Addiction professionals belong on the forefront of efforts to help individuals infected with HCV and to contain the epidemic. Beyond the lifestyle stabilization that is integral to drug abuse treatment, education is usually the most important intervention we can provide. The two critical areas for teaching are avoiding infection and staying healthy if infection occurs.
Addiction professionals also are well positioned to help patients negotiate the obstacles to care. We can assist at-risk and infected patients in obtaining a proper diagnostic assessment and treatment when needed. Success in these efforts sets the stage for an additional important dimension of help: support for those who fear liver biopsy and those who face the unpleasantness of medication side effects.
Educate for Prevention
The first, absolutely crucial message to give drug abusers is that all injection equipment—needles, syringes, cottons, cookers, and rinse water—can pick up and transmit the virus. No part of an injection outfit should ever be shared. Offer this information to noninjecting drug users, who risk rapid seroconversion if they begin injecting, as well as to past or current injectors. Inform drug-using and addicted patients about any programs in your state to make sterile injecting equipment available, either via syringe exchange programs or through direct purchase at local pharmacies without a prescription.
Sexual activity is a relatively inefficient way to transmit HCV. According to the CDC recommendations, persons with hepatitis C who are in long-term, stable, monogamous relationships do not need to use condoms, even when one partner is infected and the other is not. However, patients who have other sexually transmitted diseases and multiple sexual partners, factors that increase the risk of sexual transmission of HCV, should always use condoms. We advise patients in these groups to adopt the following policy: no glove, no love.
Other hepatitis C prevention measures include covering open wounds and cleaning up spilled blood with bleach. Razors, toothbrushes, and other items that may acquire small amounts of blood, including the straws and pipes used for snorting or smoking drugs, should never be shared.
For most patients, the consequences of hepatitis C are much less dire than those of drug abuse, and this can be a very useful focus of discussion. Most patients remain healthy in spite of their infection, especially if they abstain from alcohol and get vaccinations for hepatitis A and B.
We tell our patients: You don’t need to die of the disease. Not only that, you probably don’t even need treatment, but you must take care of yourself. Above all, don’t drink alcohol. It’s like pouring gasoline on a fire. Have your blood tested for antibodies to hepatitis A and B, and get vaccinated if you haven’t already been exposed.
We also urge: Find out all you can about your illness. If your screening test is positive, obtain a viral assay to find out whether you are still infected or your body has cleared the virus. If your viral assay is positive, try to get a biopsy to find out if your liver is being damaged. If it is, work with your doctor, and prepare yourself for treatment. If you stick with your treatment, your odds of getting rid of the virus are pretty good, about 50:50. And if the coin toss doesn’t go your way, remember that newer and better treatments are around the corner. The goal is to make sure you’ll still be around to check them out.
Three views of the hepatitis C virus.
Support Access and Adherence to Hepatitis C Care
Accessing screening and care on behalf of addicted patients with hepatitis C may take persistence. The HCV antibody screening test is relatively inexpensive, typically around $10, and thus affordable for almost everyone. The HCV viral assay is more problematic, but most county medical clinics and hospitals will provide it. Attempts to arrange a liver biopsy are worth the effort, and increasingly often, interventional radiologists who do not hesitate to treat drug abusers perform these procedures.
Pegylated interferon and ribavirin are easily accessible and usually available at no cost for low-income, uninsured patients who apply to an indigent patient program. Specialty physicians may be encouraged to treat an addicted person if an addiction professional agrees to assist with patient monitoring and compliance. Many infectious disease physicians have experience treating addicted patients with HIV, which makes them very capable clinical managers for addicted patients with hepatitis C.
Even though addiction care providers do not assume primary responsibility for hepatitis C treatment, they can contribute immensely to successful outcomes by providing support and helping to observe and manage side effects. We can learn to alleviate side effects such as nausea, insomnia, and flu-like symptoms—all of which are minor in themselves, but any of which can lead to treatment discontinuation if neglected. Addressing serious side effects, such as ribavirin-induced hemolytic anemia or neutropenia from interferon, may fall outside most addiction specialists’ scope of practice, but we can still help with monitoring for problematic or potentially worrisome symptoms, such as worsening shortness of breath. Addiction care providers may also be better able than consulting hepatologists to spot early signs of depression or mania, which develops in about one-third of patients taking interferon. Early awareness of these problems maintains treatment outcomes by permitting prompt stabilization.
Finally, every patient confronting the challenges of hepatitis C treatment needs to hear messages of hope. This is doubly true for our more marginalized and needy patients who do not have a circle of supportive friends and family. Regular moral support from within the structure of an addiction treatment program can go a long way toward helping our patients stay the course of treatment and reap the best possible results.