1. Emotional and Psychiatric Barriers to Addressing HCV Joan E. Zweben, Ph.D. Executive Director: 14 th Street Clinic and East Bay Community Recovery Project Clinical Professor of Psychiatry; University of California, San Francisco March 2003

2. ACKNOWLEDGEMENTS Judith Martin, MD. Medical Director: 14 th Street Clinic & Medical Group Chair, Opioid Treatment Committee California Society of Addiction Medicine Susan Sky: Clinic Manager, The 14 th Street Clinic; Oakland, CA. Staff and Patients of the 14 th Street Clinic

3. Barriers to Self-Care Stable housing Stable housing Transportation Transportation Lack of phone Lack of phone Active alcohol/drug use Active alcohol/drug use Support system; potential caretakers Support system; potential caretakers Depression/anxiety Depression/anxiety Co-occurring mental disorders (e.g., psychotic conditions, PTSD, etc.) Co-occurring mental disorders (e.g., psychotic conditions, PTSD, etc.)

4. Attitudes Towards Self- Care Denial Denial Hopelessness Hopelessness Confusion about appropriate direction Confusion about appropriate direction Frustration about conflicting information Frustration about conflicting information Lack of energy; feelings of inadequacy Lack of energy; feelings of inadequacy Commitment and discipline Commitment and discipline

5. Conflicting Information about Treatment “Interferon doesn’t work.” “Interferon doesn’t work.” “Patients rarely get really bad liver problems from Hep C.” “Patients rarely get really bad liver problems from Hep C.” “The doctor said I couldn’t get treated if I am on methadone/still drinking, etc.” “The doctor said I couldn’t get treated if I am on methadone/still drinking, etc.” “The doctor said my liver looked fine (normal enzymes) so I don’t have it.” “The doctor said my liver looked fine (normal enzymes) so I don’t have it.” “My doctor said I should wait for the new interferon.” “My doctor said I should wait for the new interferon.” Judith Martin, MD

6. Patient Fears “They are going to come after me with a needle the size of a lead pipe.” “They are going to come after me with a needle the size of a lead pipe.” “The side effects of treatment will make me feel like using, and I’ll relapse.” “The side effects of treatment will make me feel like using, and I’ll relapse.” “I was depressed once before, and stopped taking my medicine because ___ (it made me sleepy/couldn’t sleep/too expensive). I know it will make me depressed and I’m afraid.” “I was depressed once before, and stopped taking my medicine because ___ (it made me sleepy/couldn’t sleep/too expensive). I know it will make me depressed and I’m afraid.” “I don’t want to inject myself; it will tempt me to use needles again.” “I don’t want to inject myself; it will tempt me to use needles again.” Judith Martin, MD

7. Enhancing Motivation for Self-Care Move from denial and helplessness to empowerment, self-efficacy Move from denial and helplessness to empowerment, self-efficacy Getting past fear, shame, guilt, concerns about rejection Getting past fear, shame, guilt, concerns about rejection Assess degree to which health is a motivator Assess degree to which health is a motivator Explore obstacles and charged issues Explore obstacles and charged issues Skills for navigating health care system Skills for navigating health care system

8. OASIS Support Group Approach Bundle education, support, treatment monitoring Bundle education, support, treatment monitoring Regular open meetings; participation can be flexible. Group is provided, not required. Regular open meetings; participation can be flexible. Group is provided, not required. Food available Food available Educational materials, especially video Educational materials, especially video Blend of education and airing of feelings Blend of education and airing of feelings

9. Ongoing Counseling Issues I’m contaminated I’m contaminated What does this mean for my partner/ children? What does this mean for my partner/ children? For my future life? For my future life? Should my partner/children get tested? Should my partner/children get tested? Do I need to use protection for sexual activity? Do I need to use protection for sexual activity? What does it mean for health care and health insurance? What does it mean for health care and health insurance? What can I hope for? What can I hope for?

10. Attitudes and Feelings about Psychotropic Medication shame shame feeling damaged feeling damaged needing a crutch; not strong enough needing a crutch; not strong enough “I’m not clean” “I’m not clean” anxiety about taking a pill to feel better anxiety about taking a pill to feel better “I must be crazy” “I must be crazy” medication is poison medication is poison expecting instant results expecting instant results

11. Medication Adherence important relationship to positive treatment outcome important relationship to positive treatment outcome reasons for non-compliance: denial of illness, attitudes and feelings, side effects, lack of support, other factors reasons for non-compliance: denial of illness, attitudes and feelings, side effects, lack of support, other factors role of the counselor: periodic inquiry, exploring charged issues, keeping physician informed role of the counselor: periodic inquiry, exploring charged issues, keeping physician informed Work out teamwork, procedures with docs Work out teamwork, procedures with docs

12. Main Message to Patients There is treatment if you need it. Find out whether you need it. There is treatment if you need it. Find out whether you need it. There are patients on methadone who do very well in treatment, and start to feel better within months. There are patients on methadone who do very well in treatment, and start to feel better within months. The treatment is not lifelong; it lasts six months to a year. The treatment is not lifelong; it lasts six months to a year. Judith Martin, MD

13. Main Message to Health Care Workers Don’t give up on our patients; evaluate them for treatment; Don’t give up on our patients; evaluate them for treatment; We need to be creative about adherence and access. This is the home of the epidemic; it won’t be stopped unless we address the treatment of needle users. We need to be creative about adherence and access. This is the home of the epidemic; it won’t be stopped unless we address the treatment of needle users. Alcohol use must be addressed. Alcohol use must be addressed. Judith Martin, MD

14. Enhancing Motivation for Substance Abuse Treatment TIP #35 National Clearinghouse for Alcohol and Drug Information www.health.org Phone: (800) 729-6686

15. OASIS CLINIC WEBSITE Treatment for Hepatitis C www.oasisclinic.org