Posts Tagged ‘Hepatitis C and opioid addiction’

Hepatitis C in Opioid Addicts

Hepatitis C infection is common in people who have abused or been addicted to drugs. Of course, sharing needles is the biggest risk for contracting Hepatitis C. Some studies have found that about 90% of methadone maintenance patients who have used intravenously screen positive for the antibodies to Hepatitis C, and over 60% had active infection with the virus.(1) A Canadian study showed similar rates; 90% of intravenous drug users screened positive for Hepatitis C in that country, too. (2) It’s not only people who have shared needles to inject drugs. There’s some evidence to show Hepatitis C can be transmitted by people sharing paraphernalia to snort drugs. (3) For this reason, it would seem obvious that patients who are addicted to opioids and entering treatment need to be checked for Hepatitis C.

Worldwide, there are an estimated 170 million people infected with Hepatitis C, and more than 3 million in the U.S. Hepatitis C is the primary reason for liver transplantation in this country. About 85% of people in the U.S. with Hepatitis C either have a history of intravenous drug use, or had blood transfusions prior to 1992, when the screening test specific for Hepatitis C was released.

It’s easy to test for the virus.

It requires only a blood test to screen for Hepatitis C. The initial test looks for antibodies against the Hepatitis C virus. If this test is positive, it means the person has probably been exposed to the virus, but doesn’t tell if the virus is active. Positive screening tests only mean that further testing is necessary.

Follow up tests for the actual Hepatitis C virus, called antigen tests, are needed next. If the virus is present, viral counts are done, and the virus is sub typed. Since these subtypes, called genotypes, of the Hepatitis C virus respond differently to treatment, the information indicates the likelihood of response to treatment. Even if the Hep C virus is present in high amounts, it doesn’t necessarily mean the liver is damaged. The only way to know for sure is with a liver biopsy.

It causes significant health issues.

Not everyone with Hepatitis C has a chronic infection, but of those that do, around 20% progress to cirrhosis, and around 4% develop hepatocellular carcinoma. Therefore, Hepatitis C can cause significant health issues, to put it mildly. It can cause a whole host of other illnesses, too: kidney diseases and various autoimmune diseases.

It’s treatable.

Not all cases of chronic Hep C need treatment. Some patients are fortunate to carry the virus without ever having problems from it. But other patients need treatment. As stated above, some subtypes of Hepatitis C are easier to treat than others, so the duration of treatment is longer for patients with harder-to-treat genotypes. Of patients with Genotype 1, around half have successful outcomes with treatment consisting of interferon and ribavirin. With Genotype 2, rates are even better, with around 80% of patients having successful results with treatment. The treatment can be difficult for many patients, and often causes depression, marked fatigue, and other unpleasant symptoms. Research continues on Hepatitis C, and hopefully there will soon be better treatments available.

People with known infections with Hepatitis C can take precautions.

Hepatitis C is commonly transmitted by shared needles and re-used medical supplies, and by tattoos and body piercing, if performed with reused equipment.  It’s spread by sexual contact surprisingly infrequently, but condoms are still recommended if one partner is positive for Hep C and the other one is negative. It’s probably easier to transmit sexually if there are open sores on the genitals, or trauma to delicate tissues that causes a break in the skin. It can be transmitted by an infected mother to her fetus, but only in about 6% of such pregnancies. Since Hep C is carried in the blood, there’s a remote chance of spreading it by sharing razors and even toothbrushes.

People with Hepatitis C infection need to take some health precautions. They need to be immunized against Hepatitis A and B, if they haven’t already received these. Presently there isn’t a vaccine to prevent Hepatitis C.

This information shows how important it is to screen for Hepatitis C. However, at least in this area of the country, it’s not common to screen patients for Hepatitis C when they enter treatment at opioid treatment centers. This is due to the cost of the testing, and lack of available follow up services. At the opioid treatment program where I presently work, Hepatitis B and C testing is encouraged, but the patients have to pay for the tests. The treatment center only charges what they have to pay the lab; there’s no mark up, and no profit in testing for the treatment center. Even then, fewer than half of the entering patients agree to this screening. At present, it costs around $25 for Hepatitis C initial screening. Fortunately, Hepatitis B screening is much cheaper.

When I have to inform patients about a positive Hepatitis C screen, what’s the next step? Most of the patients I’ve seen at this clinic who screen positive for the hepatitis C antibody don’t have insurance to help them get further testing. They don’t qualify for Medicaid, and they certainly can’t pay for treatment, if it’s needed. Sometimes I feel like I give these patients another burden to worry about, and I wonder if I’m doing more harm than good.

At an opioid treatment program where I worked in the past, I was able to form a relationship with a nearby university hospital. This town had a medical school and residency program, and people without insurance could be seen by the doctors in training. I could make appointments for patients who screened positive for hep C and further testing. The wait was about four months, but if the patient kept his appointment (often quite a challenge), he could then be referred to liver specialists associated with the medical school, if it appeared that a liver biopsy would be needed. Once these patients are established at this program, they can be entered into a research study, if one is available and they meet entrance criteria.

At the opioid treatment program where I now work, it’s harder to find places to refer patients with no money and no insurance. Most often, they go without care. At the very least, they can go to the local county health department and get needed Hepatitis A and B vaccinations and they know the sort of precautions they should take to prevent transmission, until they can get further testing. I’m going to keep looking for places to send patients without insurance, but it’s a problem. In this area, it’s hard for them to even find a primary care doctor.

  1. McCarthy JJ, Flynn N, “Hepatitis C in methadone maintenance patients: Prevalence and public policy implications,” Journal of Addictive Diseases, 2001;20:19-31.
  2. Patrick DM, Buxton JA, Bignam M, et. al., “Public Health and Hepatitis C,” Canadian Journal of Public Health, 2000;91(S1):S18-S23.
  3. Aaron, S, McMahon, JM, Milano, D, et. al., “Intranasal transmission of hepatitis C virus: virological and clinical evidence.” Clinical Infectious Diseases, 10/1/08,47(7):931-934.