HCV in Addicted HCV in Addicted Patients: Patients: Overcoming the Barriers Overcoming the Barriers to Education, to Education, Treatment, and Outcomes Treatment, and Outcomes Diana L. Sylvestre, MD Diana L. Sylvestre, MD Executive Director, OASIS Executive Director, OASIS Presented by: Amy Smith, PA-C Presented by: Amy Smith, PA-C
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HCV in Addicted Patients: Overcoming the Barriers to Education, Treatment, and Outcomes Diana L. Sylvestre, MD Executive Director, OASIS Presented by:
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HCV in Addicted Patients:HCV in Addicted Patients:Overcoming the Barriers to Overcoming the Barriers to Education, Treatment, and Education, Treatment, and
OutcomesOutcomes
Diana L. Sylvestre, MDDiana L. Sylvestre, MDExecutive Director, OASISExecutive Director, OASIS
Organization to Organization to Achieve Solutions in Achieve Solutions in
Substance-AbuseSubstance-Abuse
Our situationOur situation
• Poverty, high rates of drug usePoverty, high rates of drug use– Heroin, crack cocaine, Heroin, crack cocaine,
methamphetaminemethamphetamine
• Low rates of health insuranceLow rates of health insurance– Limited access to medical careLimited access to medical care– Limited access to drug treatmentLimited access to drug treatment
• Limited access to healthcareLimited access to healthcare
Our Mission:Our Mission:
Provide high quality Provide high quality medical care to drug users medical care to drug users
(or whoever shows up)(or whoever shows up)
A Small Community A Small Community ClinicClinic
• One doctor One doctor • One physician assistant (Me)One physician assistant (Me)• 3 peer educators3 peer educators• No nurses, social workers, or case No nurses, social workers, or case
managersmanagers• A lot of willing volunteersA lot of willing volunteers
A Small Community Clinic A Small Community Clinic with an Evidence-based with an Evidence-based
ApproachApproach• Addiction is a medical illnessAddiction is a medical illness• Treatments are limited and relapse Treatments are limited and relapse
is characteristicis characteristic• Perfection is an unrealistic Perfection is an unrealistic
expectationexpectation
Treatment options Treatment options for hypertensionfor hypertension
Addiction is not a single Addiction is not a single syndrome:syndrome:
Cannabis
Methamphetamine
CocaineHeroin
Regular use
Binge use
Alcohol
Polysubstance use
Intermittent use
The evidence for addiction The evidence for addiction as a brain diseaseas a brain disease
Dopamine release in the Nucleus Dopamine release in the Nucleus Accumbens is a common Accumbens is a common characteristic of virtually every drug of characteristic of virtually every drug of abuse.abuse.
Koob, Trends in Pharm Sci, ,1992
DMT VTA
LC
Frontal Cx
N. Acc
Hippo
AMG
It quickly became It quickly became apparent that our apparent that our
little clinic had a big little clinic had a big problem:problem:
HEPATITIS CHEPATITIS C
Hepatitis C in OaklandHepatitis C in Oakland
• 96% of long-term injectors96% of long-term injectors• Limited access to drug Limited access to drug
treatmenttreatment• Syringe exchange available Syringe exchange available
on a limited basison a limited basis
How we came to How we came to treat hepatitis C:treat hepatitis C:
No one else would No one else would do it.do it.
Relative Importance of Relative Importance of Risk Factors for Risk Factors for
Hser, Y. I., et al. (2001) Arch Gen Psychiatry, 58, 503-8.
No one else would No one else would do it.do it.
We decided to try.We decided to try.
Hepatitis C Hepatitis C Treatment in Drug Treatment in Drug
UsersUsers
No one wants to No one wants to treat drug users for treat drug users for
hepatitis C.hepatitis C.
Why?Why?
Barriers: Barriers: perceived vs. realperceived vs. real
• Adherence is badAdherence is bad• Reinfection Reinfection • Interferon can exacerbate Interferon can exacerbate
psychiatric symptomspsychiatric symptoms• Interferon is an injectable Interferon is an injectable
medication and may increase the medication and may increase the risk for relapserisk for relapse
Most HCV treatment Most HCV treatment barriers are perceived barriers are perceived
or relative.or relative.
The real barrier is The real barrier is prejudiceprejudice..
Bridging Active Heroin Bridging Active Heroin Users to HCV Users to HCV
Treatment with Treatment with BuprenorphineBuprenorphine
1 R01 DA015629-01
HypothesisHypothesis
• Active, street-recruited heroin users Active, street-recruited heroin users can be safely and successfully can be safely and successfully treated for hepatitis C after 12-24 treated for hepatitis C after 12-24 weeks of buprenorphine weeks of buprenorphine stabilization.stabilization.
Study DesignStudy DesignStreet-recruited
Heroin Users
Hepatitis C Viral Testing
Active: 12-24 weeks buprenorphine
Inactive: Ineligible
HCV Treatment, n=50Buprenorphine Maintenance
Not Interested in HCV Treatment: 12 wk buprenorphine taper
76%76% 76%76% 78%78% 77%77% NSNS*Significant for the difference between screened and eligible cohorts
The study sample is The study sample is representativerepresentative
Other Other CharacteristicsCharacteristics
• 33% homeless33% homeless• Median education < high schoolMedian education < high school• Median monthly income ~$550 USDMedian monthly income ~$550 USD• 40% on probation or parole, median 40% on probation or parole, median
weeks of prior incarceration = 156weeks of prior incarceration = 156• 64% with history of “serious depression”, 64% with history of “serious depression”,
75% with history of “serious anxiety,” 75% with history of “serious anxiety,” 22% had prior suicide attempt. 14% had 22% had prior suicide attempt. 14% had been prescribed a psychiatric medication.been prescribed a psychiatric medication.
• Median number of prior treatment Median number of prior treatment attempts = 7attempts = 7
Criteria for initiating Criteria for initiating HCV treatmentHCV treatment
– Active HCVActive HCV– InterestedInterested– Attendance of >75% of weekly Attendance of >75% of weekly