401
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Chang JS, Behar E, Coffin PO. Narratives of people who inject drugs on factors contributing to opioid overdose. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 74:26-32. [PMID: 31442677 DOI: 10.1016/j.drugpo.2019.07.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 07/25/2019] [Accepted: 07/26/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND In recent years, there has been increasing national and global attention to opioid overdoses. In San Francisco, it is estimated that the population of people who inject drugs (PWID) has more than doubled in the past ten years. The risk factors for opioid overdose have been examined closely, but firsthand accounts of PWID who have experienced overdoses are less documented. In this paper, we use two theories - lay expertise and structural vulnerabilities - as frameworks to frame and qualitatively examine the narratives of PWID surrounding their recent overdose experiences. METHODS Audio-recorded semi-structured open-ended motivational interviewing counseling sessions were conducted with PWID in San Francisco who have experienced at least one non-fatal overdose event (N = 40). Participants discussed the context of recent opioid overdoses, either witnessed or personally experienced, focusing on their perceptions of unique contributing factors. Interview data were coded and analysed using ATLAS.ti. We used a thematic content analysis approach to qualitatively analyze data queries and generate themes. We used theories of structural vulnerability and lay expertise to frame the analysis. RESULTS Using quotes from the participants, we report four central themes that contributed to participants' overdose experiences: 1) Social Dynamics and Opioid Expertise; 2) Uncertain Supply, Composition, Source; 3) Balancing Polysubstance Use, and 4) Emotional Pain. CONCLUSION As PWID described their overdose experiences, many factors that contributed to their overdoses were situated at the structural level. The everyday, lived experiences of PWID often competed or conflicted with public health messages and approaches. The accumulated expertise of PWID about everyday risk factors can be leveraged by public health practitioners to inform and improve overdose prevention interventions and messages.
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Affiliation(s)
- Jamie Suki Chang
- Santa Clara University, Public Health Science Program, United States; University of California, San Francisco, United States.
| | - Emily Behar
- University of California, San Francisco, United States
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402
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Bukten A, Stavseth MR, Clasuen T. From restrictive to more liberal: variations in moratlity among patients in opioid maintenance treament over a 12-year period. BMC Health Serv Res 2019; 19:553. [PMID: 31391048 PMCID: PMC6686445 DOI: 10.1186/s12913-019-4382-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 07/30/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND As the effect of opioid maintenance treatment (OMT) on overdose mortality varies both between and within countries, treatment programs need to be evaluated in different treatment settings and over time within settings. We evaluated variations in mortality in a national programme: from the initial rollout as restrictive and low-capacity to its gradual change into more liberal and higher-volume. METHODS A 12-year prospective longitudinal cohort study including all persons (n = 6871) applying for and entering OMT in Norway (1997-2009). We followed all patients until 2009 or until death. We used crude mortality rates (CMR) to calculate overdose and all-cause mortality among patients in OMT before, during and after treatment, during a 12-year time-period. We also calculated variations in overdose and all-cause mortality over the course of treatment and after treatment termination. We fitted proportional hazards models with covariates to the data. RESULTS OMT significantly reduces risk of mortality compared to being outside of treatment. The reduction in overdose death was most substantial during the initial phase of the Norwegian OMT-programme, still; we consistently find that overdose deaths were more than halved in all calendar-periods throughout observation. We did not find an elevated risk of overdose death in the first weeks of treatment, nor in the first weeks after treatment cessation. CONCLUSION In Norway, OMT reduces overall mortality. Reduction in mortality is likely dependent of both treatment delivery and characteristics of the at-risk population.
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Affiliation(s)
- Anne Bukten
- Norwegian Centre for Addiction Research, University of Oslo, Kirkveien 166, N-0407 Oslo, Norway
| | | | - Thomas Clasuen
- Norwegian Centre for Addiction Research, University of Oslo, Kirkveien 166, N-0407 Oslo, Norway
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403
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Compton WM, Jones CM. Epidemiology of the U.S. opioid crisis: the importance of the vector. Ann N Y Acad Sci 2019; 1451:130-143. [PMID: 31378974 DOI: 10.1111/nyas.14209] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 07/05/2019] [Accepted: 07/17/2019] [Indexed: 12/26/2022]
Abstract
The roots of the remarkably lethal U.S. opioid crisis are complex and inextricably entangled with healthcare, especially in its treatment of another serious health problem: pain. Failures of the healthcare system-including lack of both training in pain management and caution in using an addictive class of medications-precipitated the rise in opioid misuse and addiction over the past two decades, but a wider range of social and economic forces has helped perpetuate the crisis and altered its character. The classic epidemiologic host-agent-environment triad can be augmented for the purpose of elucidating the current opioid crisis by addition of the "vector" to emphasize the importance of purveyors of opioids (licit and illicit), leading to our proposing an expanded host-agent-vector-environment model. Interventions addressing multiple components are needed, including solutions that account for behaviors of all vectors associated with the crisis. For prescription opioids, the vectors include clinicians and pharmaceutical-related companies involved in marketing, prescribing, distributing, and dispensing opioid medications; for illicit opioids, they include drug manufacturing and distribution networks. Attending to the vectors of opioids, while simultaneously implementing a full range of public health, clinical, law enforcement, and other approaches to ending the opioid crisis, may help to improve public health outcomes.
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Affiliation(s)
- Wilson M Compton
- National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland
| | - Christopher M Jones
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
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404
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Villarreal YR, Suchting R, Klawans MR, Lane SD, Green CE, Northrup TF, Stotts AL. Predicting HCV Incidence in Latinos with High-Risk Substance Use: A Data Science Approach. SOCIAL WORK IN PUBLIC HEALTH 2019; 34:606-615. [PMID: 31370744 DOI: 10.1080/19371918.2019.1635948] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Hepatitis C virus (HCV) in the U.S. has tripled in the prior five years, and injecting drug use is the primary risk for HCV, with up to 90% of older and former people who inject drugs (PWIDs) testing positive. Laboratory testing of HCV for any PWIDs is the gold standard, however many PWIDs lack access to health treatment or services. Identifying risks of HCV via a data science approach would aid community health workers (CHW) to rapidly link those most at risk of infection with treatment. This study employed a data-science approach to determine the strongest risk factors of HCV in a sample of Mexican-Americans WIDs n = 221 (96 negative/125 positive). Data included 238 demographic and psychosocial predictors. A Random Forest machine learning algorithm demonstrated significant prediction improvement over baseline no information rate comparison. Strongest risks for positive HCV included sharing drug-use equipment and younger age at first heroin use; receiving drug-education during incarceration was protective. A ROC curve fit to the prediction yielded an area under the curve of 0.77. Predictive variables of HCV in the present analysis can be obtained via screening by CHW. Identification of patients most at risk of HCV within community settings can maximize treatment utilization.
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Affiliation(s)
- Yolanda R Villarreal
- Department of Family and Community Medicine, McGovern Medical School at UTHealth , Houston , Texas , USA
| | - Robert Suchting
- Department of Psychiatry and Behavioral Sciences, McGovern Medical School at UTHealth , Houston , Texas , USA
| | - Michelle R Klawans
- Department of Family and Community Medicine, McGovern Medical School at UTHealth , Houston , Texas , USA
| | - Scott D Lane
- Department of Psychiatry and Behavioral Sciences, McGovern Medical School at UTHealth , Houston , Texas , USA
| | - Charles E Green
- Center for Clinical Research and Evidence-Based Medicine, McGovern Medical School at UTHealth , Houston , Texas , USA
| | - Thomas F Northrup
- Department of Family and Community Medicine, McGovern Medical School at UTHealth , Houston , Texas , USA
| | - Angela L Stotts
- Department of Family and Community Medicine, McGovern Medical School at UTHealth , Houston , Texas , USA
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405
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McCann M, Gorman M, McKeown B. No Fever, No Murmur, No Problem? A Concealed Case of Infective Endocarditis. J Emerg Med 2019; 57:e45-e48. [PMID: 31029399 DOI: 10.1016/j.jemermed.2019.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 02/12/2019] [Accepted: 03/04/2019] [Indexed: 06/09/2023]
Abstract
BACKGROUND Infective endocarditis is associated with significant morbidity and mortality, despite advances in diagnosis and treatment strategies. Injecting drug users are particularly at risk of endovascular infections, especially with multi-resistant and virulent microorganisms. Typically, patients with endocarditis present with constitutional symptoms, such as high fever and malaise combined with cardiorespiratory symptoms of valvular failure or emboli, such as septic pulmonary embolism. CASE REPORT A 33-year-old female with a history of peptic ulcer disease presented to the emergency department with 3 days of increasing unilateral calf pain and swelling. There was no history of trauma or immobilization, no fever or clinical signs of sepsis or cardiopulmonary symptoms. A history of recent i.v. amphetamine injection in the forearm was elicited and empiric treatment for endovascular infection was commenced. Workup revealed methicillin-resistant Staphylococcus aureus mitral papillary endocarditis with gastrocnemius pyomyositis, multi-joint septic arthritis, and brain abscesses. After a 60-day inpatient stay, including intensive care admission for septic shock, the patient made a good recovery. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The incidence of injecting drug use is increasing, and these patients are at risk of severe invasive infections with multi-resistant organisms. The emergency physician is most often responsible for the initial workup and treatment of patients with suspected infective endocarditis, with timely collection of blood cultures and appropriate antibiotics being essential interventions. This case highlights that even without fever, murmurs, or constitutional symptoms, severe multisystem infections from endocarditis can occur.
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Affiliation(s)
- Michael McCann
- Department of Emergency Medicine, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Michael Gorman
- Department of Cardiology, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Barry McKeown
- Department of Cardiology, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
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406
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Coyle C, Moorman AC, Bartholomew T, Klein G, Kwakwa H, Mehta SH, Holtzman D. The Hepatitis C Virus Care Continuum: Linkage to Hepatitis C Virus Care and Treatment Among Patients at an Urban Health Network, Philadelphia, PA. Hepatology 2019; 70:476-486. [PMID: 30633811 PMCID: PMC6625928 DOI: 10.1002/hep.30501] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 12/20/2018] [Indexed: 12/24/2022]
Abstract
Improving care and treatment for persons infected with hepatitis C virus (HCV) can reduce HCV-related morbidity and mortality. Our primary objective was to examine the HCV care continuum among patients receiving care at five federally qualified health centers (FQHCs) in Philadelphia, PA, where a testing and linkage to care program had been established. Among the five FQHCs, one served a homeless population, two served public housing residents, one served a majority Hispanic population, and the last, a "test and treat" site, also provided HCV treatment to patients. We analyzed data from electronic health records of patients tested for HCV antibody from 2012 to 2016 and calculated the percentage of patients across nine steps of the HCV care continuum ranging from diagnosis to cure. We further explored factors associated with successful patient navigation through two steps of the continuum using multivariable logistic regression. Of 885 chronically infected patients, 92.2% received their RNA-positive result, 82.7% were referred to an HCV provider, 69.4% were medically evaluated by the provider, 55.3% underwent liver disease staging, 15.0% initiated treatment, 12.0% completed treatment, 8.7% were assessed for sustained virologic response (SVR), and 8.0% achieved SVR. Regression results revealed that test and treat site patients were significantly more likely to be medically evaluated (adjusted odds ratio [aOR], 2.76; 95% confidence interval [CI], 1.82-4.17) and to undergo liver disease staging (aOR, 1.92; 95% CI, 1.02-2.86) than patients at the other FQHCs combined. Conclusion: In this US urban setting, over two thirds of HCV-infected patients were linked to care; although treatment uptake was low overall, it was highest at the test and treat site; scaling up treatment services in HCV testing settings will be vital to improve the HCV care continuum.
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Affiliation(s)
- Catelyn Coyle
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
- National Nurse-Led Care Consortium, Philadelphia, PA, United States
| | - Anne C. Moorman
- Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | | | - Gary Klein
- Public Health Management Corporation, Philadelphia, PA, United States
| | - Helena Kwakwa
- Philadelphia Department of Public Health, Philadelphia, PA, United States
| | - Shruti H. Mehta
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Deborah Holtzman
- Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, United States
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407
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Gicquelais RE, Genberg BL, Astemborski J, Celentano DD, Kirk GD, Mehta SH. Association of Injection Practices and Overdose With Drug Use Typologies: A Latent Class Analysis Among People Who Inject Drugs in Baltimore, 2017. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2019; 31:344-362. [PMID: 31361518 PMCID: PMC6765400 DOI: 10.1521/aeap.2019.31.4.344] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Increasing overdose mortality and new HIV outbreaks in the U.S. highlight the need to identify risk behavior profiles among people who inject drugs (PWID). We characterized latent classes of drug use among a community-based sample of 671 PWID in Baltimore during 2017 and evaluated associations of these classes with sharing syringes, obtaining syringes from pharmacies or syringe services programs (SSPs), and nonfatal overdose in the past 6 months. We identified three classes of current drug use: infrequent use (76% of participants), prescription drug use (12%), and heroin and/or cocaine injection (12%). PWID in the heroin and/or cocaine injection and prescription drug use classes had higher odds of both overdose and sharing syringes (relative to infrequent use). PWID in the prescription drug use class were 64% less likely to obtain syringes through SSPs/pharmacies relative to heroin and/or cocaine injection. Harm reduction programs need to engage people who obtain prescription drugs illicitly.
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Affiliation(s)
- Rachel E. Gicquelais
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Becky L. Genberg
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jacquie Astemborski
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - David D. Celentano
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Gregory D. Kirk
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Shruti H. Mehta
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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408
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Interprofessional team-based approach to patients with chronic hepatitis C and personality disorder: Three case studies. Arch Psychiatr Nurs 2019; 33:352-357. [PMID: 31280779 DOI: 10.1016/j.apnu.2019.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 01/25/2019] [Accepted: 02/09/2019] [Indexed: 11/23/2022]
Abstract
Hepatitis C virus is a blood borne pathogen that infects 130 million people worldwide. After a prolonged period of slowly progressive liver injury, those infected are at risk of advancing to end stage liver disease, with its associated complications, and hepatocellular carcinoma. Rates of past and/or current substance use and behavioral comorbidities are higher among those infected with hepatitis C compared to the general population. A number of patient, provider and system barriers to care and treatment have led to low rates of treatment initiation in this population despite pharmacologic advances that have made hepatitis C a curable disease. Innovation in care delivery is considered a key strategy that will help reach more patients. We present three case studies of patients with chronic hepatitis C and multiple psychiatric comorbidities who were successfully engaged in care and treated for their chronic hepatitis C in our multidisciplinary primary care-based program.
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409
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Hochstatter KR, Gustafson DH, Landucci G, Pe-Romashko K, Maus A, Shah DV, Taylor QA, Gill EK, Miller R, Krechel S, Westergaard RP. A Mobile Health Intervention to Improve Hepatitis C Outcomes Among People With Opioid Use Disorder: Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2019; 8:e12620. [PMID: 31373273 PMCID: PMC6694728 DOI: 10.2196/12620] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 04/23/2019] [Accepted: 06/18/2019] [Indexed: 12/11/2022] Open
Abstract
Background People who inject drugs are at a disproportionate risk for contracting hepatitis C virus (HCV). However, use of HCV prevention and treatment services remains suboptimal among people with substance use disorders due to various health system, societal, and individual barriers. Mobile health applications offer promising strategies to support people in recovery from substance use disorders. We sought to determine whether the Addiction-Comprehensive Health Enhancement Support System (A-CHESS), an existing mobile health application for opioid use disorder, could be adapted to improve HCV screening and treatment. Objective The goals of this paper are to describe: (1) the components and functionality of an HCV intervention incorporated into the existing A-CHESS system; and (2) how data are collected and will be used to evaluate HCV testing, linkage to care, and treatment. Methods People with recent opioid use were enrolled in a randomized controlled trial to test whether A-CHESS reduced relapse. We developed and implemented HCV intervention content within the A-CHESS platform to simultaneously evaluate whether A-CHESS improved secondary outcomes related to HCV care. All A-CHESS users received the HCV intervention content, which includes educational information, private messages tailored to an individual’s stage of HCV care, and a public discussion forum. Data on patients’ HCV risk behaviors and stage of care were collected through quarterly telephone interviews and weekly surveys delivered through A-CHESS. The proportion of people with opioid use disorder who are HCV untested, HCV-negative, HCV antibody-positive, or HCV RNA–positive, as well as linked to care, treated and cured at baseline is described here. The 24-month follow-up is ongoing and will be completed in April 2020. Survey data will then be used to assess whether individuals who received the HCV-enhanced A-CHESS intervention were more likely to reduce risky injection behaviors, receive HCV testing, link to medical care, initiate treatment, and be cured of HCV compared to the control group. Results Between April 2016 and April 2018, 416 individuals were enrolled and completed the baseline interview. Of these individuals, 207 were then randomly assigned to the control arm and 209 were assigned to the intervention arm. At baseline, 202 individuals (49%) self-reported ever testing HCV antibody-positive. Of those, 179 (89%) reported receiving HCV RNA confirmatory testing, 134 (66%) tested HCV RNA–positive, 125 (62%) were linked to medical care and 27 (13%) were treated and cured of HCV. Of the remaining 214 individuals who had never tested HCV antibody–positive, 129 (31%) had tested HCV antibody–negative within the past year and 85 (20%) had not been tested within the past year. Conclusions The A-CHESS mobile health system allows for the implementation of a bundle of services as well as the collection of longitudinal data related to drug use and HCV care among people with opioid use disorders. This study will provide preliminary evidence to determine whether HCV-specific services embedded into the A-CHESS program can improve HCV outcomes for people engaged in addiction treatment. Trial Registration ClinicalTrials.gov NCT02712034; https://clinicaltrials.gov/ct2/show/NCT02712034 International Registered Report Identifier (IRRID) DERR1-10.2196/12620
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Affiliation(s)
- Karli R Hochstatter
- Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States.,Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States
| | - David H Gustafson
- Center for Health Enhancement Systems Studies, Department of Industrial and Systems Engineering, University of Wiconsin-Madison, Madison, WI, United States
| | - Gina Landucci
- Center for Health Enhancement Systems Studies, Department of Industrial and Systems Engineering, University of Wiconsin-Madison, Madison, WI, United States
| | - Klaren Pe-Romashko
- Center for Health Enhancement Systems Studies, Department of Industrial and Systems Engineering, University of Wiconsin-Madison, Madison, WI, United States
| | - Adam Maus
- Center for Health Enhancement Systems Studies, Department of Industrial and Systems Engineering, University of Wiconsin-Madison, Madison, WI, United States
| | - Dhavan V Shah
- Center for Health Enhancement Systems Studies, Department of Industrial and Systems Engineering, University of Wiconsin-Madison, Madison, WI, United States
| | - Quinton A Taylor
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States
| | - Emma K Gill
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States
| | - Rebecca Miller
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States
| | - Sarah Krechel
- AIDS Resource Center of Wisconsin, Milwaukee, WI, United States
| | - Ryan P Westergaard
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States
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410
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Gidwani-Marszowski R, Owens DK, Lo J, Goldhaber-Fiebert JD, Asch SM, Barnett PG. The Costs of Hepatitis C by Liver Disease Stage: Estimates from the Veterans Health Administration. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2019; 17:513-521. [PMID: 31030359 DOI: 10.1007/s40258-019-00468-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND The release of highly effective but costly medications for the treatment of hepatitis C virus combined with a doubling in the incidence of hepatitis C virus have posed substantial financial challenges for many healthcare systems. We provide estimates of the cost of treating patients with hepatitis C virus that can inform the triage of pharmaceutical care in systems with limited healthcare resources. METHODS We conducted an observational study using a national US cohort of 206,090 veterans with laboratory-identified hepatitis C virus followed from Fiscal Year 2010 to 2014. We estimated the cost of: non-advanced Fibrosis-4; advanced Fibrosis-4; hepatocellular carcinoma; liver transplant; and post-liver transplant. The former two stages were ascertained using laboratory result data; the latter stages were ascertained using administrative data. Costs were obtained from the Veterans Health Administration's activity-based cost accounting system and more closely represent the actual costs of providing care, an improvement on the charge data that generally characterizes the hepatitis C virus cost literature. Generalized estimating equations were used to estimate and predict costs per liver disease stage. Missing data were multiply imputed. RESULTS Annual costs of care increased as patients progressed from non-advanced Fibrosis-4 to advanced Fibrosis-4, hepatocellular carcinoma, and liver transplant (all p < 0.001). Post-liver transplant, costs decreased significantly (p < 0.001). In simulations, patients were estimated to incur the following annual costs: US $17,556 for non-advanced Fibrosis-4; US $20,791 for advanced Fibrosis-4; US $46,089 for liver cancer; US $261,959 in the year of the liver transplant; and US $18,643 per year after the liver transplant. CONCLUSIONS Cost differences of treating non-advanced and advanced Fibrosis-4 are relatively small. The greatest cost savings would be realized from avoiding progression to liver cancer and transplant.
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Affiliation(s)
- Risha Gidwani-Marszowski
- VA Health Economics Resource Center, VA Palo Alto Health Care System, 795 Willow Rd. (152 MPD), Menlo Park, CA, 94025, USA.
- VA Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA.
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.
| | - Douglas K Owens
- VA Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA
- Center for Primary Care and Outcomes Research/Center for Health Policy, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Jeanie Lo
- VA Health Economics Resource Center, VA Palo Alto Health Care System, 795 Willow Rd. (152 MPD), Menlo Park, CA, 94025, USA
| | - Jeremy D Goldhaber-Fiebert
- Center for Primary Care and Outcomes Research/Center for Health Policy, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Steven M Asch
- VA Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Paul G Barnett
- VA Health Economics Resource Center, VA Palo Alto Health Care System, 795 Willow Rd. (152 MPD), Menlo Park, CA, 94025, USA
- VA Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA
- Center for Primary Care and Outcomes Research/Center for Health Policy, Department of Medicine, Stanford University, Stanford, CA, USA
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411
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Cook AK, Worcman N. Confronting the opioid epidemic: public opinion toward the expansion of treatment services in Virginia. HEALTH & JUSTICE 2019; 7:13. [PMID: 31338621 PMCID: PMC6717979 DOI: 10.1186/s40352-019-0095-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 07/02/2019] [Indexed: 05/16/2023]
Abstract
BACKGROUND Public opinion polls have consistently shown Americans prefer treatment over arrest policies for opioid users. As the opioid epidemic remains a major health problem in the United States, it is important to determine the type of treatment policies the public would support. Theoretically, government should take into consideration the opinion of its constituents when deciding how to act. As such, the 2018 Virginia Commonwealth Public Policy Poll determined levels of support for the expansion of community-based treatment in one's community. RESULTS Overall, the results showed 80% of Virginians (n = 788) supported the expansion of community-based treatment centers in their neighborhood, 69% supported the use of housing in their community, while less than half supported the provision of clean needles to IV drug users so they do not use dirty needles that could spread infection. Multivariate analyses revealed education, sex, and political party affiliation are significant factors in predicting support for the expansion of services. CONCLUSIONS Given the lack of progress made by the government in reducing the supply and demand of drugs over the course of the war on drugs, it is time to move away from punitive policies to responsible and pragmatic approaches that include the expansion of community-based treatment.
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Affiliation(s)
- Amy Kyle Cook
- L. Douglas Wilder School of Government and Public Affairs, Virginia Commonwealth University, 1001 W. Franklin Street, Richmond, VA, 23284, USA.
| | - Nicola Worcman
- Substance Abuse Prevention, Treatment, and Policy, Virginia Commonwealth University, Richmond, VA, USA
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412
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Elimination of hepatitis C virus infection among people who use drugs: Ensuring equitable access to prevention, treatment, and care for all. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 72:1-10. [PMID: 31345644 DOI: 10.1016/j.drugpo.2019.07.016] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 07/05/2019] [Accepted: 07/06/2019] [Indexed: 12/12/2022]
Abstract
There have been major strides towards the World Health Organization goal to eliminate hepatitis C virus (HCV) infection as a global public health threat. The availability of simple, well-tolerated direct-acting antiviral therapies for HCV infection that can achieve a cure in >95% of people has provided an important tool to help achieve the global elimination targets. Encouragingly, therapy is highly effective among people receiving opioid agonist therapy and people who have recently injected drugs. Moving forward, major challenges include ensuring that new infections are prevented from occurring and that people who are living with HCV are tested, linked to care, treated, receive appropriate follow-up, and have equitable access to care. This editorial highlights key themes and articles in a special issue focusing on the elimination of HCV among people who inject drugs. An overarching consideration flowing from this work is how to ensure equitable access to HCV treatment and care for all. This special issue maps the field in relation to: HCV prevention; the cascade of HCV care; strategies to enhance testing, linkage to care, and treatment uptake; and HCV treatment and reinfection. In addition, papers draw attention to the 'risk environments' and socio-ecological determinants of HCV acquisition, barriers to HCV care, the importance of messaging around the side-effects of new direct-acting antiviral therapies, the positive transformative potential of treatment and cure, and the key role of community-based drug user organizations in the HCV response. While this special issue highlights some successful efforts towards HCV elimination among people who inject drugs, it also highlights the relative lack of attention to settings in which resources enabling elimination are scarce, and where elimination hopes and potentials are less clear, such as in many low and middle income countries. Strengthening capacity in areas of the world where resources are more limited will be a critical step towards ensuring equity for all so that global HCV elimination among PWID can be achieved.
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413
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Heimer R, Hawk K, Vermund SH. Prevalent Misconceptions About Opioid Use Disorders in the United States Produce Failed Policy and Public Health Responses. Clin Infect Dis 2019; 69:546-551. [PMID: 30452633 PMCID: PMC6637277 DOI: 10.1093/cid/ciy977] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 11/13/2018] [Indexed: 12/20/2022] Open
Abstract
The current opioid crisis in the United States has emerged from higher demand for and prescribing of opioids as chronic pain medication, leading to massive diversion into illicit markets. A peculiar tragedy is that many health professionals prescribed opioids in a misguided response to legitimate concerns that pain was undertreated. The crisis grew not only from overprescribing, but also from other sources, including insufficient research into nonopioid pain management, ethical lapses in corporate marketing, historical stigmas directed against people who use drugs, and failures to deploy evidence-based therapies for opioid addiction and to comprehend the limitations of supply-side regulatory approaches. Restricting opioid prescribing perversely accelerated narco-trafficking of heroin and fentanyl with consequent increases in opioid overdose mortality As injection replaced oral consumption, outbreaks of hepatitis B and C virus and human immunodeficiency virus infections have resulted. This viewpoint explores the origins of the crisis and directions needed for effective mitigation.
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Affiliation(s)
- Robert Heimer
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, and Departments of
- Pharmacology, Yale School of Medicine, New Haven, Connecticut
| | - Kathryn Hawk
- Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Sten H Vermund
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, and Departments of
- Pediatrics, Yale School of Medicine, New Haven, Connecticut
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414
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Da BL, Surana P, Schueler SA, Jalaly NY, Kamal N, Taneja S, Vittal A, Gilman CL, Heller T, Koh C. Twitter As a Noninvasive Bio-Marker for Trends in Liver Disease. Hepatol Commun 2019; 3:1271-1280. [PMID: 31497747 PMCID: PMC6719740 DOI: 10.1002/hep4.1394] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 06/03/2019] [Indexed: 12/12/2022] Open
Abstract
With the success of hepatitis C virus (HCV) direct-acting antiviral therapies, there has been a shift in research focus to the other major chronic liver diseases (CLDs). The use of social media, specifically Twitter, has become a popular platform for understanding public health trends and for performing health care research. To evaluate this, we studied the areas of public interest and social media trends of the following three major CLDs: hepatitis B virus (HBV), HCV, and nonalcoholic fatty liver disease (NAFLD)/nonalcoholic steatohepatitis (NASH). Twitter activity data from January 1, 2013, through January 1, 2019, for HBV, HCV, and NAFLD/NASH were collected using the social media analytic tool Symplur Signals (Symplur LLC) software. Content and regression analyses were performed to understand and predict Twitter activity for each of the CLDs. Over the study period, there were 810,980 tweets generating 4,452,939,516 impressions. HCV tweet activity peaked in 2015 at 243,261 tweets, followed by a decline of 52.4% from 2015 to 2016 with a subsequent plateau through 2018. Meanwhile, NAFLD/NASH and HBV tweet activity has continued to increase, with projections that these two CLDs will surpass HCV by the second half of 2023 and 2024, respectively. Treatment and Management was the most popular content category for HCV and NAFLD/NASH, while Prevention was the most popular content category for HBV. Conclusion: Twitter is a useful social media tool to gauge public interest in liver disease over time. The information provided by Twitter can be used to identify gaps in public knowledge or highlight areas of interest that may need further research. Future studies on the use of Twitter in liver disease are warranted.
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Affiliation(s)
- Ben L Da
- Digestive Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases National Institutes of Health Bethesda MD
| | - Pallavi Surana
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases National Institutes of Health Bethesda MD
| | - Samuel A Schueler
- Digestive Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases National Institutes of Health Bethesda MD
| | - Niloofar Y Jalaly
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases National Institutes of Health Bethesda MD
| | - Natasha Kamal
- Digestive Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases National Institutes of Health Bethesda MD
| | - Sonia Taneja
- Digestive Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases National Institutes of Health Bethesda MD
| | - Anusha Vittal
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases National Institutes of Health Bethesda MD
| | - Christy L Gilman
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases National Institutes of Health Bethesda MD
| | - Theo Heller
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases National Institutes of Health Bethesda MD
| | - Christopher Koh
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases National Institutes of Health Bethesda MD
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Abara WE, Trujillo L, Broz D, Finlayson T, Teshale E, Paz-Bailey G, Glick S, Al-Tayyib AA, Robinson WT, Masiello-Schuette S, Sey EK, Anderson BJ, Poe J, Braunstein S. Age-Related Differences in Past or Present Hepatitis C Virus Infection Among People Who Inject Drugs: National Human Immunodeficiency Virus Behavioral Surveillance, 8 US Cities, 2015. J Infect Dis 2019; 220:377-385. [PMID: 30915477 PMCID: PMC11111175 DOI: 10.1093/infdis/jiz142] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 03/26/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Historically, older people who inject drugs (PWID) have had the highest hepatitis C virus (HCV) burden; however, young PWID now account for recent increases. We assessed factors associated with past or present HCV infection (HCV antibody [anti-HCV] positive) among young (≤35 years) and older (>35 years) PWID. METHODS We calculated adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs) to examine sociodemographic and past 12-month injection behaviors associated with HCV infection. RESULTS Of 4094 PWID, 55.2% were anti-HCV positive. Among young PWID, anti-HCV prevalence was 42.1% and associated with ≤high school diploma/General Education Development diploma (GED) (aPR, 1.17 [95% CI, 1.03-1.33]), receptive syringe sharing (aPR, 1.37 [95% CI, 1.21-1.56]), sharing injection equipment (aPR, 1.16 [95% CI, 1.01-1.35]), arrest history (aPR, 1.14 [95% CI, 1.02-1.29]), and injecting speedball (aPR, 1.37 [95% CI, 1.16-1.61]). Among older PWID, anti-HCV prevalence was 62.2% and associated with ≤high school diploma/GED (aPR, 1.08 [95% CI, 1.02-1.15]), sharing injection equipment (aPR, 1.08 [95% CI, 1.02-1.15]), high injection frequency (aPR, 1.16 [95% CI, 1.01-1.34]), and injecting speedball (aPR, 1.09 [95% CI, 1.01-1.16]). CONCLUSIONS Anti-HCV prevalence is high among PWID and varies with age. Scaling up direct-acting antiviral treatment, syringe service programs, and medication-assisted therapy is critical to mitigating transmission risk and infection burden.
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Affiliation(s)
- Winston E Abara
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Lindsay Trujillo
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Dita Broz
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Teresa Finlayson
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Eyasu Teshale
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Gabriela Paz-Bailey
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Sara Glick
- Division of Allergy and Infectious Diseases, School of Medicine, University of Washington, Seattle, Washington
| | - Alia A Al-Tayyib
- Denver Public Health, Denver Health and Hospital Authority, Denver, Colorado
| | - William T Robinson
- STD/HIV Program, Louisiana Department of Health and LSU Health Sciences Center, School of Public Health, New Orleans, Louisiana
| | | | - Ekow K Sey
- Los Angeles County Department of Public Health, Los Angeles, California
| | - Bridget J Anderson
- Bureau of HIV/AIDS Epidemiology, New York State Department of Health, Albany, New York
| | - Jonathon Poe
- TB/HIV/STD Branch, Texas Department of State Health Services, Austin, Texas
| | - Sarah Braunstein
- Bureau of HIV/AIDS Prevention and Control, New York City Department of Health and Mental Hygiene, New York
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416
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Williams N, Bossert N, Chen Y, Jaanimägi U, Markatou M, Talal AH. Influence of social determinants of health and substance use characteristics on persons who use drugs pursuit of care for hepatitis C virus infection. J Subst Abuse Treat 2019; 102:33-39. [PMID: 31202286 PMCID: PMC10530640 DOI: 10.1016/j.jsat.2019.04.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Revised: 04/21/2019] [Accepted: 04/22/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND Social determinants of health (SDOH), i.e., social, behavioral and environmental factors, are increasingly recognized for their important influence on health outcomes. Data are limited on the influence of SDOH, substance use characteristics, and their interactions on pursuit of hepatitis C virus (HCV) care among individuals with opioid use disorder (OUD). Linkage to HCV care remains low in this population despite high HCV prevalence and incidence. AIMS To investigate the influence of SDOH, substance use factors, and their interactions on HCV treatment uptake among OUD patients in a methadone treatment program. METHODS Information on patient demographics, SDOH, substance use characteristics, and co-morbid medical conditions were obtained from the paper and electronic medical records of OUD patients on methadone. We applied multiple correspondence analysis, k-means algorithm, and logistic regression with least absolute shrinkage and selection operator penalty to identify variables and clusters associated with pursuit of HCV care. RESULTS Data from 161 patients (57% male, 60% Caucasian, mean age 45 years) were evaluated. Being employed, the absence of support systems, and a history of foster care were the strongest positive predictors of treatment pursuit. The use of crack/cocaine as the initial illicit substance, criminal activity without incarceration, and the absence of a family history of chemical dependency were the strongest negative predictors. We identified clusters among persons with OUD based upon their likelihood to pursue HCV management. CONCLUSION Utilizing data from the medical record, we were able to identify factors positively and negatively associated with linkage-to-care for HCV. We were also able to divide patients into clusters of factors associated with linkage-to-care for HCV. These results could be used to identify individuals with OUD based upon their readiness for HCV care.
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Affiliation(s)
- Narissa Williams
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University at Buffalo, Buffalo, NY, USA
| | - Nicholas Bossert
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University at Buffalo, Buffalo, NY, USA
| | - Yang Chen
- Department of Biostatistics, University at Buffalo, Buffalo, NY, USA.
| | - Urmo Jaanimägi
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University at Buffalo, Buffalo, NY, USA
| | | | - Andrew H Talal
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University at Buffalo, Buffalo, NY, USA.
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417
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Huhn AS, Berry MS, Dunn KE. Review: Sex-Based Differences in Treatment Outcomes for Persons With Opioid Use Disorder. Am J Addict 2019; 28:246-261. [PMID: 31131505 PMCID: PMC6591072 DOI: 10.1111/ajad.12921] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 05/01/2019] [Accepted: 05/05/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND AND OBJECTIVES In order to address the current opioid crisis, research on treatment outcomes for persons with opioid use disorder (OUD) should account for biological factors that could influence individual treatment response. Women and men might have clinically meaningful differences in their experience in OUD treatment and might also have unique challenges in achieving successful, long-term recovery. This review summarizes and synthesizes the current literature on sex-based differences in OUD treatment outcomes. METHODS Relevant literature was identified via automated and manual searches using the terms "opioid treatment outcome sex [or gender] differences" and "opiate treatment outcome sex [or gender] differences." Search methodology was consistent with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), and were conducted within the PubMed electronic database during March and April of 2018. RESULTS The initial PubMed search yielded 241 manuscripts and 31 original research articles that met inclusion/exclusion criteria were synthesized in this review. Several important trends emerged, including findings that women are more likely than men to present to treatment with co-occurring mental health conditions such as depression, and that women might respond particularly well to buprenorphine maintenance. DISCUSSION AND CONCLUSIONS While much of the literature on this topic is subject to potential cohort effects, interventions that address co-occurring mental health conditions and psychosocial stress might improve treatment outcomes for women with OUD. SCIENTIFIC SIGNIFICANCE Funding agencies and researchers should focus attention toward human laboratory studies and clinical trials that are prospectively designed to assess sex-based differences in OUD recovery. (Am J Addict 2019;28:246-261).
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Affiliation(s)
- Andrew S. Huhn
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine
| | - Meredith S. Berry
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine
- Department of Health Education and Behavior, and Department of Psychology, University of Florida
| | - Kelly E. Dunn
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine
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418
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Abstract
Chronic hepatitis C viral (HCV) infection continues to carry a high burden of disease despite recent and emerging advancements in treatment. The persistently high prevalence of HCV is attributed to the rising opioid epidemic, with a history of injection drug use as the primary risk factor for infection. As a result, the epidemiology of HCV-infected individuals is changing. Previously a disease of "Baby Boomers," males, and non-Hispanic blacks, the new generation of patients with HCV includes younger adults from 20 to 39 years of age, both men and women similarly represented, and non-Hispanic whites. Shifting trends in these demographics may be attributed to the use of injection drugs, which also has suggested impact on fibrosis progression in infected individuals. Awareness of the changing face of HCV is necessary to expand and revise recommendations regarding screening, outreach, and care engagement of infected individuals, in order to best identify patients at-risk for infection.
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Affiliation(s)
- Tiffany Wu
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Peter G Konyn
- Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| | - Austin W Cattaneo
- Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| | - Sammy Saab
- Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA. .,Department of Surgery, University of California at Los Angeles, Los Angeles, CA, USA. .,Pfleger Liver Institute, UCLA Medical Center, 200 Medical Plaza, Suite 214, Los Angeles, CA, 90095, USA.
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419
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Flyak AI, Ruiz S, Colbert MD, Luong T, Crowe JE, Bailey JR, Bjorkman PJ. HCV Broadly Neutralizing Antibodies Use a CDRH3 Disulfide Motif to Recognize an E2 Glycoprotein Site that Can Be Targeted for Vaccine Design. Cell Host Microbe 2019; 24:703-716.e3. [PMID: 30439340 DOI: 10.1016/j.chom.2018.10.009] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 08/17/2018] [Accepted: 10/03/2018] [Indexed: 12/14/2022]
Abstract
Hepatitis C virus (HCV) vaccine efforts are hampered by the extensive genetic diversity of HCV envelope glycoproteins E1 and E2. Structures of broadly neutralizing antibodies (bNAbs) (e.g., HEPC3, HEPC74) isolated from individuals who spontaneously cleared HCV infection facilitate immunogen design to elicit antibodies against multiple HCV variants. However, challenges in expressing HCV glycoproteins previously limited bNAb-HCV structures to complexes with truncated E2 cores. Here we describe crystal structures of full-length E2 ectodomain complexes with HEPC3 and HEPC74, revealing lock-and-key antibody-antigen interactions, E2 regions (including a target of immunogen design) that were truncated or disordered in E2 cores, and an antibody CDRH3 disulfide motif that exhibits common interactions with a conserved epitope despite different bNAb-E2 binding orientations. The structures display unusual features relevant to common genetic signatures of HCV bNAbs and demonstrate extraordinary plasticity in antibody-antigen interactions. In addition, E2 variants that bind HEPC3/HEPC74-like germline precursors may represent candidate vaccine immunogens.
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Affiliation(s)
- Andrew I Flyak
- Division of Biology and Biological Engineering, California Institute of Technology, Pasadena, CA 91125, USA
| | - Stormy Ruiz
- Division of Biology and Biological Engineering, California Institute of Technology, Pasadena, CA 91125, USA
| | - Michelle D Colbert
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Tiffany Luong
- Division of Biology and Biological Engineering, California Institute of Technology, Pasadena, CA 91125, USA
| | - James E Crowe
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN 37232, USA; Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN 37232, USA; Vanderbilt Vaccine Center, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Justin R Bailey
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.
| | - Pamela J Bjorkman
- Division of Biology and Biological Engineering, California Institute of Technology, Pasadena, CA 91125, USA.
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420
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High PM, Marks K, Robbins V, Winograd R, Manocchio T, Clarke T, Wood C, Stringer M. State targeted response to the opioid Crisis grants (opioid STR) program: Preliminary findings from two case studies and the national cross-site evaluation. J Subst Abuse Treat 2019; 108:48-54. [PMID: 31303359 DOI: 10.1016/j.jsat.2019.06.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 05/18/2019] [Accepted: 06/10/2019] [Indexed: 12/20/2022]
Abstract
Opioid misuse is a national health crisis that requires sustained treatment, prevention, and recovery efforts. This study evaluates the innovative treatment approaches that two states - Kentucky and Missouri - implemented in their states using State Targeted Response to the Opioid Crisis Grant (Opioid STR) program funds from the Substance Abuse Mental Health and Services Administration (SAMHSA), as well as preliminary findings from the Opioid STR national, cross-site evaluation that is funded and managed by SAMHSA. The Kentucky approach discusses the Emergency Department (ED) bridge model, which links patients discharged from EDs to appropriate professional treatment and recovery services. Missouri implemented the Medication First (MedFirst) model, an evidence-based treatment for individuals with opioid use disorder (OUD). These states highlight novel approaches likely being implemented throughout the country to combat the opioid epidemic. Findings from the case studies and supported by the national evaluation indicate that key factors to successful program implementation - supportive state policies, partnerships and collaborations, and sustainability - facilitated the implementation of planned interventions. The novel approaches discussed combined with care across the continuum (prevention, treatment and recovery) and continued federal support is likely to have an impact on reducing opioid misuse across the U.S.
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Affiliation(s)
- Patrick M High
- Substance Abuse and Mental Health Services Administration, United States of America
| | - Katherine Marks
- University of Kentucky, Department of Behavioral Science, United States of America; Kentucky Department for Behavioral Health, Developmental and Intellectual Disabilities, United States of America
| | - Vestena Robbins
- Kentucky Department for Behavioral Health, Developmental and Intellectual Disabilities, United States of America
| | - Rachel Winograd
- University of Missouri St. Louis, Missouri Institute of Mental Health, United States of America
| | - Teresa Manocchio
- Substance Abuse and Mental Health Services Administration, United States of America
| | - Thomas Clarke
- Substance Abuse and Mental Health Services Administration, United States of America.
| | - Claire Wood
- University of Missouri St. Louis, Missouri Institute of Mental Health, United States of America
| | - Mark Stringer
- Missouri Department of Mental Health, United States of America
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421
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Bahardoust M, Mokhtare M, Sarveazad A, Karimi S, Talebi A, Chaharmahali A, Agah S. Epidemiology and Estimating the Risk Factors for the Transfer of Hepatitis B Virus Using Multivariate Analysis Model: A Retrospective Case-Control Study. INTERNATIONAL JOURNAL OF EPIDEMIOLOGIC RESEARCH 2019. [DOI: 10.15171/ijer.2019.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background and aims: Hepatitis B virus (HBV) is one of the important public health diseases in Iran. Therefore, to control the prevalence of the disease, knowledge is required regarding the risk factor of HBV. Accordingly, the aim of this study was to determine the risk factors of HB transmission. Methods: A retrospective case-control study was conducted on the possible risk factors of HBV transmission. To this end, a total of 171 patients with HBV infection and 171 controls from Rasoul-eAkram hospital were investigated during 2015-2018. All subjects were directly evaluated using a faceto-face questionnaire about demographic aspects. Finally, HBV infection and its risk factors among the subjects were detected using hepatitis B surface antigen test. Results: Overall, 171 HBV patients including 77 (42%) males and 93 (58%) females were evaluated. The mean age of the participants was 40 ± 13 years. Univariate logistic analysis showed that HBV infection in these cases was associated with addiction injection (odds ratio [OR] = 4.08, CI:1.3- 9.57), family history (OR = 4.52, CI: 1.27-10.7), and having a history of blood transfusion (OR = 3.16, CI: 1.52-5.37). There were no significant relationships between the liver function tests, alcohol consumption, the history of dental visits, and HBV participants. In addition, the logistic-regression model proved that patients with a history of HBV-infected parents (At least one of them) and addiction injection were severely subject to HB infection. In other words, there was a significant association between a history of HBV-infected parents and addiction injection and HB infection. Conclusion: In general, HBV infection was strongly related to having a family member infected with hepatitis B, suffering from addiction injection, and having blood injection.
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Affiliation(s)
- Mansour Bahardoust
- Colorectal Research Center, Iran University of Medical Science, Tehran, Iran
| | - Marjan Mokhtare
- Colorectal Research Center, Iran University of Medical Science, Tehran, Iran
| | - Arash Sarveazad
- Colorectal Research Center, Iran University of Medical Science, Tehran, Iran
| | - Shahdieh Karimi
- Internal Medicine Department, Rasoul-e-Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Atefeh Talebi
- Colorectal Research Center, Iran University of Medical Science, Tehran, Iran
| | - Arezoo Chaharmahali
- Internal Medicine Department, Rasoul-e-Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Shahram Agah
- Colorectal Research Center, Iran University of Medical Science, Tehran, Iran
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422
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Coffin PO, Santos GM, Behar E, Hern J, Walker J, Matheson T, Kinnard EN, Silvis J, Vittinghoff E, Fox R, Page K. Randomized feasibility trial of directly observed versus unobserved hepatitis C treatment with ledipasvir-sofosbuvir among people who inject drugs. PLoS One 2019; 14:e0217471. [PMID: 31158245 PMCID: PMC6546233 DOI: 10.1371/journal.pone.0217471] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 05/08/2019] [Indexed: 12/11/2022] Open
Abstract
AIMS The advent of direct-acting antivirals for hepatitis C virus (HCV) and limited effectiveness of prevention have generated interest in "Treatment as Prevention" (TasP), in which those most likely to transmit HCV (i.e. people who inject drugs [PWID]) are treated to reduced secondary transmission. However, there are scant data regarding the feasibility of treating PWID at high risk for secondary transmission or the optimal approach to treatment delivery. METHODS We conducted a 2:1 randomized trial of modified directly-observed (mDOT) versus unobserved HCV treatment with ledipasvir-sofosbuvir daily for 8 weeks among PWID with 36 weeks of follow-up in San Francisco from 2015-2017. We evaluated recruitment-enrollment, treatment completion, end-of-treatment and 12-week response, and reinfection rate. RESULTS Of 83 individuals eligible for screening, 72 (87.6%) attended the screening visit, 33 were eligible, and 31 enrolled; mean age was 42 years, 81% were male, 74% white. All but one participant (in the mDOT arm) completed treatment and 89.4% of mDOT and 96.6% of unobserved arm visits were attended. HCV was undetectable for 96.8% (30/31) at end of treatment and 89.7% (26/29) 12 weeks later (1 relapse, 1 reinfection), with no differences by arm. Two additional reinfections were subsequently identified, for a reinfection rate of 16.3 (95% CI 5.3-50.5) per 100 person-years of observation. CONCLUSIONS It was feasible to recruit active PWID for HCV treatment and achieve high retention, viral response, and satisfaction with either mDOT or unobserved protocols, supporting treatment of PWID at risk of transmitting HCV to others. The reinfection rate suggests we successfully reached a high-risk population and that successful HCV TasP initiatives may aim to be sufficient in scope to significantly lower prevalence in the community. TRIAL REGISTRATION clinicaltrials.gov NCT02609893.
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Affiliation(s)
- Phillip O. Coffin
- San Francisco Department of Public Health, San Francisco, California, United States of America
- University of California San Francisco, San Francisco, California, United States of America
- * E-mail:
| | - Glenn-Milo Santos
- San Francisco Department of Public Health, San Francisco, California, United States of America
- University of California San Francisco, San Francisco, California, United States of America
| | - Emily Behar
- San Francisco Department of Public Health, San Francisco, California, United States of America
| | - Jaclyn Hern
- San Francisco Department of Public Health, San Francisco, California, United States of America
| | - John Walker
- San Francisco Department of Public Health, San Francisco, California, United States of America
| | - Tim Matheson
- San Francisco Department of Public Health, San Francisco, California, United States of America
| | - Elizabeth N. Kinnard
- San Francisco Department of Public Health, San Francisco, California, United States of America
- University of California Berkeley School of Public Health, Berkeley, California, United States of America
| | - Janelle Silvis
- San Francisco Department of Public Health, San Francisco, California, United States of America
| | - Eric Vittinghoff
- University of California San Francisco, San Francisco, California, United States of America
| | - Rena Fox
- University of California San Francisco, San Francisco, California, United States of America
| | - Kimberley Page
- University of California San Francisco, San Francisco, California, United States of America
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Gaps in HCV Knowledge and Risk Behaviors among Young Suburban People Who Inject Drugs. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16111958. [PMID: 31159479 PMCID: PMC6604001 DOI: 10.3390/ijerph16111958] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 05/02/2019] [Accepted: 05/29/2019] [Indexed: 01/28/2023]
Abstract
Background: Hepatitis C virus (HCV) among young suburban people who inject drugs (PWID) is a growing epidemic in the United States, yet little is known about the factors contributing to increased exposure. The goal of this study was to explore and assess HCV knowledge and attitudes about treatment and identify risk behaviors among a cohort of young suburban PWID. Methods: We conducted interviews with New Jersey (NJ) service providers and staff from the state’s five syringe service programs to inform a semistructured survey addressing HCV knowledge, treatment, and risk factors among young suburban PWID. We then used this survey to conduct qualitative interviews with 14 young suburban PWID (median age 26 years) in NJ between April and May 2015. Data were analyzed using a modified grounded theory approach and coded to identify thematic relationships among respondents. Results: Most participants had substantial gaps in several aspects of HCV knowledge. These included: HCV transmission, HCV symptoms, and the availability of new direct-acting antiviral therapy. Participants also downplayed the risk of past and current risk behaviors, such as sharing drug paraphernalia and reusing needles, which also reflected incomplete knowledge regarding these practices. Conclusion: Young suburban PWID are not receiving or retaining accurate and current HCV information. Innovative outreach and prevention messages specifically tailored to young suburban PWID may help to disseminate HCV prevention and treatment information to this population.
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425
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Truong C, Krawczyk N, Dejman M, Marshall-Shah S, Tormohlen K, Agus D, Bass J. Challenges on the road to recovery: Exploring attitudes and experiences of clients in a community-based buprenorphine program in Baltimore City. Addict Behav 2019; 93:14-19. [PMID: 30682677 PMCID: PMC6528177 DOI: 10.1016/j.addbeh.2019.01.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Revised: 10/23/2018] [Accepted: 01/14/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE This qualitative study identifies and describes experiences and challenges to retention of individuals with opioid use disorder (OUD) who participated in a low-threshold combined buprenorphine-peer support treatment program in Baltimore. METHODS In-depth semi-structured interviews with staff and former clients of the Project Connections Buprenorphine Program (PCBP) (9 people) and focus group discussions with current and previous clients of PCBP (7 people) were conducted. Content analysis was used to extract themes regarding barriers to enrolling and remaining in, and transitioning from the program. RESULTS Primary challenges identified by the participants included struggles with cravings and symptoms of withdrawal, comorbid mental health issues, criminal justice system involvement, medication stigma, and conflicts over level of flexibility regarding program requirements and the role of employment. CONCLUSIONS This study identified several obstacles clients face when seeking care through a combined buprenorphine-peer support model. Findings highlight potential programmatic factors that can be improved and additional resources that may support treatment retention rates and better outcomes. Despite challenges, low-threshold and community-based programs can increase access to effective maintenance treatment for OUD, especially among vulnerable populations who may not have access to formal health services.
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Affiliation(s)
- C Truong
- Mental Health Department, Johns Hopkins Bloomberg School of Public Health, Hampton House 624 N. Broadway, Floor 8, Baltimore, MD 21205, United States.
| | - N Krawczyk
- Mental Health Department, Johns Hopkins Bloomberg School of Public Health, Hampton House 624 N. Broadway, Floor 8, Baltimore, MD 21205, United States; Behavioral Health Leadership Institute, 2200 Arden Road, Baltimore, MD 21209, United States.
| | - M Dejman
- Mental Health Department, Johns Hopkins Bloomberg School of Public Health, Hampton House 624 N. Broadway, Floor 8, Baltimore, MD 21205, United States.
| | - S Marshall-Shah
- Mental Health Department, Johns Hopkins Bloomberg School of Public Health, Hampton House 624 N. Broadway, Floor 8, Baltimore, MD 21205, United States.
| | - K Tormohlen
- Mental Health Department, Johns Hopkins Bloomberg School of Public Health, Hampton House 624 N. Broadway, Floor 8, Baltimore, MD 21205, United States.
| | - D Agus
- Mental Health Department, Johns Hopkins Bloomberg School of Public Health, Hampton House 624 N. Broadway, Floor 8, Baltimore, MD 21205, United States; Behavioral Health Leadership Institute, 2200 Arden Road, Baltimore, MD 21209, United States.
| | - J Bass
- Mental Health Department, Johns Hopkins Bloomberg School of Public Health, Hampton House 624 N. Broadway, Floor 8, Baltimore, MD 21205, United States.
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426
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Cloud DH, Ibragimov U, Prood N, Young AM, Cooper HLF. Rural risk environments for hepatitis c among young adults in appalachian kentucky. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 72:47-54. [PMID: 31113713 DOI: 10.1016/j.drugpo.2019.05.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 03/25/2019] [Accepted: 05/05/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Rural Kentucky is an epicenter of hepatitis C(HCV), especially among young adults who inject drugs. While the Risk Environment Framework (REF) has been used widely to study and address socio-ecological determinants of infectious disease among people who inject drugs (PWID), it has been almost exclusively applied to urban environments. Applying REF to rural environments can enhance our understanding of the drivers of HCV epidemics in these hard-hit areas, and inform the creation and implementation of harm reduction interventions in this local context. METHODS Participants were recruited between March and August 2017 via community-based outreach methods (e.g., cookouts, flyers) and peer referral. Individuals who met eligibility criteria (aged 18-35, recently used prescription opioids and/or heroin to get high, lived in one of the 5 target counties) participated indepth, semi-structured interviews. The interview guide was informed by the REF, and covered HCV-related risk behaviors and environmental features that shaped vulnerability to engaging in these behaviors. Interviews were transcribed and analyzed using constructivist grounded-theory methods. RESULTS Participants (N=19) described multiple intersecting risk environment features that shaped vulnerability to HCV transmission. Economic decline generated intergenerational poverty, dwindling employment prospects, and diminished social enrichment opportunities that collectively contributed to substance misuse and risky injection practices. Geographic isolation, lack of collective knowledge about HCV transmission risks, scarce harm reduction services, familial poverty, and fear of law enforcement interacted to increase the odds of people injecting in "trap houses" (akin to shooting galleries) or secluded areas, spaces in which they rushed to inject and shared injection equipment. Pervasive stigma was a structural barrier to adopting, expanding, and using harm reduction services. CONCLUSION This exploratory study identified features of rural risk environments that may contribute to significant HCV burdens in Appalachian Kentucky. Findings signal the importance of expanding proven harm reduction strategies and anti-stigma interventions tailored to rural contexts.
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Affiliation(s)
- David H Cloud
- Emory University, Rollins School of Public Health, United States.
| | | | - Nadya Prood
- Emory University, Rollins School of Public Health, United States
| | - April M Young
- University of Kentucky College of Public Health, United States
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427
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Gaska JM, Balev M, Ding Q, Heller B, Ploss A. Differences across cyclophilin A orthologs contribute to the host range restriction of hepatitis C virus. eLife 2019; 8:e44436. [PMID: 31074414 PMCID: PMC6510530 DOI: 10.7554/elife.44436] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Accepted: 04/15/2019] [Indexed: 12/22/2022] Open
Abstract
The restricted host tropism of hepatitis C virus (HCV) remains incompletely understood, especially post-entry, and has hindered developing an immunocompetent, small animal model. HCV replication in non-permissive species may be limited by incompatibilities between the viral replication machinery and orthologs of essential host factors, like cyclophilin A (CypA). We thus compared the ability of CypA from mouse, tree shrew, and seven non-human primate species to support HCV replication, finding that murine CypA only partially rescued viral replication in Huh7.5-shRNA CypA cells. We determined the specific amino acid differences responsible and generated mutants able to fully rescue replication. We expressed these mutants in engineered murine hepatoma cells and although we observed increases in HCV replication following infection, they remained far lower than those in highly permissive human hepatoma cells, and minimal infectious particle release was observed. Together, these data suggest additional co-factors remain unidentified. Future work to determine such factors will be critical for developing an immunocompetent mouse model supporting HCV replication.
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Affiliation(s)
- Jenna M Gaska
- Department of Molecular BiologyPrinceton UniversityPrincetonUnited States
| | - Metodi Balev
- Department of Molecular BiologyPrinceton UniversityPrincetonUnited States
| | - Qiang Ding
- Department of Molecular BiologyPrinceton UniversityPrincetonUnited States
| | - Brigitte Heller
- Department of Molecular BiologyPrinceton UniversityPrincetonUnited States
| | - Alexander Ploss
- Department of Molecular BiologyPrinceton UniversityPrincetonUnited States
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428
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Listing practices and graft utilization of hepatitis C-positive deceased donors in liver and kidney transplant. Surgery 2019; 166:102-108. [PMID: 31072671 DOI: 10.1016/j.surg.2019.03.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 02/22/2019] [Accepted: 03/15/2019] [Indexed: 01/25/2023]
Abstract
BACKGROUND The opioid epidemic has resulted in increasing the incidence of hepatitis C virus in the general population and more deceased organ donors with hepatitis C in the United States. We aim to describe how the changing donor landscape affects patterns of liver and kidney transplantation among donors, waitlist candidates, and transplanted recipients. METHODS Using data supplied by the United Network for Organ Sharing, we examined donor hepatitis C virus antibody (Ab) and nucleic acid testing (NAT) status, center waitlist patterns, and liver and kidney transplants and discards between 2015 and 2017 by 6-month periods. RESULTS We observed an increase in donors with any marker of the hepatitis C virus (n = 283 [6.2%] in period 1 to n = 384 [7.4%] in period 5, P = .008) and antibody positive nucleic acid testing negative donors (n = 81 [1.8%] in period 1 to n = 131 [2.5%] in period 5, P < .001). We observed a significant increase in aviremic recipients of liver transplants from antibody positive nucleic acid testing negative donors (n = 1 [1.7%] in period 1, to n = 27 [31.0%] in period 5, P = .005) and a significant decrease in the antibody positive nucleic acid testing positive liver discard rate (P = .01). By the end of the study, 75.8% (n = 97) of recipients of antibody positive nucleic acid testing negative kidneys were hepatitis C virus negative, an increase from 10.6% (n = 5) in period 1. CONCLUSION The number of donors with the hepatitis C virus is increasing. We observed a concomitant increase in the transplantation of kidneys and livers from aviremic donors, and the recipient population of these organs is increasingly hepatitis C virus negative.
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429
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Syringe services programs: An examination of legal, policy, and funding barriers in the midst of the evolving opioid crisis in the U.S. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 70:22-32. [PMID: 31059965 DOI: 10.1016/j.drugpo.2019.04.006] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 03/13/2019] [Accepted: 04/04/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Syringe Services Programs (SSPs) have been proposed as a key intervention to address increasing rates of opioid injection, overdose, and infectious disease transmission in the U.S. In recent years, multiple states and jurisdictions have enacted laws and policies to enable implementation of SSPs. These statutory and regulatory changes have resulted in the expansion of SSPs in a short period of time under a patchwork of different regulations and policies. Understanding how SSPs are responding to this evolving policy environment in the midst of a worsening opioid crisis can inform the development of strategies to maximize the role SSPs play in the response to the opioid crisis. METHODS In-depth, semi-structured and audio-recorded interviews were conducted with 25 individuals running 23 SSPs in the U.S. A thematic content analysis was employed to identify and group themes across the domains of interest based on inductive and deductive coding of verbatim interview transcripts. RESULTS Despite progress in expanding the number of SSPs in recent years, programs described encountering legal, policy, funding, and community barriers that are limiting the scope, scale, and reach of SSPs. To address these barriers, programs are employing multiple strategies to educate about and advocate for SSPs, engage policymakers and communities, combat pervasive stigma, strengthen funding, and reach at-risk populations. CONCLUSION This qualitative study of a geographically diverse sample of SSPs provides key insights into the legal and policy barriers, funding challenges, and contextual factors impacting SSPs and the strategies programs are pursuing to counter these barriers. Coupling these strategies with policy changes that address the underlying legal and financial barriers and advancing efforts to combat stigma around drug use and addiction stand to substantially expand the role of SSPs as part of the public health response to the opioid crisis in the U.S.
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430
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Morris MD, Mirzazadeh A, Evans JL, Briceno A, Coffin P, Hahn JA, Page KA. Treatment cascade for hepatitis C virus in young adult people who inject drugs in San Francisco: Low number treated. Drug Alcohol Depend 2019; 198:133-135. [PMID: 30921649 PMCID: PMC6482851 DOI: 10.1016/j.drugalcdep.2019.02.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 01/03/2019] [Accepted: 02/07/2019] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To understand the number of young adult people who inject drugs (PWID) with hepatitis C virus (HCV) infection accessing direct-acting antiviral (DAA) treatment and their barriers and facilitators to treatment uptake. METHODS Using prospective cohort data from young adult PWID in San Francisco with newly identified HCV infection, we calculated the number who: (i) accepted referral to DAA therapy, (ii) initiated DAA therapy, (iii) completed DAA therapy, and (iv) achieved sustained virologic response (SVR) or cure. Behavioral survey data identified possible barriers and facilitators to DAA therapy. RESULTS Of 60 young adult PWID with new HCV infection identified between February 2015 and January 2018, thirty accepted a referral to HCV care; five initiated and completed HCV treatment and achieved cure. Barriers to DAA uptake included fear of medical establishments, competing basic needs, and delaying care because they were feeling well. CONCLUSION While few HCV-positive young adult PWID engaged in DAA therapy, all those who did achieved cure. Youth-tailored services that overcome the stigma and marginalization related to injection drug use are needed to improve treatment uptake.
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Affiliation(s)
- Meghan D. Morris
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA,Institute for Global Health Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Ali Mirzazadeh
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA,Institute for Global Health Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Jennifer L. Evans
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Alya Briceno
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Phillip Coffin
- San Francisco Department of Public Health, San Francisco, CA, USA,Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Judith A. Hahn
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA,Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Kimberly A. Page
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
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431
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Younis IR, Lakota EA, Volpe DA, Patel V, Xu Y, Sahajwalla CG. Drug-Drug Interaction Studies of Methadone and Antiviral Drugs: Lessons Learned. J Clin Pharmacol 2019; 59:1035-1043. [PMID: 30973652 DOI: 10.1002/jcph.1405] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 02/22/2019] [Indexed: 12/29/2022]
Abstract
Different views appear in the literature on the extent of specific cytochrome P450 (CYP) involvement in methadone metabolism. The aim of this work is to leverage knowledge from drug-drug interaction (DDI) studies in new drug applications between methadone and antiviral medications to better understand methadone disposition and to inform design of future DDI studies with methadone. A database of DDI studies between all FDA-approved human immunodeficiency virus and hepatitis C virus medications and methadone was constructed. The database contains data from 29 DDI studies. Sixteen of the 29 studies had statistically significant changes in methadone area under the concentration-time curve. Methadone exposure was either decreased or unchanged when it was coadministered with weak to strong CYP3A inhibitors or a moderate CYP3A4 inducer. Methadone exposure was reduced when it was coadministered with CYP2B6 inducers. The role of other enzymes (CYP2C9, CYP2C19, and CYP2D6) cannot be fully elucidated from these studies. In conclusion, CYP2B6 plays a prominent role in methadone metabolism, although methadone exposure is not sensitive to CYP3A perturbation. In designing methadone DDI studies, (1) measuring R- and S-methadone is more informative than measuring total methadone, and (2) CYP2B6 genotyping of subjects enrolled in methadone DDI studies should be considered. Finally, there is a need for the development of predictive models to determine the influence of medications on methadone disposition.
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Affiliation(s)
- Islam R Younis
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA.,Current affiliation: Astellas Pharma Global Development, Inc, Northbrook, IL, USA
| | - Elizabeth A Lakota
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA.,Intitute for Clinical Pharmacodynamics, Schenectady, NY, USA
| | - Donna A Volpe
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Vikram Patel
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Yun Xu
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Chandra G Sahajwalla
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
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432
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Winetsky D, Zucker J, Slowikowski J, Scherer M, Verna EC, Gordon P. Preliminary Screening Results Outside the 1945-1965 Birth Cohort: A Forgotten Population for Hepatitis C? Open Forum Infect Dis 2019; 6:ofz178. [PMID: 31123691 PMCID: PMC6524825 DOI: 10.1093/ofid/ofz178] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 04/08/2019] [Indexed: 01/22/2023] Open
Abstract
In December 2017, our academic medical center implemented universal hepatitis C virus screening among adult hospitalized patients. We reviewed charts of patients screening positive outside the birth cohort (1945–1965) in the first 6 months after implementation. Documented risk factors were common in younger patients but rare in patients born before 1945.
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Affiliation(s)
- Daniel Winetsky
- Comprehensive Health Program (CHP), New York Presbyterian Hospital, New York, New York.,Division of Infectious Diseases, Department of Internal Medicine, Columbia University Irving Medical Center, New York, New York.,HIV Center for Clinical and Behavioral Studies at Columbia University and New York State Psychiatric Institute, New York, New York
| | - Jason Zucker
- Comprehensive Health Program (CHP), New York Presbyterian Hospital, New York, New York.,Division of Infectious Diseases, Department of Internal Medicine, Columbia University Irving Medical Center, New York, New York.,Division of Infectious Diseases, Department of Pediatrics, Columbia University Irving Medical Center, New York, New York
| | - Jacek Slowikowski
- Comprehensive Health Program (CHP), New York Presbyterian Hospital, New York, New York
| | - Matthew Scherer
- Comprehensive Health Program (CHP), New York Presbyterian Hospital, New York, New York.,Division of Infectious Diseases, Department of Internal Medicine, Columbia University Irving Medical Center, New York, New York
| | - Elizabeth C Verna
- Center for Liver Disease and Transplantation, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Peter Gordon
- Comprehensive Health Program (CHP), New York Presbyterian Hospital, New York, New York.,Division of Infectious Diseases, Department of Internal Medicine, Columbia University Irving Medical Center, New York, New York
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433
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Patel EU, Mehta SH, Boon D, Quinn TC, Thomas DL, Tobian AAR. Limited Coverage of Hepatitis C Virus Testing in the United States, 2013-2017. Clin Infect Dis 2019; 68:1402-1405. [PMID: 30239645 PMCID: PMC6451991 DOI: 10.1093/cid/ciy803] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Accepted: 09/13/2018] [Indexed: 12/09/2022] Open
Abstract
In the US household population, hepatitis C virus testing coverage marginally increased between 2013 and 2017 among persons born between 1966 and 1994 (13.2% to 16.8%) and persons born between 1945 and 1965 (12.3% to 17.3%). Testing coverage remains limited and sociodemographic disparities were observed in both populations.
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Affiliation(s)
- Eshan U Patel
- Department of Pathology, Johns Hopkins University School of Medicine
| | - Shruti H Mehta
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health
| | - Denali Boon
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health
| | - Thomas C Quinn
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases
| | - David L Thomas
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Aaron A R Tobian
- Department of Pathology, Johns Hopkins University School of Medicine
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434
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Abstract
PURPOSE OF REVIEW We sought to review the contemporary epidemiology of cirrhosis, focusing on the relative burden of the most common chronic liver diseases. RECENT FINDINGS The key findings in the review highlight the increasing prevalence and impact of alcohol-related liver disease, particularly among young people, and the epidemic of nonalcoholic fatty liver commensurate with rising rates of obesity. We also contrast recent advances in the care of persons with hepatitis C with the lamentable rise in new infections associated with intravenous drug use. Finally, we highlight the impact of both conventional complications of cirrhosis (namely hepatic encephalopathy) but also the host of patient-reported outcomes adversely impacted by the symptoms of cirrhosis. Cirrhosis is associated with an expanding footprint in contemporary public health. In order to improve global outcomes, we must not only focus on the identifying and treating persons with viral hepatitis but also preventing the rise of alcohol-related liver disease and nonalcoholic fatty liver disease while attending to the urgent patient-centered needs posed by the symptoms of cirrhosis.
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Affiliation(s)
- Jad A Baki
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA
| | - Elliot B Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA. .,Gastroenterology Section, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.
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435
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Davis SM, Kristjansson AL, Davidov D, Zullig K, Baus A, Fisher M. Barriers to using new needles encountered by rural Appalachian people who inject drugs: implications for needle exchange. Harm Reduct J 2019; 16:23. [PMID: 30940136 PMCID: PMC6444507 DOI: 10.1186/s12954-019-0295-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Accepted: 03/20/2019] [Indexed: 01/28/2023] Open
Abstract
Background Using a new needle for every injection can reduce the spread of infectious disease among people who inject drugs (PWID). No previous study has examined new needle use barriers among PWIDs residing in the rural Appalachian part of the United States, an area currently in the midst of a heroin epidemic. Objective Therefore, our primary aim was to explore self-reported barriers to using a new needle by PWID attending a needle exchange program (NEP). Methods We conducted a cross-sectional survey of PWID attending two NEPs in rural West Virginia located in the heart of Central Appalachia. A convenience sample of PWID (n = 100) completed the Barriers to Using New Needles Questionnaire. Results The median number of barriers reported was 5 (range 0–19). Fear of arrest by police (72% of PWID “agreed” or “strongly agreed”) and difficulty with purchasing needles from a pharmacy (64% “agreed” or “strongly agreed”) were the most frequently cited barriers. Conclusions/Importance Congruent with previous findings from urban locations, in rural West Virginia, the ability of PWID to use a new needle obtained from a needle exchange for every injection may be compromised by fear of arrest. In addition, pharmacy sales of new needles to PWID may be blunted by an absence of explicit laws mandating nonprescription sales. Future studies should explore interventions that align the public health goals of NEPs with the occupational safety of law enforcement and health outreach goals of pharmacists. Electronic supplementary material The online version of this article (10.1186/s12954-019-0295-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Stephen M Davis
- Department of Health Policy, Management, and Leadership, School of Public Health, Robert C. Byrd Health Sciences Center, West Virginia University, PO Box 9190, Morgantown, WV, 26506, USA. .,Department of Emergency Medicine, West Virginia University, PO Box 9149, Morgantown, WV, 26506, USA.
| | - Alfgeir L Kristjansson
- Department of Social and Behavioral Sciences, West Virginia University, PO Box 9190, Morgantown, WV, 26506, USA
| | - Danielle Davidov
- Department of Emergency Medicine, West Virginia University, PO Box 9149, Morgantown, WV, 26506, USA.,Department of Social and Behavioral Sciences, West Virginia University, PO Box 9190, Morgantown, WV, 26506, USA
| | - Keith Zullig
- Department of Social and Behavioral Sciences, West Virginia University, PO Box 9190, Morgantown, WV, 26506, USA
| | - Adam Baus
- Department of Social and Behavioral Sciences, West Virginia University, PO Box 9190, Morgantown, WV, 26506, USA
| | - Melanie Fisher
- Department of Medicine, Section of Infectious Diseases, West Virginia University, PO Box 9163, Morgantown, WV, 26506, USA
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436
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Carlyle M, Rockliff H, Edwards R, Ene C, Karl A, Marsh B, Hartley L, Morgan CJ. Investigating the Feasibility of Brief Compassion Focused Therapy in Individuals in Treatment for Opioid Use Disorder. SUBSTANCE ABUSE-RESEARCH AND TREATMENT 2019; 13:1178221819836726. [PMID: 31043786 PMCID: PMC6446438 DOI: 10.1177/1178221819836726] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 12/05/2018] [Indexed: 11/17/2022]
Abstract
Opioid use disorder (OUD) is reaching epidemic proportions worldwide, and is notoriously difficult to treat. Compassion focused therapy (CFT) has emerged as therapeutic tool for treating individuals exhibiting high levels of self-criticism and low self-esteem, both of which are common in OUD. Until now, however, there had been no research investigating this therapy in patients with OUD. Before running a premature clinical trial, it is important to fully assess the feasibility and acceptability of this treatment in this group of individuals. We aimed to assess the feasibility of CFT treatment in individuals with OUD in a short group intervention, which was co-created by the research team, service users and a local drugs service. The intervention involved three 2-hour sessions held over 3 weeks, where participants engaged in compassion-orientated psychoeducation and self-compassionate exercises. Individuals were randomly assigned to either the CFT group (n = 15), the active control (relaxation) group (n = 12) or the waitlist control group (n = 11). Of 103 individuals approached, 45% attended a baseline visit suggesting the treatment was acceptable to this group. A relatively low attrition rate across the 3 groups was found for CFT (21.1%), with no difference in drop-out between the groups. Qualitative analysis of interviews with participants identified a desire for more sessions. Compassion focused therapy was thus feasible and well-tolerated in those with OUD, and a further trial to evaluate any clinical differences may be warranted.
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Affiliation(s)
- Molly Carlyle
- Psychopharmacology and Addiction Research Centre (PARC), College of Life and Environmental Science, University of Exeter, Exeter, UK
| | - Helen Rockliff
- Psychopharmacology and Addiction Research Centre (PARC), College of Life and Environmental Science, University of Exeter, Exeter, UK
| | | | - Crina Ene
- Psychopharmacology and Addiction Research Centre (PARC), College of Life and Environmental Science, University of Exeter, Exeter, UK
| | - Anke Karl
- Psychopharmacology and Addiction Research Centre (PARC), College of Life and Environmental Science, University of Exeter, Exeter, UK
| | - Beth Marsh
- Psychopharmacology and Addiction Research Centre (PARC), College of Life and Environmental Science, University of Exeter, Exeter, UK.,Clinical Psychopharmacology Unit, Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | | | - Celia Ja Morgan
- Psychopharmacology and Addiction Research Centre (PARC), College of Life and Environmental Science, University of Exeter, Exeter, UK
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Cost Effectiveness of Universal Screening for Hepatitis C Virus Infection in the Era of Direct-Acting, Pangenotypic Treatment Regimens. Clin Gastroenterol Hepatol 2019; 17:930-939.e9. [PMID: 30201597 DOI: 10.1016/j.cgh.2018.08.080] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 08/24/2018] [Accepted: 08/31/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Most persons infected with hepatitis C virus (HCV) in the United States were born from 1945 through 1965; testing is recommended for this cohort. However, HCV incidence is increasing among younger persons in many parts of the country and treatment is recommended for all adults with HCV infection. We aimed to estimate the cost effectiveness of universal 1-time screening for HCV infection in all adults living in the United States and to determine the prevalence of HCV antibody above which HCV testing is cost effective. METHODS We developed a Markov state transition model to estimate the effects of universal 1-time screening of adults 18 years or older in the United States, compared with the current guideline-based strategy of screening adults born from 1945 through 1965. We compared potential outcomes of 1-time universal screening of adults or birth cohort screening followed by antiviral treatment of those with HCV infection vs no screening. We measured effectiveness with quality-adjusted life-years (QALY), and costs with 2017 US dollars. RESULTS Based on our model, universal 1-time screening of US residents with a general population prevalence of HCV antibody greater than 0.07% cost less than $50,000/QALY compared with a strategy of no screening. Compared with 1-time birth cohort screening, universal 1-time screening and treatment cost $11,378/QALY gained. Universal screening was cost effective compared with birth cohort screening when the prevalence of HCV antibody positivity was greater than 0.07% among adults not in the cohort born from 1945 through 1965. CONCLUSIONS Using a Markov state transition model, we found a strategy of universal 1-time screening for chronic HCV infection to be cost effective compared with either no screening or birth cohort-based screening alone.
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438
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Kennedy-Hendricks A, Bluestein J, Kral AH, Barry CL, Sherman SG. Establishing Sanctioned Safe Consumption Sites in the United States: Five Jurisdictions Moving the Policy Agenda Forward. Psychiatr Serv 2019; 70:294-301. [PMID: 30755131 DOI: 10.1176/appi.ps.201800398] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Safe consumption sites enable use of preobtained drugs in hygienic settings where trained staff are available to respond to overdoses and connect individuals with health and social services. This study examined efforts to advance policies to establish safe consumption sites in the United States, where no sanctioned sites exist. METHODS Between April and July 2018, the authors conducted 25 telephone interviews with a purposive sample of key informants in five communities considering safe consumption site implementation. Participants included organizers and advocates, government officials, and personnel with social service and health organizations. Interview notes were analyzed by using hybrid inductive-deductive coding. RESULTS Key strategies for organizing support for safe consumption sites included involving people who use drugs, engaging diverse partners, supporting allies in related causes, and using various tactics to garner support from policy makers. Major barriers to adoption included identifying the right locations, uncertainty about the federal response, mistrust arising from racial injustice in drug policy, and financing. Participants identified facilitators of progress toward safe consumption site adoption, such as building on existing harm reduction programs, securing political champions, and exposing community officials to programs operating internationally. CONCLUSIONS A window of opportunity may be opening to advance policy related to safe consumption sites; whether sanctioned sites become part of the broader policy strategy for addressing drug use and overdose in the United States will depend on the experiences of the first sites. Organizing around this issue may facilitate engagement among people who use drugs in broader conversations about drug policy.
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Affiliation(s)
- Alene Kennedy-Hendricks
- Department of Health Policy and Management (Kennedy-Hendricks, Bluestein, Barry), Center for Mental Health and Addiction Policy Research (Kennedy-Hendricks, Bluestein, Barry, Sherman), and Department of Health Behavior and Society (Sherman), all at Johns Hopkins Bloomberg School of Public Health, Baltimore; Behavioral Health and Criminal Justice Division, RTI International, San Francisco (Kral)
| | - Jenna Bluestein
- Department of Health Policy and Management (Kennedy-Hendricks, Bluestein, Barry), Center for Mental Health and Addiction Policy Research (Kennedy-Hendricks, Bluestein, Barry, Sherman), and Department of Health Behavior and Society (Sherman), all at Johns Hopkins Bloomberg School of Public Health, Baltimore; Behavioral Health and Criminal Justice Division, RTI International, San Francisco (Kral)
| | - Alex H Kral
- Department of Health Policy and Management (Kennedy-Hendricks, Bluestein, Barry), Center for Mental Health and Addiction Policy Research (Kennedy-Hendricks, Bluestein, Barry, Sherman), and Department of Health Behavior and Society (Sherman), all at Johns Hopkins Bloomberg School of Public Health, Baltimore; Behavioral Health and Criminal Justice Division, RTI International, San Francisco (Kral)
| | - Colleen L Barry
- Department of Health Policy and Management (Kennedy-Hendricks, Bluestein, Barry), Center for Mental Health and Addiction Policy Research (Kennedy-Hendricks, Bluestein, Barry, Sherman), and Department of Health Behavior and Society (Sherman), all at Johns Hopkins Bloomberg School of Public Health, Baltimore; Behavioral Health and Criminal Justice Division, RTI International, San Francisco (Kral)
| | - Susan G Sherman
- Department of Health Policy and Management (Kennedy-Hendricks, Bluestein, Barry), Center for Mental Health and Addiction Policy Research (Kennedy-Hendricks, Bluestein, Barry, Sherman), and Department of Health Behavior and Society (Sherman), all at Johns Hopkins Bloomberg School of Public Health, Baltimore; Behavioral Health and Criminal Justice Division, RTI International, San Francisco (Kral)
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439
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Boesecke C, Rockstroh JK. (Mid)West Side Story: Acute Hepatitis C Virus Infection and the Opioid Epidemic in the United States. Hepatology 2019; 69:1832-1834. [PMID: 30251386 DOI: 10.1002/hep.30290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
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440
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Saloner B, McGinty EE, Beletsky L, Bluthenthal R, Beyrer C, Botticelli M, Sherman SG. A Public Health Strategy for the Opioid Crisis. Public Health Rep 2019; 133:24S-34S. [PMID: 30426871 PMCID: PMC6243441 DOI: 10.1177/0033354918793627] [Citation(s) in RCA: 135] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Drug overdose is now the leading cause of injury death in the United States. Most overdose fatalities involve opioids, which include prescription medication, heroin, and illicit fentanyl. Current data reveal that the overdose crisis affects all demographic groups and that overdose rates are now rising most rapidly among African Americans. We provide a public health perspective that can be used to mobilize a comprehensive local, state, and national response to the opioid crisis. We argue that framing the crisis from a public health perspective requires considering the interaction of multiple determinants, including structural factors (eg, poverty and racism), the inadequate management of pain, and poor access to addiction treatment and harm-reduction services (eg, syringe services). We propose a novel ecological framework for harmful opioid use that provides multiple recommendations to improve public health and clinical practice, including improved data collection to guide resource allocation, steps to increase safer prescribing, stigma-reduction campaigns, increased spending on harm reduction and treatment, criminal justice policy reform, and regulatory changes related to controlled substances. Focusing on these opportunities provides the greatest chance of making a measured and sustained impact on overdose and related harms.
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Affiliation(s)
- Brendan Saloner
- 1 Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Emma E McGinty
- 1 Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Leo Beletsky
- 2 School of Law and the Bouvé College of Health Sciences, Northeastern University, Boston, MA, USA
- 3 School of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Ricky Bluthenthal
- 4 Department of Preventive Medicine and the Institute for Prevention Research at the Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Chris Beyrer
- 5 Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Michael Botticelli
- 1 Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- 5 Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- 6 Grayken Center for Addiction at Boston Medical Center, Boston, MA, USA
| | - Susan G Sherman
- 7 Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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441
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Park H, Wang W, Henry L, Nelson DR. Impact of All-Oral Direct-Acting Antivirals on Clinical and Economic Outcomes in Patients With Chronic Hepatitis C in the United States. Hepatology 2019; 69:1032-1045. [PMID: 30289989 PMCID: PMC6393174 DOI: 10.1002/hep.30303] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 09/17/2018] [Indexed: 12/13/2022]
Abstract
Approved treatment for hepatitis C virus (HCV) with all-oral direct-acting antivirals (DAA) therapy is now entering into its fourth year; however, little has been reported on the real-world clinical (decompensated cirrhosis [DCC] and hepatocellular carcinoma [HCC]) and economic outcomes. A retrospective cohort analysis of the Truven Health MarketScan Database (2012-2016) was conducted. In a cohort of 26,105 patients with newly diagnosed HCV, 30% received all-oral DAA therapy (DAA group) and 70% were not treated (untreated group). Multivariate Cox proportional hazards models were used to compare the risk of developing HCC and DCC, stratified by cirrhosis status. Among patients with cirrhosis (n = 2157), DAA therapy was associated with a 72% and a 62% lower incidence of HCC (hazard ratio [HR], 0.28; 95% confidence interval [CI], 0.15-0.52) and DCC (HR, 0.38; 95% CI, 0.26-0.56). Similarly, DAA therapy was associated with a 57% and a 58% lower incidence of HCC (HR, 0.43; 95% CI, 0.26-0.71) and DCC (HR, 0.42; 95% CI, 0.30-0.58) in patients with noncirrhotic HCV (n = 23,948). A propensity score-matched cohort of 8064 HCV-infected patients who had at least a 12-month follow-up after HCV treatment was included for economic analysis. For patients with cirrhosis in the DAA group, the mean adjusted liver-related costs ($1749 vs. $4575; P < 0.001) and all-cause medical costs ($19,300 vs. $33,039; P < 0.001) were significantly lower compared with those in the untreated group. The mean adjusted costs were not statistically different between the two groups among patients without cirrhosis. Conclusion: In the short term, all-oral DAA treatment for HCV infection was associated with a decreased risk of developing HCC and DCC, resulting in decreased health care costs, especially in patients with cirrhosis. A longitudinal study is necessary to confirm our findings.
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Affiliation(s)
- Haesuk Park
- Department of Pharmaceutical Outcomes and Policy, College of PharmacyUniversity of FloridaGainesvilleFL
| | - Wei Wang
- Department of Pharmaceutical Outcomes and Policy, College of PharmacyUniversity of FloridaGainesvilleFL
| | - Linda Henry
- Department of Pharmaceutical Outcomes and Policy, College of PharmacyUniversity of FloridaGainesvilleFL
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442
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Jones CM, McCance-Katz EF. Characteristics and prescribing practices of clinicians recently waivered to prescribe buprenorphine for the treatment of opioid use disorder. Addiction 2019; 114:471-482. [PMID: 30194876 DOI: 10.1111/add.14436] [Citation(s) in RCA: 105] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 08/02/2018] [Accepted: 08/31/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIMS Expanding access to medication-assisted treatment with buprenorphine is a cornerstone of the opioid crisis response, yet buprenorphine remains underutilized. Research has identified multiple barriers to prescribing buprenorphine. This study aimed to examine clinician characteristics, prescribing practices and barriers and incentives to prescribing buprenorphine among clinicians with a federal Drug Addiction Treatment Act of 2000 (DATA) waiver to prescribe buprenorphine for opioid use disorder treatment. DESIGN Electronic survey of 4225 clinicians conducted between March and April 2018. SETTING United States. PARTICIPANTS Clinicians obtaining an initial federal DATA waiver or an increase in authorized patient limit to prescribe buprenorphine for opioid use disorder treatment in 2017. MEASUREMENTS Descriptive statistics and multivariable logistic regression examined clinician characteristics, prescribing practices and primary barriers and incentives to prescribing buprenorphine or prescribing at or near the authorized patient limit. FINDINGS Among respondents, 75.5% had prescribed buprenorphine since obtaining a DATA waiver; the mean (standard deviation) number of patients treated in the past month was 26.6 (40.3), and 13.1% of providers were prescribing at or near their patient limit in the past month. Lack of patient demand, cited by 19.4% of clinicians, was the most common primary barrier to prescribing buprenorphine or prescribing to the authorized patient limit, followed by time constraints in practice (14.6%) and insurance reimbursement, prior authorization or other insurance requirements (13.2%). Increased patient demand (22.2%), institutional support for buprenorphine treatment (12.5%) and increased reimbursement (12.2%) were the most endorsed primary incentives for buprenorphine prescribing. Multivariable logistic regression models identified multiple clinician characteristics associated with buprenorphine prescribing and prescribing at or near the authorized patient limit. CONCLUSIONS US clinicians recently waivered to prescribe buprenorphine for opioid use disorder treatment appear to prescribe well below their patient limit, and many do not prescribe at all.
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Affiliation(s)
- Christopher M Jones
- Substance Abuse and Mental Health Services Administration, Rockville, MD, USA
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443
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Tolentino B, Singh RR, Misra S, Dieterich DT, Sarpel D. An update on the management of hepatitis C virus and human immunodeficiency virus co-infection. Future Virol 2019. [DOI: 10.2217/fvl-2018-0116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
An estimated 2.3 million people globally are co-infected with HIV and HCV. Liver disease is now a leading cause of non-AIDS-related mortality among HIV-infected patients. The development of direct-acting antiviral agents has revolutionized the treatment of HIV/HCV co-infection with sustained virologic response response rates above 95% in most patient populations. This article provides an update on the management of acute and chronic HCV in patients co-infected with HIV including a section on drug–drug interactions.
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Affiliation(s)
- Bryan Tolentino
- Department of Medicine, Division of Infectious Disease, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Ritu R Singh
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Suresh Misra
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Douglas T Dieterich
- Department of Medicine, Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Dost Sarpel
- Department of Medicine, Division of Infectious Disease, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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444
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Øvrehus A, Nielsen S, Hansen JF, Holm DK, Christensen P. Test uptake and hepatitis C prevalence in 5483 Danish people in drug use treatment from 1996 to 2015: a registry-based cohort study. Addiction 2019; 114:494-503. [PMID: 30347471 DOI: 10.1111/add.14479] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 05/02/2018] [Accepted: 10/17/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS The aims of this study were, in people in treatment for drug use in Funen, Denmark, to: (1) assess prevalence of hepatitis C virus (HCV) test uptake and prevalence of HCV; (2) identify predictors of test update and HCV infection; and (3) characterize changes between 1996 and 2015 in test uptake, HCV prevalence and drug use. DESIGN Cohort study linking the Danish National Registry on Drug Users in Treatment to the regional hepatitis test registry and the Danish Death Certificate Registry, thus combining longitudinal data on drug use with data on HCV testing and results. SETTING AND PARTICIPANTS People recorded as having received treatment for drug use between 1996 and 2015 (n = 5483) in Funen, Denmark. In the cohort, 24.8% were female, median age 23 years [interquartile range (IQR) = 20-32] at entry and 50% had self-reported injecting or had received opiate substitution therapy (OST). MEASUREMENTS The main outcomes were the test for HCV ever and latest HCV-RNA being positive. The main predictors were for test and infection investigated; ever receiving OST, self-reported injecting, age at entry and connection to treatment centre offering outreach hepatitis care. FINDINGS HCV test uptake was 52% and prevalence of current HCV-RNA+ was 21% in people alive at the end of follow-up. Positive predictors of having undergone HCV testing were: receiving OST [odds ratio (OR) = 3.7; 95% confidence interval (CI) = 3.2-4.5], self-reported injecting (OR = 2.3; 95% CI = 2.0-2.7), female gender (OR = 1.7; 95% CI = 1.4-1.9) and having been connected to centres with outreach hepatitis care (OR = 1.4; 95% CI = 1.2-1.7). In people alive, HCV-RNA+ prevalence was 31% if ever on OST or self-reported injecting. Among HCV-infected people, 69% were in drug use treatment at end of follow-up. For participants entering the cohort after 2010, only 5% reported opiates as main drug of use and 17% had experience of injecting. CONCLUSION Among Danish people in treatment for drug use from 1996 to 2015, receiving opiate substitution therapy had the largest associating to being tested for hepatitis C virus. As opiate use is declining, adapting test strategies will be necessary.
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Affiliation(s)
- Anne Øvrehus
- Department of Infectious Diseases, Odense University Hospital, Odense C, Denmark
| | - Stine Nielsen
- Department of Infectious Diseases, Odense University Hospital, Odense C, Denmark
| | | | - Dorte Kinggaard Holm
- Department of Clinical Immunology, Odense University Hospital, Odense C, Denmark
| | - Peer Christensen
- Department of Infectious Diseases, Odense University Hospital, Odense C, Denmark
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445
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Hofmeister MG, Rosenthal EM, Barker LK, Rosenberg ES, Barranco MA, Hall EW, Edlin BR, Mermin J, Ward JW, Ryerson AB. Estimating Prevalence of Hepatitis C Virus Infection in the United States, 2013-2016. Hepatology 2019; 69:1020-1031. [PMID: 30398671 PMCID: PMC6719781 DOI: 10.1002/hep.30297] [Citation(s) in RCA: 337] [Impact Index Per Article: 67.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 09/24/2018] [Indexed: 02/06/2023]
Abstract
Hepatitis C virus (HCV) infection is the most commonly reported bloodborne infection in the United States, causing substantial morbidity and mortality and costing billions of dollars annually. To update the estimated HCV prevalence among all adults aged ≥18 years in the United States, we analyzed 2013-2016 data from the National Health and Nutrition Examination Survey (NHANES) to estimate the prevalence of HCV in the noninstitutionalized civilian population and used a combination of literature reviews and population size estimation approaches to estimate the HCV prevalence and population sizes for four additional populations: incarcerated people, unsheltered homeless people, active-duty military personnel, and nursing home residents. We estimated that during 2013-2016 1.7% (95% confidence interval [CI], 1.4-2.0%) of all adults in the United States, approximately 4.1 (3.4-4.9) million persons, were HCV antibody-positive (indicating past or current infection) and that 1.0% (95% CI, 0.8-1.1%) of all adults, approximately 2.4 (2.0-2.8) million persons, were HCV RNA-positive (indicating current infection). This includes 3.7 million noninstitutionalized civilian adults in the United States with HCV antibodies and 2.1 million with HCV RNA and an estimated 0.38 million HCV antibody-positive persons and 0.25 million HCV RNA-positive persons not part of the 2013-2016 NHANES sampling frame. Conclusion: Over 2 million people in the United States had current HCV infection during 2013-2016; compared to past estimates based on similar methodology, HCV antibody prevalence may have increased, while RNA prevalence may have decreased, likely reflecting the combination of the opioid crisis, curative treatment for HCV infection, and mortality among the HCV-infected population; efforts on multiple fronts are needed to combat the evolving HCV epidemic, including increasing capacity for and access to HCV testing, linkage to care, and cure.
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Affiliation(s)
- Megan G. Hofmeister
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Elizabeth M. Rosenthal
- Department of Epidemiology and Biostatistics, University at Albany School of Public Health, State University of New York, Rensselaer, New York
| | - Laurie K. Barker
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Eli S. Rosenberg
- Department of Epidemiology and Biostatistics, University at Albany School of Public Health, State University of New York, Rensselaer, New York
| | - Meredith A. Barranco
- Department of Epidemiology and Biostatistics, University at Albany School of Public Health, State University of New York, Rensselaer, New York
| | - Eric W. Hall
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Brian R. Edlin
- National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jonathan Mermin
- National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - John W. Ward
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia
- Program for Viral Hepatitis Elimination, The Task Force for Global Health, Decatur, Georgia
| | - A. Blythe Ryerson
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia
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446
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Childs E, Assoumou SA, Biello KB, Biancarelli DL, Drainoni ML, Edeza A, Salhaney P, Mimiaga MJ, Bazzi AR. Evidence-based and guideline-concurrent responses to narratives deferring HCV treatment among people who inject drugs. Harm Reduct J 2019; 16:14. [PMID: 30744628 PMCID: PMC6371610 DOI: 10.1186/s12954-019-0286-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 01/30/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Hepatitis C virus (HCV) infection is increasingly prevalent among people who inject drugs (PWID) in the context of the current US opioid crisis. Although curative therapy is available and recommended as a public health strategy, few PWID have been treated. We explore PWID narratives that explain why they have not sought HCV treatment or decided against starting it. We then compare these narratives to evidence-based and guideline-concordant information to better enable health, social service, harm reduction providers, PWID, and other stakeholders to dispel misconceptions and improve HCV treatment uptake in this vulnerable population. METHODS We recruited HIV-uninfected PWID (n = 33) through community-based organizations (CBOs) to participate in semi-structured, in-depth qualitative interviews on topics related to overall health, access to care, and knowledge and interest in specific HIV prevention methods. RESULTS In interviews, HCV transmission and delaying or forgoing HCV treatment emerged as important themes. We identified three predominant narratives relating to delaying or deferring HCV treatment among PWID: (1) lacking concern about HCV being serious or urgent enough to require treatment, (2) recognizing the importance of treatment but nevertheless deciding to delay treatment, and (3) perceiving that clinicians and insurance companies recommend that patients who currently use or inject drugs should delay treatment. CONCLUSIONS Our findings highlight persistent beliefs among PWID that hinder HCV treatment utilization. Given the strong evidence that treatment improves individual health regardless of substance use status while also decreasing HCV transmission in the population, efforts are urgently needed to counter the predominant narratives identified in our study. We provide evidence-based, guideline-adherent information that counters the identified narratives in order to help individuals working with PWID to motivate and facilitate treatment access and uptake. An important strategy to improve HCV treatment initiation among PWID could involve disseminating guideline-concordant counternarratives to PWID and the providers who work with and are trusted by this population.
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Affiliation(s)
- Ellen Childs
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
| | - Sabrina A Assoumou
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Katie B Biello
- Center for Health Equity Research, Brown University School of Public Health, Providence, RI, USA
- Departments of Behavioral and Social Health Sciences and Epidemiology, Brown University School of Public Health, Providence, RI, USA
- The Fenway Institute, Fenway Health, Boston, MA, USA
| | - Dea L Biancarelli
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
- Evans Center for Implementation and Improvement Sciences, Boston University School of Medicine, Boston, MA, USA
| | - Mari-Lynn Drainoni
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
- Evans Center for Implementation and Improvement Sciences, Boston University School of Medicine, Boston, MA, USA
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, USA
| | - Alberto Edeza
- Center for Health Equity Research, Brown University School of Public Health, Providence, RI, USA
- Departments of Behavioral and Social Health Sciences and Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Peter Salhaney
- Center for Health Equity Research, Brown University School of Public Health, Providence, RI, USA
| | - Matthew J Mimiaga
- Center for Health Equity Research, Brown University School of Public Health, Providence, RI, USA
- Departments of Behavioral and Social Health Sciences and Epidemiology, Brown University School of Public Health, Providence, RI, USA
- The Fenway Institute, Fenway Health, Boston, MA, USA
- Department of Psychiatry and Human Behavior, Brown University Alpert Medical School, Providence, RI, USA
| | - Angela R Bazzi
- Department of Community Health Sciences, Boston University School of Public Health, 801 Massachusetts Ave, 442e, Boston, MA, 02118, USA.
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447
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Hepatitis C continuum of care and utilization of healthcare and harm reduction services among persons who inject drugs in Seattle. Drug Alcohol Depend 2019; 195:114-120. [PMID: 30611979 PMCID: PMC6440747 DOI: 10.1016/j.drugalcdep.2018.11.026] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 11/20/2018] [Accepted: 11/23/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND To describe the "continuum of care" for hepatitis C virus (HCV) and related health service utilization among persons who inject drugs (PWID) in the Seattle metropolitan area. METHODS The study analyzed data from the 2015 National HIV Behavioral Surveillance system focused on PWID, which included local questions on HCV treatment and testing. We calculated respondent driven sampling (RDS)-adjusted percentages of participants who had completed each step of the care continuum and compared healthcare harm reduction services among participants who were HCV + vs. HCV- using bivariate analyses. RESULTS 513 PWID were screened for HCV antibodies (Ab). Of those, 59.7% were HCV Ab+. Among those HCV Ab+, 86.4% had been tested for HCV at least once; 69.9% reported a previous diagnosis. Of those diagnosed, 55.9% had received a confirmatory test, 17.2% had ever received any medications for HCV, and 7.2% had completed treatment. The majority of HCV Ab + participants had seen a health care provider in the past 12 months (85.6%). CONCLUSIONS There is a large gap between HCV screening and treatment among Seattle area PWID.
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448
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Kilaru SM, Jacobson IM. Sofosbuvir/velpatasvir/voxilaprevir in the treatment of chronic hepatitis C infection. Future Virol 2019. [DOI: 10.2217/fvl-2018-0134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The landscape of HCV treatment has been entirely transformed due to the development of direct-acting antivirals (DAAs), but there are limited data guiding salvage therapy in patients who previously failed an NS5A inhibitor-containing DAA regimen. We review the preclinical and clinical data for sofosbuvir/velpatasvir/voxilaprevir (SOF/VEL/VOX), an interferon-free, oral, once daily, pan-genotypic treatment for chronic HCV infection. This combination is a highly effective, well-tolerated and safe 12-week treatment regimen for patients with any genotype, including genotype-3 patients with baseline resistance-associated substitutions (RAS). Its most distinctive role is in patients who have previously failed treatment with advanced DAA regimens. Its efficacy is not significantly affected by RASs, and treatment-emergent RASs are uncommon.
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Affiliation(s)
- Saikiran M Kilaru
- Department of Medicine, New York University School of Medicine, New York, NY 10016, USA
| | - Ira M Jacobson
- Department of Medicine, New York University School of Medicine, New York, NY 10016, USA
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449
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Tasillo A, Eftekhari Yazdi G, Nolen S, Schillie S, Vellozzi C, Epstein R, Randall L, Salomon JA, Linas BP. Short-Term Effects and Long-Term Cost-Effectiveness of Universal Hepatitis C Testing in Prenatal Care. Obstet Gynecol 2019; 133:289-300. [PMID: 30633134 PMCID: PMC6501827 DOI: 10.1097/aog.0000000000003062] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To estimate the clinical effects and cost-effectiveness of universal prenatal hepatitis C screening, and to calculate potential life expectancy, quality of life, and health care costs associated with universal prenatal hepatitis C screening and linkage to treatment. METHODS Using a stochastic individual-level microsimulation model, we simulated the lifetimes of 250 million pregnant women matched at baseline with the U.S. childbearing population on age, injection drug use behaviors, and hepatitis C virus (HCV) infection status. Modeled outcomes included hepatitis C diagnosis, treatment and cure, lifetime health care costs, quality-adjusted life years (QALY) and incremental cost-effectiveness ratios comparing universal prenatal hepatitis C screening to current practice. We modeled whether neonates exposed to maternal HCV at birth were identified as such. RESULTS Pregnant women with hepatitis C infection lived 1.21 years longer and had 16% lower HCV-attributable mortality with universal prenatal hepatitis C screening, which had an incremental cost-effectiveness ratio of $41,000 per QALY gained compared with current practice. Incremental cost-effectiveness ratios remained below $100,000 per QALY gained in most sensitivity analyses; notable exceptions included incremental cost-effectiveness ratios above $100,000 when assuming mean time to cirrhosis of 70 years, a cost greater than $500,000 per false positive diagnosis, or population HCV infection prevalence below 0.16%. Universal prenatal hepatitis C screening increased identification of neonates exposed to HCV at birth from 44% to 92%. CONCLUSIONS In our model, universal prenatal hepatitis C screening improves health outcomes in women with HCV infection, improves identification of HCV exposure in neonates born at risk, and is cost-effective.
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Affiliation(s)
- Abriana Tasillo
- Boston Medical Center, Section of Infectious Diseases, Boston, Massachusetts; the Centers for Disease Control and Prevention, Division of Viral Hepatitis, Atlanta, Georgia; Boston Medical Center, Section of Infectious Diseases, Section of Pediatric Infectious Diseases; and the Bureau of Infectious Disease and Laboratory Sciences, Massachusetts Department of Public Health, Boston, Massachusetts; and Stanford University, Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford, California
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450
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Byrne T, Troszak L, Midboe AM, Fincke BG, Shwartz M, Gifford AL, McInnes DK. A Novel Measure to Assess Variation in Hepatitis C Prevalence Among Homeless and Unstably Housed Veterans, 2011-2016. Public Health Rep 2019; 134:126-131. [PMID: 30699304 DOI: 10.1177/0033354918821071] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We constructed a novel measure of homelessness to examine differences in hepatitis C virus (HCV) prevalence across 3 categories of unstably housed and homeless veterans and across US Department of Veterans Affairs Medical Center facilities. We used Veterans Affairs administrative data to classify a cohort of 434 240 veterans as at risk of homelessness, currently homeless, or formerly homeless, and we examined variation in HCV prevalence by using descriptive measures and mixed-effect logistic regression models. HCV prevalence was highest among veterans who were formerly homeless (16.7%; 32 490 of 195 000), followed by currently homeless (12.4%; 22 050 of 178 056) and at risk of homelessness (8.2%; 5015 of 61 184). Veterans Affairs Medical Center-level prevalence ranged from 5.4% to 21.5%. Differences in HCV prevalence were significant by sex, race/ethnicity, and age. Targeting specific populations of homeless veterans for tailored HCV interventions and allocating additional resources to certain Veterans Affairs Medical Centers may be warranted.
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Affiliation(s)
- Thomas Byrne
- 1 Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, USA.,2 Boston University School of Social Work, Boston MA, USA
| | - Lara Troszak
- 3 Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Stanford University, Palo Alto, CA, USA
| | - Amanda M Midboe
- 3 Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Stanford University, Palo Alto, CA, USA
| | - B Graeme Fincke
- 1 Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, USA.,4 Departments of Medicine, and Health Law, Policy, and Management, Boston University Schools of Medicine and Public Health, Boston, MA, USA
| | - Michael Shwartz
- 5 Center for Healthcare Organization and Implementation Research, Boston VA Healthcare System, Boston MA, USA
| | - Allen L Gifford
- 4 Departments of Medicine, and Health Law, Policy, and Management, Boston University Schools of Medicine and Public Health, Boston, MA, USA.,5 Center for Healthcare Organization and Implementation Research, Boston VA Healthcare System, Boston MA, USA
| | - D Keith McInnes
- 1 Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, USA.,4 Departments of Medicine, and Health Law, Policy, and Management, Boston University Schools of Medicine and Public Health, Boston, MA, USA
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