change, my cynical mind asks a few questions: Why didn’t the company make this change earlier?

In 2002, a Purdue Pharma representative testified before congress, saying that the company was working on a re-formulation of OxyContin, to make it harder to use intravenously. This representative said they expected to have the re-formulated pill on the market within a few years. (1)  But it took eight more years.

Sterling, the drug company that makes Talwin, another opioid pain medication, was able to re-formulate their drug within a few years when they discovered it was being abused frequently. This was in the 1980s, when, presumably, medication technology wasn’t as advanced as today. Sterling added naloxone, an opioid blocker that’s inactive when taken by mouth, but puts an addict into withdrawal when it’s crushed and injected. It worked great. Talwin isn’t a commonly abused drug.

 I’m assuming that Purdue Pharma holds the patent for this new formulation that makes their tablet gummy when crushed. Purdue probably teaches its sales staff to market the new OxyContin as a safer option than older versions, perhaps available in cheaper generics. So did they wait to re-formulate until their patent was ready to expire? I don’t know, but time will tell.

At any rate, this drug is now just a little bit safer, for now. People with addictions are often clever and creative. I won’t be surprised if soon there’s a way to defeat this new technology.

Just think what addicted people could do, if they directed their talent and intelligence in ways that would help and not hurt them. There would be no stopping them.

1. United States Senate. Congressional hearing of the Committee on Health, Education, Labor, and Pensions, on Examining the Effects of the Painkiller OxyContin, 107th Congress, Second Session, February, 2002.