Conference Presentation

Injection drug users (IDUs) constitute the largest group of persons infected with the hepatitis C virus (HCV) in the United States, and most new infections occur in IDUs. Controlling the HCV epidemic, therefore, will require developing, testing, and implementing prevention and treatment strategies that will be effective in persons who inject drugs. Preventing morbidity and mortality from HCV will require reducing exposure to HCV, reducing infection among those exposed, and reducing disease among those infected. Injection drug use could be greatly reduced if all those who needed substance abuse treatment could get it (prevention of exposure). HCV spread among drug users can be prevented if drug users have access to sterile syringes, HCV counseling and testing, and outreach programs that teach them how they can avoid acquiring and transmitting the virus (prevention of infection). Finally, barriers to medical treatment must be overcome so that drug users can benefit from advances in HCV treatment (prevention of disease). (1) HCV treatment may also reduce transmission (prevention of infection), because HCV-infected IDUs are the source for most HCV transmission in the United States. Efforts are particularly important to identify persons with new HCV infections, in whom treatment may be more effective during the acute phase than later, and those with advanced hepatic fibrosis, in whom treatment may improve survival.

Caring for drug users presents special challenges to the health care team that require patience, experience, and tolerance. Fortunately, substantial research and clinical experience in the prevention and management of chronic viral infections among IDUs, especially HIV infection, has led to the development of effective principles for engaging drug users in health care relationships (Table). (2–5) Learning from this experience will be critical for efforts to control HCV. Successful programs invariably adopt a respectful approach to substance users, understand the medical and behavioral sequelae of addiction, and refrain from moralistic judgments. These strategies reflect a harm reduction approach. (6,7) Harm reduction strategies help patients reduce high-risk behaviors without imposing unrealistic demands for global change. When ceasing all drug use is not likely in the immediate future, other measures must be taken to help patients reduce the harmful consequences of injection drug use. (8,9) Decisions about the treatment of HCV infection in patients who use illicit drugs, as in other patients, should be made by the patients together with their physicians based on individualized risk-benefit assessments. (1) Adherence, psychological side effects, and the possibility of reinfection present challenges to effective treatment for some drug users.

Fortunately, an array of effective strategies exists to overcome each of these challenges. Attention to ensuring optimal adherence is important for all patients, not just those who use drugs. (10) This is so because although certain risk factors for noncompliance have been identified, including depression, psychological stress, homelessness, lack of social support, and drug use, physicians are not able to predict accurately which patients will adhere to a treatment regimen. (11) Effective strategies for improving adherence range from basic clinical practices—such as establishing a consistent, trusting physician-patient relationship, providing clear information

1. Establish a climate of mutual respect.

2. Maintain a professional approach that reflects the aim of enhancing patients’ well-
    being; avoid creating an atmosphere of blame or judgment.

3. Educate patients about their medical status, proposed treatments, and their side effects.

4. Include patients in decision-making.

5. If possible, establish a multidisciplinary team consisting of primary care physicians, HIV
    specialists, psychiatrists, social workers, and nurses.

6. Have a single primary care provider coordinate the care delivered by such a team to
    maximize consistency and continuity.

7. Define and agree on the roles and responsibilities of both the health care team and the
    patient.

8. Set appropriate limits and respond consistently to behavior that violates those limits. 9.
    Minimize barriers to participation (penalties for missed visits, etc.).

10.Recognizing that patients must set their own goals for behavior change, work with
     patients to achieve commitment to realistic goals for healthier behaviors.

11. Acknowledge that abstinence is not always a realistic goal; emphasize risk reduction
     measures for patients who continue to use drugs.

12. Acknowledge that sustaining abstinence is difficult and that success may require
     several attempts. 

13. Be familiar with local resources for the treatment of drug users.
 

The psychological side effects of interferon-based regimens for the treatment of HCV infection are of concern in all patients. Interferon may have severe psychological side effects in patients with or without pre-existing psychiatric disorders. (18,19) To minimize psychological toxicity, all patients should be screened for depression and other mental health conditions before undergoing HCV treatment, treated for these conditions if necessary, and monitored for them during HCV treatment.

Because those successfully completing HCV therapy may be at risk for reinfection, drug users need detailed counseling and support to avoid risky injection practices in case they continue or return to injecting drugs. Those who inject drugs after receiving effective treatment for HCV infection can avoid reinfection by using a new sterile syringe for each injection and by not sharing their injection equipment with other users. (20,21) There are 174 syringe exchange programs in 120 cities in 34 states in the United States, and the number is increasing yearly. For drug users without access to such programs, physicians in at least 46 states are allowed by law to prescribe syringes so that their patients can avoid acquiring and transmitting bloodborne infections. (22–24) IDUs can master safe injection practices, and many do inject safely. When given access to sterile syringes, IDUs readily make use of them, reducing their high-risk behavior (25–27) and rates of disease transmission. (28,29) Physicians should refer patients who inject drugs to syringe exchange programs or, if necessary, prescribe syringes for them. HCV may be more readily transmitted than the human immunodeficiency virus (HIV) through the sharing of injection equipment other than syringes, such as “cookers” (bottle caps, spoons, and other containers used to dissolve drugs) and “cottons” (filters used to draw up the drug solution into a syringe). (30) Thus, it is particularly important for physicians to instruct their patients not to share these items. (20,21)

All injection drug users should be offered treatment for substance abuse and such treatment should be provided to those wishing it. Medical services should be integrated with substance abuse treatment. (3) Alcohol treatment is particularly important because of the strong effect of heavy alcohol intake on the progression of hepatitis C. Finally, all patients with HCV infection should be instructed in how to avoid transmitting the infection to others. Patients should be warned that their blood may be infectious even in minute quantities. Those who inject drugs should be instructed not to share syringes or any other injection equipment with other persons and to avoid blood contact with others. They should be given biohazard sharps containers or instructed to safely dispose of injection equipment in puncture-resistant containers. (31)

Clinical Data

There is abundant evidence that when treatment strategies for drug users take into account the circumstances of their lives, very high rates of adherence can be achieved. (11,15–17,32–38) Several recent studies have demonstrated the safety and effectiveness of hepatitis C treatment in drug users, even when they are not completely abstinent from drug use. (39–41) Backmund et al. reported a 36 percent sustained virologic response rate in 50 injection drug users who were treated simultaneously for HCV infection and substance abuse, even though 80 percent of the patients  relapsed to drug use. (39) Sustained response rates were not significantly different for patients who relapsed and those who did not. All patients were treated and supervised by physicians who specialized in both hepatology and addiction medicine. Patients who relapsed to drug use were offered opiate replacement therapy and were allowed to continue their HCV treatment even if they injected heroin again. The strongest predictor of virologic response was whether patients continued to keep their appointments; 45 percent of those who kept > 67 percent of their appointments but only 6 percent of those who did not had sustained virologic responses. This study demonstrates the importance of combining expertise in both hepatology and substance abuse and maintaining strong relationships with patients that can be sustained even through relapse to drug use.

Because those successfully completing HCV therapy may be at risk for reinfection, drug users need detailed counseling and support to avoid risky injection practices in case they continue or return to injecting drugs. Those who inject drugs after receiving effective treatment for HCV infection can avoid reinfection by using a new sterile syringe for each injection and by \\\not sharing their injection equipment with other users. (20,21) There are 174 syringe exchange programs in 120 cities in 34 states in the United States, and the number is increasing yearly. For drug users without access to such programs, physicians in at least 46 states are allowed by law to prescribe syringes so that their patients can avoid acquiring and transmitting bloodborne infections. (22–24) IDUs can master safe injection practices, and many do inject safely. When given access to sterile syringes, IDUs readily make use of them, reducing their high-risk behavior (25–27) and rates of disease transmission. (28,29) Physicians should refer patients who inject drugs to syringe exchange programs or, if necessary, prescribe syringes for them. HCV may be more readily transmitted than the human immunodeficiency virus (HIV) through the sharing of injection equipment other than syringes, such as “cookers” (bottle caps, spoons, and other containers used to dissolve drugs) and “cottons” (filters used to draw up the drug solution into a syringe). (30) Thus, it is particularly important for physicians to instruct their patients not to share these items. (20,21)

All injection drug users should be offered treatment for substance abuse and such treatment should be provided to those wishing it. Medical services should be integrated with substance abuse treatment. (3) Alcohol treatment is particularly import ant because of the strong effect of heavy alcohol intake on the progression of hepatitis C. Finally, all patients with HCV infection should be instructed in how to avoid transmitting the infection to others. Patients should be warned that their blood may be infectious even in minute quantities. Those who inject drugs should be instructed not to share syringes or any other injection equipment with otherpersons and to avoid blood contact with others. They should be given biohazard sharps containers or instructed to safely dispose of injection equipment in puncture-resistant containers. (31)

Clinical Data

There is abundant evidence that when treatment strategies for drug users take into account the circumstances of their lives, very high rates of adherence can be achieved. (11,15–17,32–38) Several recent studies have demonstrated the safety and effectiveness of hepatitis C treatment in drug users, even when they are not completely abstinent from drug use. (39–41) Backmund et al. reported a 36 percent sustained virologic response rate in 50 injection drug users who were treated simultaneously for HCV infection and substance abuse, even though 80 percent of the patients relapsed to drug use. (39) Sustained response rates were not significantly different for patients who relapsed and those who did not. All patients were treated and supervised by physicians who specialized in both hepatology and addiction medicine. Patients who relapsed to drug use were offered opiate replacement therapy and were allowed to continue their HCV treatment even if they injected heroin again. The strongest predictor of virologic response was whether patients continued to keep their appointments; 45 percent of those who kept > 67 percent of their appointments but only 6 percent of those who did not had sustained virologic responses. This study demonstrates the importance of combining expertise in both hepatology and substance abuse and maintaining strong relationships with patients that can be sustained even through relapse to drug use.

Sylvestre et al. have treated 67 methadone maintenance patients with combination interferon/ribavirin, with an interim sustained virologic response rate in the first 59 patients of 29 percent, a rate identical to that in a comparison group of nonopioid-dependent patients. (40) No serious side effects occurred, although 61 percent of the patients had a prior psychiatric diagnosis. Response rates were not significantly different in patients who did or did not have 6 months of sobriety, nor in patients who did or did not consume alcohol. They were not significantly worse in patients who continued using drugs unless they used every day. This study demonstrates that HCV can be effectively treated in patients receiving maintenance opiate replacement therapy despite substantial pre-existing psychiatric disease and despite ongoing, intermittent drug use.

Finally, Backmund et al. reported no reinfection during 24 weeks in 10 patients who continued to inject heroin. (39) They carefully instructed their patients how to avoid acquiring HCV when injecting drugs. Dalgard et al. reported one reinfection during 5 years in 9 patients who relapsed to injection drug use after sustained virologic responses to HCV treatment. (41)

Success in treating HCV infection in IDUs will require collaboration between experts in hepatitis and substance use to create programs specifically designed for drug users. Efforts to control HCV, including both prevention and treatment, can benefit from the expertise of those with experience working with drug users. Substance abuse treatment professionals have expertise working with drug users in treatment. Harm reduction workers and many substance abuse researchers have expertise working with out-of-treatment drug users. And many AIDS medical providers have expertise providing medical care to drug users both in and out of substance abuse treatment. Involvement of these professionals in HCV prevention and treatment efforts will greatly improve their effectiveness. A sound policy for the control of the hepatitis C epidemic will require implementing prevention and treatment programs designed for IDUs, the group most severely affected by the epidemic. (42) Controlling the HCV epidemic, therefore, will require further research to develop and test prevention and treatment strategies that will be effective in persons who inject drugs. In the meantime, however, substantial progress can be made to control hepatitis C if existing knowledge and resources are brought to bear.

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Injection Drug Use and Hepatitis C
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