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The Challenge of Addiction and Hepatitis C Diana Sylvestre, MD University of CA, San Francisco OASIS.

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Presentation on theme: "The Challenge of Addiction and Hepatitis C Diana Sylvestre, MD University of CA, San Francisco OASIS."— Presentation transcript:

1 The Challenge of Addiction and Hepatitis C Diana Sylvestre, MD University of CA, San Francisco OASIS

2 HCV Prevalence by Selected Groups United States Hemophilia Injection drug users Surgeons, PSWs* Hemodialysis Average Percent Anti-HCV Positive Gen population adults Military personnel STD clients Pregnant women * PSWs (personal-service workers) are individuals whose occupations involve close personal contact with clients (e.g., hairdressers, barbers, estheticians, cosmetologists, manicurists, pedicurists, massage therapists). Adapted from CDC Hepatitis Slide Kit HIV patients

3 Injecting Drug Use and HCV Transmission Highly efficient – Contamination of drug paraphernalia, not just needles and syringes Rapidly acquired after initiation – 30% prevalence after 3 years – >50% prevalence after 5 years Four times more common than HIV Adapted from CDC Hepatitis Slide Kit.

4 Relative Importance of Risk Factors for Hepatitis C Remote (>15 yrs ago) Recent (<15 yrs ago) Transfusion Sexual Other* Unknown Transfusion Injection Drug Use Unknown Other* Sexual Injection Drug Use * Nosocomial, occupational, perinatal Adapted from CDC Hepatitis Slide Kit

5 “Drug Users” are heterogeneous Cannabis Methamphetamine CocaineHeroin Regular use Binge use Polysubstance use Intermittent use Injection Intra-nasalOral

6 The evidence for addiction as a brain disease Dopamine release in the Nucleus Accumbens is a common characteristic of virtually every drug of abuse. Koob, Trends in Pharm Sci,,1992 DMT VTA LC Frontal Cx N. Acc Hippo AMG

7 Treatment options for depression Tricyclics (TCAs) –Amitriptyline, imipramine, nortriptyline, etc. Monoamine oxidase inhibitors (MAOIs) –Phenelzine, tranylcypromine, isocarboxazid, etc. Selective serotonin reuptake inhibitors (SSRIs) –Fluoxetine, sertraline, paroxetine, fluvoxamine, citalopram, etc. Serotonin antagonists –Trazodone, nefazodone Other agents –Bupropion, venlafaxine, mirtazapine, reboxetine, etc.

8 Treatment options for addiction Alcohol –Disulfiram, acamprosate, naltrexone Opiate –Methadone, buprenorphine, naltrexone Stimulants –?

9 Heroin-associated Mortality Hser, Y. I., et al. (2001) Arch Gen Psychiatry, 58, 503-8.

10 Progression of Liver Fibrosis Among IDUs With Chronic HCV 119 prospectively followed IDUs Demographics –96% were African American –97% HCV genotype 1 –27% HIV-infected –Median age 42 years. After 4.2 years median follow- up 21% had progression of fibrosis Wilson LE, et al. Hepatology. 2006 Apr;43(4):788-95. Significant Fibrosis 9.3% Insignificant Fibrosis 90.7% Significant fibrosis was defined as modified Ishak score 3 or greater, and progression of fibrosis was defined as an increase 2 or more units or clinical evidence of end- stage liver disease. Significant fibrosis at first biopsy:

11 “HCV therapy has been successful even when the patients have not abstained from continued drug or alcohol use... Thus, it is recommended that treatment of active injection drug use be considered on a case-by-case basis, and that active injection drug use in and of itself not be used to exclude such patients from antiviral therapy.” --NIH Consensus Statement on HCV, 2002

12 The data As it exists….

13 HCV Treatment in Methadone Patients P = NS 36 53 24 40 Overall SVRRelapsed and Returned to Treatment Relapsed and Did Not Return to Treatment Did Not Relapse Backmund M, et al. Hepatology. 2001;34:188-193. 0 20 40 60 80 100 Patients (%) SVR Rates in Injection Drug Users in Detox (N = 50) n=10n=15 n=25

14 Attendance predicts SVR Backmund M, et al. Hepatology. 2001;34:188-193. 45 6 0 20 40 60 80 100 >2/3 Appts<2/3 Appts SVR, % n=12 n=38 P <0.05

15 Mauss, et al. (Hepatology, 2004) p=0.16 n=50

16 HCV Treatment in the Setting of Active Drug Use 0 48 31 7.6 61 50 NoncomplianceEnd of Treatment Response SVR Patients (%) Active IDUs Nonactive IDUs P = NS HCV Treatment Outcomes: Active IDUs vs Nonactive IDUs (N = 406) Robaeys G, et al. Eur J Gastroenterol Hepatol. 2005;18:159-166. 0 20 40 60 80 100 P = NS

17 SVR Rate May Increase with Abstinence ≥ 6 mo< 6 moNoneOccasionalRegular Abstinence DurationSubstance Use 22 30 35 21 0 Sylvestre DL, et al. J Subst Abuse Treatment. 2005;29:159-165. 10 20 30 40 Sustained Virologic Response (%) Degree of Drug Use and SVR (N = 76) 0 P =.18 P =.09

18 Protective Immunity? Patients with ongoing or prior HCV infection may develop immunity that protects against further infection with HCV despite repeated exposure Dove L, Phung Y, Bzowej N, Kim M, Monto A, Wright TL. Viral evolution of hepatitis C in injection drug users. J Viral Hepat. 2005 Nov;12(6):574-83. Grebely J, Conway B, Raffa JD, Lai C, Krajden M, Tyndall MW. Hepatitis C virus reinfection in injection drug users. Hepatology. 2006 Nov;44(5):1139-45. Currie S, Tracy D, Ryan J, Belaye T, Kim M, Monto A. Injection drug users who resolve the HCV virus appear to be protected from reinfection. AASLD 2006: 167A.

19 Current Studies at OASIS

20 A Brief HCV Prevention Education Intervention for In- and Out-of- Treatment Drug Users CDC U50/CCU923257



23 Protocol Two test populations, two video curricula: –Out of treatment drug users at syringe exchange, n=100 Brief, 7-minute peer-based prevention education video –In-treatment drug users enrolled in methadone maintenance, n=450 30 minute peer based education video –Two viewing formats: single session vs. 4 session

24 Protocol Demographic/risk behavior questionnaire Randomization: –Usual care vs. video intervention SEP 1:1 MMT 1:1:1 (1 usual care: 1 single session: 1 4-part viewing) KAM test (Knowledge/Attitudes/Motivations) –Baseline –Immediate post video –Week 4 –(Week 8) –Week 12 Free HCV testing and HAV/HBV vaccinations offered

25 Sample Knowledge Questions: SEP Which of the following can transmit HCV infection? (MC) How often is hepatitis C passed on by sex? –Never/rarely/frequently/DK Which of the following can you get vaccinated for? Most people with hepatitis C don’t need treatment: T/F/DK Most people with HCV get yellow jaundice: T/F/DK Most people with hepatitis C will die from it: T/F/DK

26 Preliminary Results

27 MMTSEP Enrollment282/450100/100 Age (x)4643 White (%)42 Black (%)4150 Latino (%)107 < High School33%26% Uninsured30%41% 1 0 care in ER23%42% Tested for HIV97%98% Tested for HCV84%72% Told HCV+59%67% Demographics

28 MMTSEP HAV Vax33%35% HBV Vax33%34% Active EtOH51%73% Shared works <1yr17%25% Never condom58%46% Always condom34%29% >3 sex partners <1yr13%45% Prev STD38%51% Tattoo in jail28%19% Demographics

29 SEP Knowledge 3321304140n293023 ** ** P<0.001 for difference from usual care at all time points

30 MMT Knowledge Scores 8485526847735343n36 ** P<0.001 for difference from usual care at all time points ** p=0.02

31 MMT Attitudes/Motivation 46 43 85 68 52 84 64 55 36 n p=0.02 p=0.01 p=0.19 * * * *

32 Transitioning Street- Recruited Heroin Users to HCV Treatment using Buprenorphine NIDA DA015629-01

33 Study Design Street-recruited Heroin Users Hepatitis C Viral Testing Active: 12-24 weeks buprenorphine HCV Treatment, n=50 Buprenorphine Maintenance 24 week buprenorphine taper Not Interested in HCV Treatment: 12 wk buprenorphine taper Inactive: Ineligible

34 Enrollment All screened = 415 Eligible = 275 –Ineligible = 140 (33%) Not viremic = 94 (23%) On methadone = 29 (7%) No opioid addiction = 17 (4%)

35 Relevance All Screened: n=415 n = 275 n = 188n = 146

36 ScreenedEligibleEnrollStart Study Meds P Value n 415275188146 Age 46 (20-69) 46 (24-69) 46 (24-64) 46 (24-64) NS Male 70.4%74.9%73.9%71.2%NS White 34.5%32.0%31.9%33.6%NS Black 37.3%40.0%39.4%41.8%NS Latino 23.9%23.6%23.4%19.2%NS The study sample is representative

37 ScreenedEligibleEnrollStart Bupe P Value Yr. exposed 2425 ALT 46535554<0.001* % Cocaine 47.550.648.650.0NS % Meth 15.614.913.513.2NS % Alcohol 58.050.360.155.5NS Genotype 1 76% 78%77%NS *Significant for the difference between screened and eligible cohorts The study sample is representative

38 Drug Use Week 0-12

39 Treatment Retention (n=146) 58% 45%

40 Interest in HCV Treatment (n=146) Early Bupe termination Chose HCV Tx Chose taper

41 HCV Treatment Outcomes Completed treatment, n=37 Early termination, n=18 –3 incarcerated –4 medical –10 FTS –1 side effects

42 Outcomes by Genotype 3710262113732 11 20

43 Relevance to heroin users who initiate buprenorphine

44 Relevance to all eligible heroin users

45 OASIS Resources Providers: –Hepatitis C University Patients: –HepC411

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